Every finding on record at Harmony Village of Warren

Based on observation and interview, the facility failed to maintain general cleanliness and repair in five resident rooms (Rooms 101, 303, 307, 308 and 311) and in the 300-unit ice machine room. This resulted in an increased potential for contamination and decreased satisfaction of living conditions. Findings Include: room [ROOM NUMBER] On 7/14/2026 at 11:45 AM, room [ROOM NUMBER] was observed with a stained radiator that was detached from the wall, the radiator appeared with layers of dried liquids and debris. The room was observed to remained in the same condition on 7/15/26 and 7/16/26. On 07/14/26 at 9:30 AM, the floor drain located in the 300 unit ice machine room was observed to be coated with black, slimy mold. room [ROOM NUMBER]: On 07/14/26 at 9:51 AM, the baseboard heating vent was observed to be bent and mangled, and the front cover was detached from the unit. The overbed wall mounted light fixture located near bed 3 was observed to be held together by tape. In addition, the walls next to bed 3 were observed to be heavily soiled. When queried on 07/15/26 at 1:55 PM, Maintenance Staff E stated housekeeping should clean the walls as needed, but that the resident is always in bed, so it makes it hard to get to the wall. Maintenance Staff E further stated he was unaware of the radiator cover and over-bed light fixture in disrepair and stated that he relies on staff to put maintenance issues into the electronic building maintenance program. room [ROOM NUMBER]: On 07/14/26 at 9:55 AM, there was an unknown brown substance observed on the wall near bed 1. room [ROOM NUMBER]: On 07/15/26 at 2:00 PM, the overbed table located near bed 2 was observed with edging that was falling off, leaving rough exposed particle board. When queried at the time, Maintenance Staff E confirmed the overbed table was in disrepair and needed to be replaced. room [ROOM NUMBER]: On 07/15/26 at 2:20 PM, the wall mounted baseboard radiator cover was observed to be bent and detached from the unit. When queried at that time, Maintenance Staff E stated it was just brought to his attention this morning and that they are trying to figure out the best way to fix it.

Based on interview and record review, the facility failed to develop a resident centered care plan for diabetes for one resident (R39) out of one resident reviewed for care planning. Findings include:Review of a progress note from R39's electronic medical record (EMR) revealed a nurse practitioner note dated 4/14/2026 which documented, New onset DM-II (Type 2 Diabetes) per labs from 3/3/2026 revealing a Hgba1c (Hemoglobin A1C, a way to test for blood sugar control) of 9.5% (normal range for diabetes 6.5% or higher). The EMR did not reveal a care plan for diabetes which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs.R39's EMR revealed they were admitted into the facility on [DATE] with diagnoses of age-related physical debility, generalized muscle weakness, and hypertensive heart disease (heart disease related to high blood pressure). The recent Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating impaired cognition. Further review of R39's care plans revealed they had last been reviewed 4/27/2026 (13 days after new diagnosis of diabetes).Review of active medication orders for R39 revealed they are receiving Humalog (insulin lispro), with a start date of 4/27/2026 and directions to inject per a sliding scale (amount of insulin injected based off R39's blood sugar readings). On 07/15/2026 at 12:48 PM, an interview was conducted with Registered Nurse, Unit Manager (RN) F who said if someone has diabetes and is taking insulin, it would be standard for them to have an individualized care plan. They further stated if someone has diabetes without that diagnosis appearing in the diagnoses section of their EMR, the doctor should be notified because they are usually the ones who would be entering in that diagnosis to the medical record. The diagnosis not being entered would make it more difficult to ensure a care plan is completed because those diagnoses are how they would know of the need to create a care plan.On 07/15/2026 at 1:03 PM, an interview was conducted with the Director of Nursing (DON) who confirmed a resident with diabetes should have a care plan for it. They further stated that R39's diagnosis of diabetes should have been added to the appropriate section of R39's EMR so the team would know that a care plan is needed for it, and that a new diagnosis would be caught by the time a care conference is conducted for a resident and be discussed by the Interdisciplinary Team (IDT) for care planning.Review of a facility policy titled Care Planning, last reviewed/revised 6/2024, revealed The comprehensive care plan. is reviewed and revised by the IDT (interdisciplinary team) as necessary.

Based on interview and record review, the facility failed to administer as needed low blood sugar medications for one resident (R15) of one reviewed for physician orders. Findings include: A review of R15's medical record revealed they were admitted into the facility on [DATE] with diagnosis of Diabetes. Further review revealed the resident was cognitively intact and required one person assist for Activities of Daily Living. Review of R15's medical record revealed the following active as needed orders: Glucose Gel 40 % (Dextrose (Diabetic Use))Give 10 gram by mouth as needed for blood sugar (BS) 70 or less & Conscious Use 1 tube. Ordered 4/22/26.Glucose Tablet Chewable (Dextrose (Diabetic Use)Give 3 tablets by mouth as needed for BS 70 or less and Conscious. Ordered 8/23/24.A review of R15's blood sugar readings for the month of June (2026) revealed a blood sugar reading of 56 on 6/30/26. Review of the resident's Medication Administration Record (MAR) revealed the two as needed orders listed above were not documented as administered.On 07/15/2026 at 3:30 PM, the Director of Nursing (DON) was asked about the lack of documentation following R15's blood sugar of 56 and indicated they would look into it.On 07/16/2026 at 11:29 AM, the DON explained they spoke to R15's assigned nurse (Licensed Practical Nurse, LPN C) from 6/30/26 and the nurse said they provided the resident with crackers and orange juice and confirmed the nurse had been educated. On 07/16/2026 at 12:57 PM, LPN C was interviewed via phone regarding the interventions taken for R15's low blood sugar. LPN C confirmed they provided the resident with orange juice and crackers and had been educated on documenting the interventions. LPN C was asked if R15 had any physician orders or interventions for their low blood sugar, and stated, No. On 07/16/2026 at 3:20 PM, the physician's order policy was requested from the facility, and was not received by survey exit.

Based on observation, interview, and record review, the facility failed to follow up on recommendations made by the audiologist (physician specializing in hearing loss) for one resident (R129) of one resident reviewed for hearing services. Findings include:On 07/14/2026 at 9:33 AM, R129 was observed lying in bed and asked about their care in the facility. They explained they had been seen by audiology but continued to have difficulty with hearing. R129 also explained they have noticed they have to speak louder because they can't hear themselves. A review of R129's medical record revealed they were admitted into the facility on 1/8/25 with diagnoses which included Cerebral Palsy, Diabetes, and Obesity. Further review revealed they were cognitively intact and required assistance for Activities of Daily Living (ADLs). Review of R129's medical record revealed an audiology exam dated 6/17/26 with the following recommendations for both of the resident's ears, Cerumen (ear wax) Management .Deep wax still present, needs PCP (primary care physician) removal . Further review of R129's medical record revealed the resident had been seen twice since 6/17/26 by their primary care physician and/or nurse practitioner. On 07/16/2026 at 11:30 AM, the Director of Nursing (DON) was asked about the audiology recommendations not being followed up on by the PCP. The DON explained the recommendations had been logged in the physician's book however; it had not been addressed by the physician as it should be. On 07/16/2026 at 3:20 PM, a request was made to the facility for the policy related to ancillary and physician services however, they were not received by the end of the survey.

Based on observation, interview, and record review, the facility failed to implement leg braces for one resident (R113) of three reviewed for range of motion (ROM). Findings include: On 07/14/2026 at 9:35 AM, R113 was observed in bed asleep, leg braces observed on the resident's nightstand. A review of R113's medical record revealed they were admitted into the facility on 5/7/26 with diagnoses of Muscle Wasting and Atrophy, Ataxic Gait (unsteady walking) and Unspecified Multiple Injuries. Further review revealed the resident was severely cognitively impaired and required one person assist for activities of daily living. Review of the medical record revealed the following active order dated 6/15/26, Order Summary: PT (physical therapy) recommends B/L (bilateral) knee brace up to 4 hours/daily or as tolerated to prevent contracture (shortening of the muscle). Further review of the medical record did not reveal documentation that the leg braces had been applied. On 07/15/2026 at 2:23 PM, the Director of Therapy was asked about the recommendations for R113 following their discharge from therapy and provided the resident's discharge summary revealing the resident was discharged from therapy due to their max potential being achieved, and the recommendations following discharge was for the resident to have bilateral leg braces to prevent contractures. Further review of the discharge summary noted the following, Functional Maintenance Program Established/Trained=Splint and Brace Program. The Director of Therapy was asked how the orders get implemented, and explained the recommendations are provided to nursing staff.On 07/16/2026 at 9:56 AM, R113 was observed sitting in their chair located in the hallway. The resident's knee braces were observed on their nightstand. On 07/16/2026 at 2:26 PM, the Director of Nursing (DON) was asked about R113 not having documented application of the bilateral knee splints and explained the order had not been confirmed therefore, the order was not being followed despite being ordered 30 days prior.On 7/16/26 at 3:20 PM, a request for the range of motion policy was made to the facility however, it was not received by the end of the survey.

Based on interview and record review, the facility failed to provide notification of transfers/discharges to the Long-Term Care Ombudsman for two residents (R132 and R134) of four reviewed for transfers/discharges. Findings include:R132 A review of R132's medical record revealed they were admitted into the facility on 4/20/26 with diagnoses which included Cardiomegaly, Schizophrenia, and Dementia. Further review revealed the resident was petitioned to the hospital on 4/23/26 due to increased agitation, paranoia, and combativeness. On 07/16/2026 at 9:27 AM and 12:30 PM, a request for the list of transfers/discharges sent to the Long-Term Care Ombudsman for the months of April and June (2026) was made to the facility. On 07/16/2026 at 1:39 PM, the Nursing Home Administrator (NHA) was asked about the request for the list of transfers/discharges sent to the Ombudsman and explained the social worker is responsible for sending the lists to the Long-Term Care Ombudsman however, they had deleted their sent items therefore, unable to provide the requested list. On 7/16/2026 at 3:20 PM, a policy was requested from the facility related to notification however, it was not received by the end of survey. R134 A review of R134's medical record revealed R134 was admitted on [DATE] and discharged on 6/9/26. Further review of 134's medical record noted an undated interdisciplinary team meeting which addressed R134's request to be discharged from the facility. R134's medical record did not reveal notification to the state ombudsman of the discharge. On 7/16/2026 at 3:20 PM, a policy was requested from the facility related to notification however, it was not received by the end of survey.

Based on observation, interview, and record review, the facility failed to provide showers per resident preference for one resident (R128) out of three reviewed for Activities of Daily Living (ADLs) findings include:On 7/14/2026 at 9:39 AM, R128 was observed sitting in a geriatric chair (geri-chair). R128 was asked about their stay in facility and if they had any concerns. R128 was noted to be nonverbal and was making circular motions with their hands on their body and pointing outside their room. They then used their communication board and pointed to a picture of a shower. R128 was asked if they wanted a shower, and they gave a thumbs up. R128 was asked if they knew their shower days, or the last time they received a shower and they shrugged their shoulders (indicating they were unsure). A review of the tasks noted R128 scheduled shower days were Monday and Thursday evenings (3:00pm-11:00pm). Further review of the last 30 days of shower documentation revealed R128 had documented bed baths, not showers for the last thirty days. Review of the care plan noted the following, Focus: I'm also resistive to ADL care, showers and getting out of bed frequently. Revision on 5/18/2026. Interventions/Tasks: BATHING-. I require total assistance to take baths/showers 2x week. On days that I may refuse please re-approach x3. Offer alternate days or bed baths. Document and notify nurse of all refusals. Revision on 9/9/2023. A review of the last 30 days of progress notes did not reveal any refusal of showers.On 7/16/2026 at 2:30 PM, an interview was conducted with the Director of Nursing (DON) who reported R128 usually prefers bed baths, will refuse to get in the shower, and would only allow one certified nursing assistant (CNA) to give them a shower, but that CNA no longer works on that side of the facility. The DON stated it has always just been an assumption that R128 wanted only bed baths. A review of a facility policy titled, Activities of Daily Living noted the following, .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

This citation pertains to Intake: 3008257.Based on interview and record review, the facility failed to report an injury of unknown origin to the State Agency (SA) for one resident (R901) of three reviewed for reporting of alleged violations. Findings include: A review of documentation submitted to the SA revealed R901 had sustained an ankle fracture of unknown origin, and the Nursing Home Administrator did not report it to the SA stating it occurred during care.A review of R901's medical record revealed they were admitted into the facility on [DATE] with diagnoses which included, Dementia, Metabolic Encephalopathy, and Anemia. Further review revealed the resident was severely cognitively impaired and required two-person assistance for transfers and bed mobility.Further review of the medical record revealed x-ray results dated 5/5/26 revealed R901 had sustained a left ankle fracture. A progress note: 5/5/2026 19:31 IDT (interdisciplinary team) Review .Resident is currently on hospice services with diagnoses of osteoarthritis and degenerative joint disease (DJD). Resident noted to have a confirmed ankle fracture with no observed or reported trauma consistent with a fall. Resident is alert to self only, limiting ability to provide reliable history regarding incident. Interdisciplinary team-initiated investigation. Review of recent documentation, staffing reports, and incident logs revealed no witnessed falls or reported injuries. No environmental hazards identified in resident room or common areas at time of review. Staff interviews completed with no concerns voiced regarding recent fall or injury event .On 5/12/26 at 10:57 AM, a request was made to review Facility Reported Incident (FRI) documentation submitted to SA. The Nursing Home Administrator (NHA) explained a FRI had not been submitted, and a Past Non-Compliance (PNC) had been completed as a result.A review of the PNC revealed a compliance date of 5/6/26, however, there was no documentation the FRI had yet been submitted to the SA.A review of the facility's Abuse, Neglect, and Exploitation policy revealed the following, .VII. Reporting/Response A. The facility will implement the following:1. Reporting of all alleged violations to the facility Administrator (Abuse Coordinator) immediately after ensuring resident safety. 2. Reporting of all alleged violations to the state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 05/05/25 between 7:15 AM-7:45 AM, during an initial tour of the kitchen, the following items were observed: In the walk-in cooler, there was a large piece of cardboard on the floor underneath the rack holding the milk crates. The surface of the cardboard was covered with a spotty, black mold-like substance. In addition, there was an opened 1 gallon container of Italian dressing with a use-by date of 4/28. According to the 2017 FDA Food Code section 4-101.19 Nonfood-Contact Surfaces, NonFOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or that require frequent cleaning shall be constructed of a CORROSION-RESISTANT, nonabsorbent, and SMOOTH material. According to the 2017 FDA Food Code section 6-101.11 Surface Characteristics, (A) Except as specified in (B) of this section, materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: .(3) Nonabsorbent for areas subject to moisture such as food preparation areas, walk-in refrigerators, warewashing areas, toilet rooms, mobile food establishment servicing areas, and areas subject to flushing or spray cleaning methods. The ice scoop holder located in the dining room was observed with a black, slimy gel accumulated on the bottom inside surface. The tip of the ice scoop was resting in the slimy gel. According to the Food & Drug administration (FDA) 2017 Model Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not potentially hazardous (time/temperature control for safety food) . On 05/05/25 at 7:50 AM, when queried about the moldy cardboard in the walk-in cooler, Food Service Manager (FSM) H stated it would be removed right away. When shown the soiled ice scoop holder, FSM H stated it would be cleaned right away. On 05/05/25 at 7:30 AM, there were individual covered bowls of oatmeal (approximately 45 bowls) on a tray next to the steam table . The oatmeal was not being held hot. On 05/05/25 at 8:00 AM, there were 6 bowls of oatmeal left on the tray, to be served to the last few residents for breakfast. The internal temperature of the oatmeal was measured to be 125 degrees Fahrenheit. When queried, FSM H provided no explanation as to why the oatmeal was not being held at 135 degrees Fahrenheit or above. According to the 2017 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding, 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be maintained: 1. (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; P.

Based on interview and record review, the facility failed to complete monthly medication regimen reviews (MRRs) and follow up physician notification of pharmacy recommendations for four residents (R62, R68, R73 and R105) of five reviewed for unnecessary medications. Findings include: R105 A review of R105's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Dysphagia, Peripheral Vascular Disease, and Anxiety. Further review revealed the resident was cognitively intact and independent for transfers and bed mobility. Further review of R105's medical record revealed a missing medication regimen review for July 2024. In addition, the dates of: 11/20/24, 12/27/25, and 3/15/25 noted the following, [x] See report for any noted irregularities. On 5/6/25 at 1:40 PM and 2:14 PM, and again on 5/7/25 at 8:30 AM, R105's July MRR and irregularities reports were requested from the facility however, they were not received by the end of this survey. 32220 R62 A review of the record for R62 revealed R62 was admitted into the facility on [DATE] with a readmission on 11/06/24. Diagnoses included Schizoaffective Disorder, Biploar Disorder and Insomnia. A review of the pharmacy medication regimen reviews revealed the review for July 2024 had not been completed. R68 A review of the record for R68 revealed R68 was admitted into the facility on [DATE]. Diagnoses included Dysphagia (Difficulty Swallowing) and Alzheimer's. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition, substantial/maximal assistance was needed for eating. A review of the pharmacy medication regimen reviews revealed the review for July 2024 had not been completed. R73 A review of the record for R73 revealed R73 was admitted into the facility on [DATE] with a readmission on 01/21/25 and 03/14/25. Diagnoses included Heart Failure, Kidney Disease and High Blood pressure. A review of the pharmacy medication regimen reviews revealed the review for July 2024 had not been completed. On 5/7/25 at 2:28 PM, the Director of Nursing (DON) was asked about the missing MRRs and confirmed they never received the July MRRs. Regarding the irregularity reports, they explained they were unsure of what occurred as they had been provided to the unit managers upon receipt. A policy and procedure for pharmacy services related to pharmacy reviews was requested via email on 05/07/2025 at 12:46 PM, but not received prior to survey exit.

Based on interview and record review, the facility failed to ensure a Change in Condition level one screening Form DCH (Department of Community Health/3877) was submitted to the local Community Mental Health Services Program (CMHSP) for a level two OBRA (Omnibus Budget Reconciliation Act) evaluation upon a change in the resident's condition for two (R16 and R64) of two residents reviewed for Preadmission Screening/Annual Resident Review (PASARR). Findings include: R64 A clinical record review revealed R64 was admitted to the facility on [DATE] with diagnoses of hemiparesis following a stroke, schizoaffective disorder, anxiety disorder, and major depressive disorder. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicated an intact cognition. On 5/06/25, a review of the available PASARR form revealed a 3877 form dated 4/18/24 and it was completted as a change of condition with no noted follow up. There was no evidence of R64 being referred for a level II evaluation or evaluation completed to their diagnoses of mental disorders. On 5/06/25 at 9:44 AM, a request was made to the facility requesting documentation of R64's PASARR documentation (Level II evaluation/3878-dementia exemption). On 05/07/25 at 9:30 AM, an interview with completed with Social Worker B regarding R64 and the incomplete [NAME] II screen. Social Worker B confirmed the level II was not done. On 05/07/25 at 12:30 PM, an interview occurred with the Nursing Home Administrator (NHA) regarding expectations for the PASARRs and [NAME] II screens. The NHA stated the expectation is that PASARRs' and level II evaluations should be completed timely per policy. 40384 R16 A review of R16's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Major Depressive Disorder, Generalized Anxiety Disorder, and Spinal Stenosis. Further review revealed the resident was cognitively intact and required one person assist for bathing. Further review of the medical record revealed an active physician order dated 3/12/25, Cymbalta (anti-depressant) Oral Capsule Delayed Release Particles 30 MG (milligrams) .Give 1 capsule by mouth one time a day. Further review of the medical record revealed a PASARR Level I Change in Condition screening form dated for 5/3/24 in which the the following questions were documented as No. 1. The person has a current diagnosis of Mental Illness or Dementia .The person has received treatment for Mental Illness or Dementia .The person has routinely receive one or more prescribed antipsychotic or antidepressant medications within the last 14 days . On 5/7/25 at 10:15 AM, Social Worker B was interviewed regarding R16's PASARR and acknowledged the form was completed inaccurately. On 5/7/25 at 2:28 PM, the Director of Nursing (DON) was asked about social work services and acknowledged the need for additional social workers in the facility. A review of the facility's Resident Assessment-Coordination with PASARR program revealed the following, 5 .a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or related condition to the appropriate state designated authority for Level II PASARR evaluation and determination.

Based on interview and record review, the facility failed to initiate a Post-Traumatic Stress Disorder (PTSD) care plan for one resident (R87) of two reviewed for care plans. Findings include: A review of R87's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Cerebral Infarction, Heart Failure, and Major Depressive Disorder. Further review revealed the resident was cognitively impaired and required one person assistance for bathing and dressing. Further review of R87's medical record revealed two Omnibus Budget Reconciliation Act (OBRA) evaluations (A document that records the results of the in-person evaluation used to assess a person's need for specialized services). Both evaluations were completed in 2024 and 2025 noted the resident was diagnosed with Post-Traumatic Stress Disorder. Further review of R87's medical record revealed a care plan which did not address R87's diagnosis. On 5/7/25 at 10:15 AM, Social Worker B was asked about the missing care plan for R87's diagnosis and acknowledged that it should have been added. On 5/7/25 at 2:28 PM, the Director of Nursing (DON) was asked about social work services and acknowledged the need for additional social workers in the facility. A review of the facility's Comprehensive Care Plan policy revealed, .4. If the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable .

Based on interview and record, review the facility failed to update interventions on a psychiatric care plan for one resident (R95) of two residents reviewed for care plans. Findings include: On 5/5/25 at 1:57 PM, an observation was made of R95 lying in their bed, awake, yelling, screaming, and swearing. A review of R95's electronic medical record (EMR) revealed R95 was admitted to the facility on [DATE] with diagnoses that included Mood disorder and Major Depressive disorder. R95's most recent minimum data set assessment (MDS) dated [DATE] revealed R95 had a moderately impaired cognition with no mood indicators listed on the assessment. A review of R95's orders revealed that R95 was prescribed the following: Remeron (treament for depression) Oral Tablet 15 mg (milligrams) Give one tablet by mouth at bedtime for mood. A review of R95's care plan revealed the following psychiatric care plan goal/intervention: Focus: I use antidepressant medication r/t (related to) Depression .Interventions/Tasks: I am followed by [Psychiatric provider agency] for psychoactive medication. Date Initiated: 6/10/22. On 5/7/25 at 3:01 PM, Social Worker B was interviewed regarding psychiatric treatment services provided for R95 and R95's care plan and interventions were reviewed with Social Worker B. Social Worker B indicated the psychiatric service provider agency listed on R95's care plan no longer was involved with R95's treatment. Social Worker B was asked if R95's interventions listed on their psychiatrc care plan should be updated to reflect current treatment practices. Social Worker B indicated the interventions should be updated. On 5/7/25 at 3:15 PM, the Director of Nursing (DON) was interviewed regarding their expectations for updating of interventions on care plans and confrimed interventions should be updated when needed. A review of a facility policy titled, Care Planning Date Reviewed/Revised: .6/24 was reviewed and did not address the updating of interventions when care planning.

Based on interview and record review, the facility failed to obtain a gastroenterology and infectious disease consultation for one resident (R105) of one reviewed for consults. Findings include: A review of R105's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Dysphagia, Peripheral Vascular Disease, and Anxiety. Further review revealed the resident was cognitively intact and independent for transfers and bed mobility. A review of R105's medical record revealed the following progress note: Physician Progress Note: 5/30/2024 14:55 (2:55pm) Practitioner Progress Notes. Chief complaint: Hepatitis C and preventive screening .[R105] with PMH (previous medical history) of polysubstance abuse, Hepatitis C, Hepatitis B, COPD (chronic obstructive pulmonary disease), severe protein calorie malnutrition, hepatitis, alcoholism, diabetes, insomnia, sinusitis, and thyroid disease. Resident seen today to discuss chronic disease management, specifically [their] hepatitis C. [R105] has a history of polysubstance abuse and states [they were] told 'a long time ago' that [they have] hepatitis C but [they do] not believe [they had] ever been treated for it. We also discussed colonoscopy recommendations and GI (gastrointestinal) follow up to which [they] is agreeable. Further review of the medical record revealed the following two active orders: CONSULT to gastroenterology [physician] for colonoscopy/routine colorectal cancer screening. [Digestive Facility]. This order was dated 6/6/24. CONSULT to [physician] for evaluation and management of chronic hepatitis c. History of polysubstance abuse. This order was dated 5/30/24. On 5/6/25 at 2:40 PM, the Director of Nursing (DON) was asked about the missing consults and acknowledged they had not been followed through on. A review of the facility's Physician Orders and Clarification Orders did not address carrying out physician orders.

Based on observation, interview, and record review, the facility failed to ensure a supra-pubic catheter (SP- catheter inserted via an incision through the abdomen into the bladder) urinary catheter was changed timely for one resident (R73) of one resident reviewed for catheter care. Findings include: R73 On 05/06/25 at 9:01 AM, R73 was observed to be seated in a wheelchair. The urinary catheter tubing was observed to be coiled up on the right thigh with the connection point to the drainage bag visible. The tubing appeared faded and soiled with areas of black along the length of the visible tubing. On 05/06/25 at 10:18 AM, the observation of the urinary catheter was reviewed with Licensed Practical Nurse (LPN) E'. LPN E reported R73 had a supra-pubic catheter and they believed R73 was out regularly to the urologist and had been out to the hospital recently. A review of the record revealed the last urology appointment was on 02/05/24, in which the physician documented related to the urinary catheter .ECF(extended care facility) to change every 6 weeks . Notes: Patient needs SP changed every six weeks with 20 F (french) 10 cc (cubic centimeters) balloon, clean stat lock weekly, and clean around the catheter, Vaseline to be applied after showering . Additional review of a hospital discharge summary dated 10/14/24 documented R73 had a urinary tract infection, R73 has had the suprapubic catheter since 2023 and the catheter was changed during the hospital stay. A review of the nephrology (kidney) doctor's notes did not document a change of the suprapubic catheter. A nephrology consult note dated 02/27/25 documented, .Urology follow up exit site for SP catheter . On 05/06/25 at 10:35 AM, R73 reported they were not sure when they last saw a urologist or had the urinary catheter changed. The drainage tube was observed to be clouded with sediment. At 10:39 AM further review with LPN E confirmed the last catheter change was not found. Further review of the record revealed orders revised 03/17/25 were for a catheter (generally inserted into the bladder via the urethra) and to use an 18 French (gauge) catheter. The timing for change was not specified. An order dated revised 01/22/25 and discontinued 03/11/25 documented the catheter as a suprapubic catheter and the size to be an 18 french. On 05/06/25 at 2:09 PM, the unit manager, LPN F for R73 reported a conversation with the urologist about when the next follow up was needed and it was not indicated at this time. On 05/07/25 at 9:15 AM the physician for R73, Physician G reported there was no real time frame, but generally a resident with a suprapubic catheter is out to the urologist monthly to have it changed and it was not usually done by the facility. On 05/06/25 at 5:30 PM and on 05/07/25 at 1:52 PM, the Director of Nursing (DON) was asked for documentation of the catheter changes that had been completed and reported they would look into it. The DON had reported they were not able to provide additional documentation. No further documentation of any suprapubic catheter changes for R73 was provided prior to survey exit. A review of the record for R73 revealed R73 was admitted into the facility on [DATE] with a readmission on 01/21/25 and 03/14/25. Diagnoses included Heart Failure, Chronic Kidney Disease and High Blood pressure. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition and the need for partial/moderate assistance with toileting hygiene. Hospital discharge information for the readmissions was not found in the electronic medical record. A review of the catheter information provided from the book Physiological Basis for Nursing Practice did not address the timing for change of the suprapubic catheter. A review of the facility policy titled, Physician Orders and Clarification Orders dated 12/01/21, revealed, .The clarification order is needed to initiate treatment according (to) the plan of care .

Based on observation, interview, and record review, the facility failed to ensure one delayed release medication and two extended release medications were not crushed prior to administration and a cranberry tablet dosage was correctly administered out of 33 medications observed, resulting in a medication error rate of 12.12%. Findings include: On 05/07/25 at 9:29 AM, a medication pass observation for R68 was conducted with Licensed Practical Nurse (LPN)C. The following medications were prepared, crushed and placed into applesauce: Aspirin 81 mg (milligrams) tablet one time a day, Megestrol 400 mg/10ml, liquid, 10 ml (milliliters) two times a day; Zunveyl (Benzgalantamine Gluconate) Oral Tablet Delayed Release 10 mg two times a day; Loratadine 10 mg one time a day; Cranberry 400 mg tablet one time a day, (450 mg tablet given); Losartan 100 mg tablet in the morning; Metoprolol succinate 100 mg ER (extended release) tablet; Amlodipine 5 mg tablet in the morning; and Klor-con potassium ER 20 MCG (micrograms) tablet one time a day. The Zunveyl was for Alzheimer's and the Metoprolol was for blood pressure control. The observation was noted to the Director of Nursing (DON) at this time and the DON acknowledged the error concern. On 05/07/25 at 1:54 PM, Nurse Practitioner D reported the delayed release and extended release medications should not be crushed. The Nurse Practitioner further noted they had not been made aware these medications were being crushed. A review of the record for R68 revealed R68 was admitted into the facility on [DATE]. Diagnoses included Dysphagia (Difficulty Swallowing) and Alzheimer's. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition, substantial/maximal assistance was needed for eating and a mechanically altered diet (ground/minced) for food was required. A review of the facility policy titled, Medication Crushing Guidelines dated June 2019, revealed, .The solid dosage forms of many medications should not be crushed for a variety of reasons . Timed release tablets are designed to release over a sustained period, usually 8-24 hours. These formulations are designed to reduce stomach irritation in some cases and to achieve prolonged medication action in other cases. In either case these tablets should not be crushed .

Based on interview and record review, the facility failed to timely issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF/ABN - notice informing of pay charges) for one resident (R73) of three reviewed for beneficiary notification. Findings include: An ABN list provided by the facility revealed R73 had a Medicare Part A discharge date of [DATE] and remained living in the facility. Review of the notices provided by the facility for R73's revealed there was no SNF/ABN notice issued to R73's resident and/or representative (RR) informing them of the potential pay charges for continued services at the facility. On 5/7/25 at 12:30 PM, Business Office Manager A (BOM) was interviewed regarding the missing SNF/ABN notice for R73 and indicated it was an oversight (R73's RR did not recieve notice) . On 5/7/25 at 1:02 PM, the Administrator was interviewed regarding their expectation for beneficiary notification and comfirmed they should be issued timely.

Based on observation, interview, and record review, the facility failed to ensure water was accessible for one resident (R115) of one resident reviewed for accommodation of needs. Findings include: On 5/5/25 at 8:02 AM, R115 was observed in their room in bed with their water cup being out of reach on their dresser. R115 was interviewed and asked about the accessibility of their water cup and indicated they could not reach it and did not want to get up to get it because they didn't want to fall. On 5/7/25 at 10:27 AM, an observation was made of R115 having no water cup. R115 was observed to be in their room in bed. R115 was interviewed and asked about the location of their water and indicated that someone had come into their room and taken it. R115 was asked if they felt thirsty and stated, sometimes. On 5/7/25 at 1:30 PM, the Director of Nursing (DON) was interviewed about their expectations regarding accessibility of fresh water for residents when in their rooms and indicated fresh water should be available. A record review of R115's electronic medical record (EMR) revealed that R115 was admitted to the facility on [DATE] with diagnoses that included Cerebral palsy (congenital disorder of movement, muscle tone, or posture) and Difficulty in walking. R115's most recent minimum data set assessment (MDS) dated [DATE] revealed that R115 had a moderately impaired cognition and required setup help-substantial assistance for all activities of daily living (ADLs) other than eating. A review of R115's care plan revealed that R115 was at risk for falls and dehydration and had interventions on their care plan to prevent falls and monitor for signs and symptoms of dehydration. On 5/7/25 at 10:35 AM, a facility policy regarding accommodation of needs related to provision of water for residents was requested and not received prior to survey exit.

This citation has two deficient practice statements. Deficient practice number one. This citation pertains to Intake MI00059836. Based on observation, interview, and record review, the facility failed to protect one resident from physical abuse from staff (R800) out of three reviewed for abuse, this deficient practice resulted in an Immediate Jeopardy (IJ) and the likelihood for serious physical and /or psychosocial harm, injury, impairment, or death. Findings include: R800 A review of Facility Reported Incident (FRI) noted the following, On April 3, 2025, Abuse coordinator made aware of an abuse allegation by DON [Director of Nursing] .around 10AM. [DON] stated, while rounding the A-wing unit, [R800] stated [they] was slapped by [their] midnight nurse. [R800] BIM [Brief Interview for Mental Status] score of 15, who also locomotes freely within the facility with a wheelchair. Around ten am, [R800] reported to the DON that a midnight nurse slapped [their] arm during care. The employee was immediately suspended, pending investigation . On 4/16/2025 at 10:12 AM, an interview was completed with R800 regarding the incident with Licensed Practical Nurse (LPN) E on 4/3/2025. R800 reported they were having a bowel movement and LPN E took their wheelchair so they could not go to the bathroom. R800 reported LPN E was very mean to them and would not let them use the bathroom. R800 reported LPN E told them to shut the f*** up and was calling them names. R800 reported LPN E then slapped them in the arm twice. R800 reported another person (Certified Nurse Assistant (CNA) C, was in the room with them and tried to tell LPN E to stop, but they did not listen. R800 reported the other person in the room left, and they were in there with LPN E until their assigned nurse came back, and subsequently went to the hospital. R800 indicated nothing like that ever happened to them in the facility before and they felt embarrassed about the whole situation. R800 reported they do not feel safe in the facility at this time. A review of the medical record revealed R800 was admitted into the facility on [DATE] with the following medical diagnoses, Dysphagia and Weakness. A review of the Minimum Data Set (MDS) assessment revealed Brief Interview for Mental status (BIMS) score of 15/15 indicating an intact cognition. R800 also required staff assistance with bed mobility and transfers. On 4/16/2025 at 3:06 PM, a phone interview was conducted with LPN D. LPN D reported R800 was having diarrhea, throwing up, and sweating profusely. LPN D reported LPN E came to sit with R800 along with CNA C, while they prepared the paperwork to send them out to the hospital. LPN D reported while they were at the nurses' desk when CNA C walked by and said they were not going to be involved with what LPN E had going on. LPN D reported CNA C did not report anything else to them and they were focused on getting everything together for R800's transfer to the hospital. LPN D reported after they were done getting R800's transfer together, they went back in the room with LPN E and R800. LPN D indicated the whole event started approximately around 2:00 AM until 3:00 AM when R800 left the facility. LPN D reported that after R800 left the facility, LPN E went back to their set and continued working their assigned residents until the end of their shift. Further review of CNA C witness statement dated 4/11/2025 noted the following, On the morning of 4/3/2025 .R800 threw himself to the floor. We placed him back on the toilet. That's when LPN E started yelling and told R800 if you have to s*** then take a s***. [LPN E] was speaking loudly, very loud. R800 yelled saying [they] were sick, after that [LPN E] took [their] right hand and slapped [R800] on [their] left arm two times. I told [LPN E] to stop and [LPN E] yelled at me, got in my face, and was very aggressive. I ran out the room and told [LPN D] that [LPN E] was 'tripping' .I called the Administrator immediately and I texted the DON at 7:00 AM when I got off work. On 4/16/2025 at 12:35PM, an interview was conducted with the DON. The DON reported that they were informed about the incident around 7:30AM-8:00AM on April 3rd, when they came in the facility. The DON reported when they came in the facility R800 was also coming back in from their hospital visit. At 12:55, an interview was conducted with the Nursing Home Administrator (NHA). The NHA reported they were informed about the incident around 10:00 AM from the DON when they were completing room rounds. The NHA reported they informed Human Resources, and they called and suspended LPN E. The NHA reported they called the police, reported the incident to the State Agency (SA) and began their full investigation. The NHA reported that LPN E did continue to work their entire shift following the incident and was suspended the following morning. Further review of incident submitted to State Agency on 4/3/2025 at 11:49 AM, the abuse was substantiated. The Immediate Jeopardy (IJ) started on 4/3/2025 and was identified on 4/16/2025. The Nursing Home Administrator (NHA) was notified of the IJ on 4/16/2025 at 3:35 PM and was asked to submit a plan to remove the immediacy. The IJ was removed on 4/17/2025, based on the facility's implementation of the removal plan as verified onsite. Although the immediacy was removed on 4/17/2025, the facility's deficient practice was not corrected and remained isolated with actual harm. Removal Plan: 1. Identification of Residents Affected or Likely to be Affected: o On 4/16/25 the DON and designee(s) interviewed/assessed residents with BIMS scores of 8 and above for potential abuse. Residents with BIMs below 8 were assessed by a license nurse for an acute change in condition. Concerns were/were not identified. o On 4/16/25 Social Services completed a supportive visit with R800. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. o LPN E was suspended pending investigation on 4/3/25 and has not returned to the facility. o On 4/4/25, the Abuse, Neglect and Exploitation policy was reviewed by the Administrator and deemed appropriate. o Beginning on 4/16/25, the Administrator/designee re-educated all staff on the Abuse, Neglect and Exploitation policy, highlighting the requirement to notify the Abuse Coordinator (Administrator) immediately with all abuse allegations. No staff member will be permitted to work until re-education is received. o The facility Medical Director was notified of this event on 4/16/25. o Facility IDT Team held an ADHOC QAPI meeting on 4/16/25. o From the abuse policy all staff were educated all on: VI. Protection of Resident o The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: o A. Responding immediately to protect the alleged victim and integrity of the investigation; o B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; o C. Increased supervision of the alleged victim and residents; o D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; o E. Protection from retaliation; o F. Providing emotional support and counseling o CENA that left the room, was provided 1:1 education regarding not to leave resident alone with abuser and the LPN assigned to the resident was provided 1:1 education to immediately report allegations of abuse and remove abuser as well and the educations received will be added to both their employee files. o Facility IDT Team conducted an audit on all residents for their Safety/ Abuse on 4/16/25. Any negative findings will be Immediately corrected. o All findings will be taken to QAPI on 5/8/25 to follow up/ track for any systematic changes that may be needed. Deficient practice number two. This citation pertains to Intake MI00152184. Based on observation, interview and record review, the facility failed to protect one resident (R801) from physical abuse by another resident (R802) out of three reviewed for abuse. Findings include: A review of Facility Reported Incident (FRI) noted the following, .Around 10 AM, [Receptionist A] communicated that while both residents were in the lobby, [R802] walked up to [R801] and slapped [them] in the face . A review of the medical record revealed R801 was admitted into the facility on [DATE] with the following medical diagnoses, Cerebral Infarction and Anxiety Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15, indicating an impaired cognition. R801 also required assistance with bed mobility and transfers. A review of the medical record revealed R802 was readmitted into the facility on [DATE] with the following medical diagnoses, Schizoaffective Disorder and Bipolar Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 10/15 indicating an impaired cognition. R802 also required staff assistance with bed mobility and transfers. On 4/16/2025 at 11:14 AM, an interview was conducted with R801. R801 did not recall the incident and stated they did not have a problem with anyone in the facility. On 4/16/2025 at 11:52 AM, an interview was conducted with Receptionist A. Receptionist A reported the incident occurred at approximately 9:05 AM and R802 was already in the lobby. Receptionist A reported R801 was sitting on one couch and R802 was sitting opposite of them on another couch. Receptionist A reported R802 got off the couch, walked towards R801 and slapped them in the face. Receptionist A reported they went over to R802 and informed them they could not put their hands on anybody to which R802 stated they will do it again. Receptionist A reported R802 then walked away and they (the receptionist) went and told the Nursing Home Administrator (NHA) what they witnessed. On 4/16/2025 at 12:04 PM, an interview was conducted with the Social Service Director (SSD) B. SSD B stated Receptionist A came in morning meeting and told the NHA about the incident. The SSD reported they asked R802 did they slap R801?, and the resident confirmed they did and will do it again. At 1:04 PM, an interview was conducted with the NHA. The NHA reported R802 was sent to in patient psychiatric and has not returned since the incident. A review of a facility policy titled, Abuse, Neglect, and Exploitation Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.

This citation pertains to Intake MI00151378. Based on interview and record review, the facility failed to honor the rights, notify, or obtain consent from a Durable Power of Attorney (DPOA) regarding a resident discharge for one resident (R504) of three sampled residents reviewed, resulting in the released to an unauthorized family member. Findings include: R504 R504's Electronic Medical Record EMR was reviewed on 4/8/25 at 11:30 AM. R504 was admitted to the facility on [DATE] with the diagnosis of Cervical Disc Disorder, Type 2 Diabetes Mellitus, and Carcinoma of the Prostate, in addition to other diagnoses. R504's Brief Interview for Mental Status (BIMS) Score dated 1/15/25, assessed by the facility, was 6/15. A BIMS score of 6 indicates severe cognitive impairment. R504 Minimum Data Set (MDS) assessment dated [DATE] revealed they are frequently incontinent with both bowel and bladder elimination patterns and requires substantial/maximal assistance with Activities of Daily Living (ADLs). A review of R504's electronic record revealed on 3/4/25, the facility discharged R504 with another family member not listed in the contact list of R504's Face Sheet to another state (Indiana). No home care, Rehab Therapy, Pharmacy, or Physician were arranged for follow-up care after R504 was discharged . According to Adult Protective Services staff member A, on 4//8/25 at 9:15 AM, during an interview by phone, the facility did not honor the resident's Durable Power of Attorney and Designated Patient's Advocate despite legal documents submitted to show evidence that R504's stepson was the legally appointed Durable Power of Attorney. As a result, R504 was released and discharged to an estranged family (birth son), who did not notify nor obtain permission from the DPOA. An interview with the Social Services Director (SSD) B was conducted on 4/8/25 at 12:15 PM. R504 was admitted in January 2025, and was their own responsible party. However, the stepson was making decisions for them. SSD B revealed she called the stepson on March 4, 2025, to update him on the plan. Because the stepson did not call back, the facility released R504 to the estranged family member (son) who showed up and presented his birth certificate as proof that he was R504's son. R504's family came to visit and decided to bring R504 home with them in Indiana; SSD B added that the facility called R504's estranged ex-wife, who was the mother of the estranged son, and confirmed that he was the birth son of R504. The SSD B indicated it was the DON and her who decided to release R504 to the birth son. SSD B confirmed not arranging home care, no physician order, no pharmacy, no DME (Durable Medical Equipment), or hospice arrangement when R504 was discharged . When asked why, SSD B explained that they took the resident to Indiana, where the son and his family live. SS'B was questioned why the signed Patient Advocacy form or the DPOA documents were not honored and replied R504 was their own responsible party and did not have a change in cognition. The Social Services Notes were reviewed. A late entry: written by SSD B dated 2/14/25 was noted. It revealed that: SW (Social Worker) informed APS (name mentioned) that the staff had tried to inform DPOA (name mentioned) of resident's medical health decline and that it would be in the resident's (R504) best interest to remain in LTC (Long Term Care) placement . R504's Designation of Advocate Form was reviewed on 4/8/25 at 1:35 PM. It specified the name and address of residence of the appointed Patient Advocate with the instructions: My Patient Advocate may only act if I am unable to participate in making decisions regarding my medical treatment. My Patient Advocate shall have the authority to make all decisions and to take all actions regarding my care, custody, and medical treatment . This document is to be treated as a Durable Power of Attorney for Health Care and shall survive my disability or incapacity . If I am unable to participate in making decisions for my care and there is no Patient Advocate able to act for me, I request that the instructions I have given in this document be followed and that this document be treated as conclusive evidence of my wishes . I am providing these instructions of my free will. I have not been required to give them in order to receive or have care withheld or withdrawn . Signed by R504 on October 17, 2024, with two witnesses and acknowledged by the designated by the appointed Patient Advocate on 10/18/2024. An interview with the Director of Nursing (DON) was conducted on 4/8/25 at 2:59 PM. The DON revealed that on 3/8/25, R504's family (birth son and granddaughters) came to visit R504. They have been estranged for over 5 years. The son came in and presented a Birth Certificate, and the estranged son's mom (R504's ex-wife) confirmed the family in possession of the birth certificate was their son together over the phone. When the DON was asked how she verified the ex-wife's identity, she said she did not. When the DON was asked if R504's son or ex-wife was on R504's contact list, She stated, No. The Administrator was interviewed on 4/8/25 at 3:16 PM. He stated that R504 had not changed from their baseline since admission, so there was no indication to change anything. The Power of Attorney papers were for Financial POA, not medical decisions.

This citation pertains to Intakes: MI00139923, MI00139924, MI00138212. Based on observation, interview, and record review, the facility failed to ensure the safety and prevent an elopement for one resident (R905) who has a legal guardian, and is incapable of making safe decisions. R905 eloped from the facility which is located on a busy four lane intersection on 7/25/2023 between 12:00pm and12:30pm without the facility staff being aware of the resident's whereabouts for approximately one hour. R905 was allowed to exit the facility by a visitor between 12:00-12:30pm on 7/25/23. R905 exited through the front door which requires a code to enter/exit. R905 walked toward their home of origin, which is approximately 2 miles away, and admitted ly got into the car of an unknown male who drove them the remainder of the way. R905 attempted to enter their old home, and the local police department was contacted by the owner. The local police notified the facility to inform them that they had the resident in their custody at approximately 1:28pm. R905 was returned to the facility at approximately 1:45pm. This resulted in an Immediate Jeopardy (IJ) to the safety and health to the residents in the facility and the likelihood for serious harm, injury, or death. Immediate Jeopardy: The Immediate Jeopardy (IJ) started on 7/25/23 and the immediacy was removed 7/26/23 per review of the facility's responding interventions as verified on 1/19/24. The IJ was identified on 1/18/24 during an abbreviated survey. The facility was notified of the IJ on 1/18/24 at 2:52pm and was asked for a removal plan. The IJ was removed on 7/26/23, based on the facility's implementation of the removal plan as verified onsite on 1/19/24. Findings Include: A review of R905's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Bi-Polar Disorder, Unspecified Psychosis, Adjustment Disorder with Anxiety, Vascular Dementia, and Hypertension. Further review revealed that the resident was cognitively intact, and was independent for activities of daily living. Further review of R905's medical record revealed an elopement risk assessment dated [DATE] indicating that the resident was at risk for elopement. Further review of R905's medical record revealed the following progress notes: 6/28/2023 13:23 (1:23pm) Social Service Progress Note Note Text: Resident continues to come to SS (social services) office to state [they are] leaving the building, resident has a wander guard related to [them] being a elopement risk. [R905] is re-directed from the door. Unit manager aware that resident has been sitting in the front lobby, [R905] is monitored related to [them] verbalizing [they want] to leave the building. Resident has a Guardian in place. 7/20/2023 14:50 (2:50pm) Nursing Progress Note Note Text: writer noted that wander guard was not in place at this writing, patient would not give location of wanderguard or how it was removed, unit manager notified, no replacement not available at this this time per unit manager. 7/25/2023 18:54 (6:54pm) Nursing Progress Note Note Text: Resident had left the building looking to go to [their] house. Responsible party notified, Physician notified, Administrator notified, DON (Director of Nursing) notified. Immediate intervention implemented: resident has 1:1 Staff supervision. 7/25/2023 18:44 (6:54p) Nursing Progress Note Note Text: Event occurred on 07/25/2023 2:00 PM. Resident was outside of the building and had a fall after trying to go to [their] house . Physician and responsible party notified. On 1/17/24 at 1:40 PM, R905 was observed in their room sitting on their bed, and was asked about the day they left the building, and were returned by the police. R905 explained that they were in the lobby, and exited out the front door as a visitor was entering the building. R905 explained that they began walking to their home and ultimately fell which was witnessed by an unknown male who offered to drive them to their home. R905 explained that they did not know the driver but willingly got into the car so that they could drive them to their residence. R905 explained that upon arriving at their home, there was someone inside the home that was there illegally and would not allow them to enter. R905 explained that as a result of not being allowed inside the home, they walked across the street to speak with the neighbors. R905 explained that the police arrived, and transported them back to the facility. R905 explained that they should not be residing the facility and needs an attorney to get the woman living in their home out. R905 was asked if they had spoken to their guardian about concerns with the facility and wanting to discharge, and they stated, I don't have a guardian. A review of the local police department's police reports dated, and time stamped for 7/25/23 at 12:58pm revealed the following, Spoke to caller [identifying information] who resides at [R905's previous address]. [caller] stated the [R905] attempted to gain entry into [their] house. Located the subject across the street and [R905] was identified as listed [R905]. [R905] used to reside there as listed on [their] driver's license. [R905] also had a [nursing facility] card on [their] person. Dispatch confirmed that [R905] was a walk away from there. We transported [R905] back and turned [them] over to [facility staff] . A review of the facility's investigation revealed that the R905 was last seen by facility staff, Nurse G between 12:00pm-12:30pm on 7/25/23, and that the facility received a call from the local police at 1:28pm informing them that R905 was in their custody. R905 returned to the facility at 1:45pm with a scraped knee and forearm due to the fall they sustained while walking. On 1/18/24 at 10:43 AM, Social Worker F was asked about R905's elopement risk and current behaviors. Social Worker F explained that R905 had a guardian in place prior to their admission into the facility, and that the guardian has spoken to the resident and explained that their home has been sold, and they cannot return there. Social Worker 'F explained that R905 has mental health concerns, and had made comments about leaving which is why they were considered a resident that staff needed to watch. Social Worker F was asked about R905 removing their Wander Guard, and explained that R905 had removed their Wander Guard at least 3 times that she is aware of. A review of R905's medical record revealed the following Elopement Care Plan: Focus: I am at risk for elopement r/t (related to) the fact that I refuse to wear a Wander Alert and my efforts to exit the facility independently. I frequently say that I am leaving the building and I am going to call the police. I am high functioning, ambulate independently and have the potential to present as a visitor. I do not take medications that have been prescribed to me. I have the potential to remove my wanderguard device. I am required to be re-directed away from the front door for safety. Date Initiated: 06/08/2022. Revision on: 08/03/2023 . Interventions: -Document any behaviors I exhibit in POC. Date Initiated: 02/22/2022. -Educate resident/family/friends on LOA (leave of absence) procedure Date Initiated: 08/07/2022. -Elopement risk assessment on admission, then quarterly and PRN (as needed). Date Initiated: 02/22/2022 do not have a wanderguard device on my ankle. Please notify the NHA (nursing home administrator) if I require a replacement band. Right now, I have increased supervision to keep me safe from elopement. Date Initiated: 08/02/2023. -I need direct supervision while outside the facility. Date Initiated: 08/07/2022. -Increase supervision from staff to assist in keeping me safe from the potential harm that could result as a result of my wandering. Date Initiated: 07/25/2023. -Notify the DON or designee if I remove my wanderguard device. Date Initiated: 07/25/2023 -Place information in the elopement book per policy. Date Initiated: 08/07/2022 . On 1/18/24 at 11:10 AM, an interview was conducted with the NHA regarding R905 eloping from the facility, and she explained that R905 exited out of the front door, which is equipped with a Wander Guard alarm, and requires a code to exit out of the facility. The NHA explained that the Ombudsman held a resident council meeting and informed the residents that they can leave whenever they want to, and R905 felt as though this applied to them. The NHA was asked about the increased supervision and monitoring of R905 who was a known elopement risk and had previously removed their Wander Guard. The NHA explained that the resident was a part of the facility's elopement program, which means that staff is aware that they are an elopement risk, observations are made if a resident is approaching doors, and that they are placed in the elopement book. On 1/18/24 at 1:43 PM, the DON was asked about R905 eloping from the facility, and she explained that she was new in her role at that time, and could not speak to what monitoring and supervision was in place for the resident, but that they have implemented interventions for R905 who has not eloped from the facility since July 2023. The DON was asked about the progress note on 7/20/23 indicating that R905 had taken off their Wander Guard, and that there were none available to replace it. The DON explained that that is not true, and that it was a poorly written progress note, and that another Wander Guard had been provided to the resident after that date, which they had taken off and threw it in the trash. A review of the facility's Elopements and Wandering Residents policy was reviewed and revealed the following, Policy: This facility ensures that residents who exhibit wandering behavior and/or are risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing unique factors contributing to wandering or elopement risk .5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing intervention to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . Facility Removal Plan: The facility provided the following information to demonstrate that the immediacy of the cited deficiencies has been removed; .The following plan has been implemented for compliance: Maintenance has checked doors and alarms 2x per day. Elopement drills will be conducted monthly Access codes will be changed at least once a month or as needed. An elopement assessment will be completed for all new admissions. If deemed at risk information will be added to the elopement binder. Wander alert will be checked daily. Administrator will ensure wander alerts are available. If resident is non-compliant DON or designee will be notified and appropriate individualizes interventions will be initiated to ensure safety. The IDT will review residents at risk for elopement weekly. Signs were posted on exit doors asking visitors not to assist residents out of the building and to be mindful of residents who may try to exit with them. Areas identified requiring quality improvement. An AD-HOC QAPI was held 7/26/2023. The organization's elopement policy and procedures were reviewed and deemed appropriate by the committee. Actions to prevent occurrence/recurrence The DON or designee will check the clinical dashboard daily for any new/re-admisssions identified at risk for elopement. Interventions will be initiated. Maintenance Director or designee will check doors and alarm weekly and report any concerns to the Administrator. Maintenance Director will change access codes and conduct elopement drills monthly Social Services will review the Elopement binders weekly for 4 weeks to ensure accuracy. Administrator will ensure extra wander alerts will be available for residents deemed at risk and needing the alert. New hires will be in-serviced on the Elopement policies and procedures. Negative findings from the audits will be addressed immediately. Results will be brought to QAPI for review and recommendations. Administrator will be responsible for sustained compliance. Date of compliance: 7/26/23

This citation has three deficient practices. Deficient Practice Statement number 1. Based on observation, interview, and record review, the facility failed to appropriately assess and recognize skin alterations for one resident (R28) of four reviewed for quality of care, resulting in the development of untreated wounds, acute osteomyelitis, and toe amputation. Findings include: A review of R28's medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on [DATE] and most recently readmitted from the hospital on 11/18/22. Further review revealed that R28's Brief Interview for Mental Status (BIMS) was 13/15, indicating an intact cognition, and that the resident's medical diagnoses include Heart Failure, Chronic Lung Disease, Muscle Weakness, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Anemia, Anxiety, Depression, Psoriasis, Hypertension, and Knee Contractures. On 12/15/22 at 10:28 AM, R28 was observed lying in bed. R28's feet were mostly exposed except the heels, which were covered by heel cushion pads secured with Velcro. R28's right foot was observed with a lengthy incision line where their great toe used to be. R28's right foot and remaining toes appeared red with crusty skin, and there was a dark reddish-brown crusty substance (like old, dried blood) noted between R28's right toes and along the incision line. R28's former roommate, R106, was at the resident's bedside visiting R28 (R106's most recent BIMS score from 11/11/22 was noted to be a 15/15 indicating intact cognition). When queried regarding their right toe amputation, R28 stated, I was having an infection in my foot that no one knew about, and I didn't know about it until one day the nurse saw my toe and said it looked bad .Everyone came to look at it and said it didn't look good .They weren't going to send me [to the hospital] at first, but then sent me. R106 explained that this occurred when they shared a room with R28. R106 further stated, The room smelled like a rotten dead possum for a month and we told them, but they just came in and sprayed stuff. R28 explained that prior to the amputation, staff had been documenting giving them a complete bed bath. R28 further explained that although they received a bed bath, staff wasn't washing their feet. When queried further regarding past issues with their feet/toes, or if they had been seen by a podiatrist, R28 indicated that they had been seen by the foot doctor who treated a minor infection on their toe. R28 stated that the podiatrist wrapped their foot but hadn't come back since. R28 indicated that they have diabetes and neuropathy, and cannot feel anything in their feet/toes. R28 also stated that prior to going to the hospital for the toe amputation, staff hadn't been checking their feet for, around a month. A review of R28's medical record revealed the following: -9/12/22 Podiatrist Note: Pt c/o (complains of) elongated painful toenails .unable to trim [themselves]. Have become bothersome .Assessment: .Painful dystrophic onychomycosis (a fungal infection of the nail) with acute paronychia (infection of the tissue folds around the nails) and incurvation lateral nail border left hallux/minimal lymphagitis (sic) .Plan: .nails debrided x10 with sterile [NAME] without incident .nurse notified to perform daily dressing changes left hallux x 14 days .F/u 2 months . No podiatry note was found for the resident for November 2022. -Shower sheets provided by the facility: 10/29/22 bed bath marked as given, both feet noted to be circled on photo but no description written of skin issue or why the feet were circled; 11/2/22 bed bath marked as given with no skin issues written other than psoriasis on resident's back. -11/11/2022 09:17 (AM) Nursing Progress Note Note Text: Resident has a history of refusing .shower related to 11/09/2022 resident request for complete bed-bath to be given care plan reviewed and updated. [No corresponding shower/bath sheet found nor provided by facility]. -Weekly Skin Sweep .Date: 11/11/2022 10:01 (AM) [Completed by Licensed Practical Nurse (LPN) F] .tx (treatment) in progress for psoriasis - all other skin is clean, dry and intact . -11/12/2022 08:30 (AM) Nursing Progress Note Late Entry: Note Text: Resident has a decubitus ulcer on right foot and great toe. Right foot is red and swollen. Right foot has foul odor. Right foot cleansed. Dressing applied .Physician and Director of Nursing (DON)notified. Physician ordered resident to be sent to hospital for evaluation and treatment. Resident sent to .Hospital via ambulance for evaluation and treatment. [Written by LPN E]. -11/18/2022 22:27 (10:27 PM) Nursing Progress Note Note Text: Resident received back in the facility .resident big great toe on the right foot was amputated, resident has 4 other digits on the right foot, writer counted 16 stitches on resident all together, on .toe and on the bottom of .foot area . -R28's Infection Report dated 11/18/22 indicated that the resident was to receive oral and intravenous (IV) antibiotic treatment for 42 days due to osteomyelitis (infection into the bone) in the resident's right foot. -11/20/2022 15:07 (3:07 PM) ., IDT (Interdisciplinary Team) met to discuss resident re-admit to facility on 11/18/2022. Resident .Alert and oriented x3 .has open area right related to recent right great toe amputated 16 stitches .single lumen picc-line (peripherally inserted central catheter) right arm for ivpb (intravenous piggyback) of ceftriaxone (IV antibiotic) 2 gm (grams) daily along with oral flagyl (antibiotic) 500 mg bid (twice a day) x 42 days. Pain managed with [opioid as needed] . A review of R28's records from their hospitalization on [DATE] revealed that the resident's great right toe was amputated on 11/15/22 and they were discharged from the hospital back to the facility on [DATE]. On 12/16/22 at 2:09 PM, R28 was observed lying in bed. A PICC line was noted in the resident's right arm. When queried regarding how much longer they will be receiving antibiotic treatment, R28 stated, Supposed to be about a month total, I'm still getting them .I've been having some diarrhea . R28's right foot and remaining toes still appeared red with crusty skin, with a dark reddish-brown crusty substance (like old, dried blood) noted between R28's right toes and along the incision line. On 12/20/22 at 9:48 AM, R28's right foot and remaining toes still appeared red with crusty skin, with a dark reddish-brown crusty substance (like old, dried blood) noted between R28's right toes and along the incision line. When queried if anyone had come to care for their feet, R28 responded that a nurse had assessed their feet but no one had offered to clean them. On 12/21/22 at 10:11 AM, the DON was queried if LPN E or LPN F were available for interview. The DON indicated they were not in the building and provided their contact information. On 12/21/22 at 10:20 AM, the Wound Care Nurse (WCN) wound care nurse was interviewed and queried regarding what a Weekly Skin Sweep assessment entails. The WCN responded that a skin sweep means that the resident's skin is assessed from head to toe. When queried specifically regarding the discrepancy between the skin sweep for R28 completed on 11/11/22 by LPN F and the findings on 11/12/22 by LPN E, the WCN stated she was unable to get a lot of information regarding what happened. The WCN indicated she had reviewed R28's progress notes after they had been readmitted into the facility on [DATE], but that the resident was not being followed by wound care prior to the hospitalization because to her knowledge, the resident had no wounds. The WCN indicated no skin issues had been reported to her, and that staff knew the process for reporting and initiating treatment for new wounds or skin issues. When queried regarding the timeline for the development of osteomyelitis, the WCN stated that she did not feel this situation involving R28's right great toe could have happened over the course of one day. The WCN further explained that regardless of the resident receiving a shower or bed bath, it is the nurse's responsibility to assess all skin when a shower/bath is given, and that nurse aides are required to report new skin alterations to the resident's assigned nurse. On 12/21/22 at 10:37 AM, R28 was observed lying in bed. The WCN assessed R28's right foot. The resident's right foot and remaining toes still appeared red with crusty skin, with a dark reddish-brown crusty substance (like old, dried blood) noted between R28's right toes and along the incision line. The WCN indicated she was unsure of what the substance was - indicated it could be blood or possibly betadine - between R28's toes and that it did not appear anyone had been tending to the resident's feet. On 12/21/22 at 10:47 AM, the Infection Control Nurse (ICN) was interviewed and queried regarding the timeline of the development of osteomyelitis. The ICN stated, It won't develop in a day, there will be indications/symptoms first, a wound etc. When a wound is found, we would expect front line staff to be bringing it to someone's attention so it doesn't turn into osteomyelitis. On 12/21/22 at 1:21 PM, LPN E was called for interview and left a voicemail, however no call back was received prior to survey exit. On 12/21/22 at 1:23 PM, LPN F was called for interview and left a voicemail, however no call back was received prior to survey exit. On 12/21/22 at 1:38 PM, the DON was interviewed and queried regarding the circumstances surrounding R28's hospitalization and right toe amputation. The DON indicated that the facility was currently working on a past non-compliance related to the issue (no PNC information was provided prior to survey exit). The DON stated, There was an odor in the room for a week. On the 12th (11/12/22), the nurse (LPN E) went into the room and noted a skin alteration on [R28's] foot. [R28] was sent to the hospital, and an X-ray showed acute osteomyelitis. They amputated the great toe and possibly one or two others. When queried regarding the discrepancy found between R28's skin assessments and the LPN E's findings, and subsequent same-day hospitalization that resulted in toe amputation, the DON explained that she discovered this was a trend and now has unit managers completing and verifying full skin sweeps of residents on their units, and that this is ongoing. Review of the facility assessment revealed that under, Part 2: Services and Care We Offer Based on our Residents' Needs . the facility's, Management of medical conditions . included performing, Assessment, early identification of problems/deterioration, [and] management of medical and psychiatric symptoms and conditions . 40384 Deficient Practice Statement #2 Based on observation, interview and record review, the facility failed to reassess and monitor after a noted health concern for one sampled resident (R117), of two residents reviewed for change in condition, resulting in unmet care needs and hospitalization . Findings include: On 12/15/22 at 9:34 AM, R117 was observed sitting in the hallway. They were pleasant upon approach and denied any concerns regarding the facility. A review of R117's medical record revealed that they were admitted into the facility on [DATE] with diagnoses of Heart Failure, Dementia, and Diabetes. Further review revealed a Minimum Data Set assessment dated [DATE] revealing a Brief Interview for Mental Status score of 11/15 indicating a moderately impaired cognition, and required supervision to extensive assistance for Activities of Daily Living. Further review of R117's medical record revealed the following progress notes: 10/24/2022 06:29 (6:29am) Nursing Progress Note: Resident complained of pain in lower abdomen with the urge to urinate. [R117] stated 'I can not pee!'. Resident was given pain meds and a note was put in the Dr's (doctor's) book. Will pass on to dayshift . Resident currently resting in bed. 10/31/2022 08:48 (8:48am) Discharge Emergent Note. Was a physician order obtained for transfer/discharge?: Physician ordered resident to be sent to hospital. What is the reason for resident transfer/discharge?: Resident has a Gastrointestinal Bleed . Large amount of bright red blood lost from rectum. History of Gastrointestinal Hemorrhage. Where is the resident is being transferred? Who is providing the transportation?: Resident transferred to [local hospital]. Resident transferred via 911 Ambulance at 4:30 am . Further review of R117's medical record revealed that R117 was admitted to the hospital on 10/31/22 and discharged on [DATE] with diagnoses of Acute LGIB (lower gastrointestinal bleeding, acute blood loss anemia, Thrombocytopenia (low platelet level), and constipation. Radiology results revealed the following, Diagnostic Results: CT (Xray images) ABD (abdominal)/Pelvis w (with)/ Contrast Impression 3 .Moderate to large amount of stool in the colon 4. Massively enlarged prostate gland measuring 10 x 8 x 11 cm (centimeters) 5. Mild circumferential wall thickening of the urinary bladder which may be due to chronic outlet obstruction . On 12/20/22 at 12:55 PM, R117 was interviewed regarding their hospitalization and indicated that they were admitted into the hospital for feeling weak and they have always had stomach issues as a kid. On 12/20/22 at 1:51 PM, a request for physician notes for R117 between 10/24/22 and 10/31/22 were requested from the facility. There was no documentation provided by the end of the survey. On 12/21/22 at 1:50 PM, the Director of Nursing (DON) was asked about R117's hospitalization , and lack of assessment after complaints of pain, and inability to urinate. The DON indicated that she would look into it and get back with surveyor. On 12/21/22 at 3:18 PM, the DON explained that there was a note written in the doctor's book however, there was no indication that it was followed up on. 32220 Deficient practice number 3. Based on observation interview and record review the facility failed to ensure labs for monitoring of Dilantin (for treatment of seizures) and Digoxin (for treament of high blood pressure) were completed per physician orders for one sampled resident (R13) of 31 residents whose plans of care were reviewed, resulting in the potential for decrease efficacy of the medications. Findings include: On 12/15/22 at 10:56 AM, R13 was observed to dressed and seated on their bed. R13 was asked about care at the facility and reported that their Dilantin was not always given to them. R13 reported that the Dilantin was taken to help prevent seizures and reported they a had a couple of seizures over the last month. R13 reported they were also on Keppra for seizure control. A review of the facility record for R13 revealed R13 was admitted into the facility on [DATE]. Diagnoses included Epilepsy, High Blood Pressure and Schizophrenia. The care plan titled have seizure disorder dated 11/30/21 documented obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. The care plan initiated 11/30/21 indicated R13 to be at risk for elevated blood pressure. A review of the physician orders revealed the following: -An order dated 11/22/22 for a stat (right away) Dilantin order; -An order dated 09/13/21 for a Dilantin and Digoxin levels; -An order dated 02/09/21 for a Digoxin and Dilantin level next draw and then every two months; -An order dated 12/01/19 for a Dilantin level every three months. A review of available lab results for the Dilantin and Keppra revealed labs were completed on 04/08/21 and 11/29/22. A lab for the Dilantin was also completed on 02/09/21 and the level was low at 9.5 (range 10-20). A review of available lab results for the Digoxin revealed labs were completed on 02/09/21 and 06/08/22. Additional lab draws for the Digoxin and Dilantin were requested on 12/20/22 at 9:30 AM, but not received prior to survey exit. A review of the December 2022 medication administration record (MAR) revealed the Digoxin and Dilantin were documented as administered. The November 2022 MAR revealed the Dilantin and Digoxin were not documented as given for at least one dose on November 7. The October 2022 MAR revealed a dose for the Dilantin on 10/13,10/15, 10/18, 10/25, 10/27, 10/29/22 and the Digoxin on 10/27, and 10/2922 were not documented as given. The September 2022 MAR revealed at lease one dose for the Digoxin on 09/04 and 09/17 and for the Dilantin on 09/04, 9/05, 9/17, 9/20/22 were not documented as given. The August 2022 MAR revealed at least one dose for the Digoxin on 08/24 and the Dilantin on 8/19, 8/24, 8/27/22 were not documented as given. A pharmacy review dated 05/27/22 revealed a recommendation to the physician which indicated The resident is receiving routine doses of Digoxin every day. I would suggest a regularly scheduled Digoxin level. Serum Digoxin level now and every six months. The recommendation was signed as a telephone order per the doctor on 12/21/22. On 12/20/22 at 12:45 PM, the missing labs for R13 were reviewed with the Director of Nursing (DON). The DON reported the labs should be completed as ordered by the physician. A review of the Medication Monitoring policy dated June 2019 revealed, .The Consultant Pharmacist identifies irregularities through a variety of sources including the resident's medical record, pharmacy records and other applicable documents .The Consultant Pharmacist recommendations are acted on by the prescriber and/or nursing staff .

This citation pertains to intake MI 425. Based on interview and record review, the facility failed to provide care consistent with professional standards of practice to treat existing pressure ulcers by 1) failing to initiate wound care treatments timely, 2) failing to complete wound care per orders, and 3) failing to follow up on a noted skin concern, affecting one sampled resident (R906) of five reviewed, resulting in the delayed and extended healing of wounds and infection, pain, and the potential for additional skin complications. Findings include: A review of R906's medical record indicated that the resident was initially admitted into the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R906's Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident was severely cognitively impaired and completely dependent on staff for activities of daily living (ADLs). R906's medical record indicated that the resident was hospitalized from 4/1/22 to 4/12/22, from 5/14/22 to 5/17/22, from 6/24/22 to 7/1/22 (admitted on to hospice services upon return), and passed away in the facility on 7/29/22. Continued review revealed R906 was admitted on [DATE] with an abdominal wall surgical incision, unstageable sacral pressure ulcer, unstageable right hip pressure ulcer, unstageable left heel pressure ulcer, and left posterior leg venous stasis ulcer, per the wound care note dated 3/16/22. The note indicated the following measurements and information: -Abdominal wall surgical incision 15 cm (centimeters) with 16 staples in place -Sacral unstageable pressure ulcer 12.5 (centimeters) x 18.7 x UTD (unable to determine depth) 80% slough 20% necrotic tissue -Right hip unstageable pressure ulcer 13.8 x 11.5 x UTD 80% slough 20% necrotic -Left heel unstageable pressure ulcer 3.0 x 3.0 x UTD -Right anterior leg varcular (sic) ulcer 5.0 x 1.0 x UTD -Left posterior leg venous stasis ulcer 2.5 x 2.5 x 1.2 cm. Additionally, the wound care note dated 3/16/22 did not provide any indication that any of R906's wounds were showing signs of infection. A review of R906's wound care orders revealed that treatments for the resident's wounds were not initiated on the treatment administration record (TAR) until 3/17/22. Furthermore, a review of R906's March 2022 TAR revealed: -Dakins (1/4 strength) Solution 0.125 % (Sodium Hypochlorite) Apply to sacrum and Rt (right) hip topically every day shift for wound care. apply with ABD and border gauze. -Start Date- 03/17/2022 -D/C (discontinue) Date- 04/04/2022 - was not documented as completed on 3/18, 3/19, or 3/22/22. A review of R906's progress notes revealed: 3/21/2022 18:59 (6:59 PM) Practitioner Progress Notes Late Entry: Note Text: .pt seen and examined for f/u (follow-up), continues to be confused .some worsening to R-hip/ischial wound on triad dressing per wound care .Skin: Abd (abdominal) wound with staples, healing .coccyx/R-buttock/hip wound pink w/o (without) drainage or foul odor . 3/23/2022 15:00 (3:00 PM) Nursing Progress Note .Writer noted odor from right hip wound during wound care rounds with MD (Physician). Informed ID (Infectious Disease) of new findings. Received orders from ID for xray to rt hip, lab work, and antibiotic therapy . 3/28/2022 20:29 (8:29 PM) .Infectious Disease Initial Evaluation Note .evaluated at the request of staff for the antibiotic management to treat an infected right hip pressure ulcer. Vital signs have been stable .afebrile .Most recent laboratory data show slightly elevated WBC (white blood cell) count of 12.4. Right hip x-ray obtained was negative for [CONDITION(S)], may consider advanced imaging. Right hip appears with slough, necrotic tissue associated with significant malodor. Appears to be clinically infected. Patient started on IV [MEDICATION(S)] and [MEDICATION(S)] (antibiotics) . R906 was sent to the hospital on 4/1/22 for respiratory distress and readmitted to the facility on [DATE]. The wound care note dated 4/20/22 indicated the following wound details: -Rt shoulder abrasion - Length x Width x Depth: 7.0 (centimeters) x 5.2 x UTD -Rt heel unstageable 2.6 x 3.3 x UTD -sacrum 4 (Stage IV - full thickness skin loss extending to tendon, muscle, and/or bone) 38.5 x 17.8 x 6.7 -Rt medial foot unstageable -Lt ant knee scattered 3.5 x 3.5 x UTD -Lt lat leg unstageable 4.0 x 5.0 x 0.2 -Rt hip 4 (Stage IV) 17.2 x 16.5 x 6.8. No wound measurements or wound care assessments were noted from 4/12/22 prior to 4/20/22 (A wound assessment with effective date of 4/12/22 was seen in the record, however, it was signed as completed on 4/20/22). Review of the resident's April 2022 TAR revealed that detailed wound care orders were not entered into the record until 4/20/22, and were not initiated until 4/21/22 after the resident returned to the facility on [DATE]. The following wound care orders lacking details on what locations to apply the treatments were entered into the record: -[MEDICATION(S)] Wound/Burn Dressing Paste (Wound Dressings) Apply to wound topically every day shift every Tue, Fri for wound healing -Start Date- 04/15/2022 -D/C Date- 04/22/2022 (Also not documented as completed on the TAR on 4/15 or 4/22). -Silver [MEDICATION(S)] Ointment 10 % Apply to affected area topically one time a day for wound healing -Start Date- 04/13/2022 1000 -D/C Date- 05/16/2022. The following wound care orders were not documented as completed on 4/24/22 and 4/29/22: -Dakins (1/4 strength) Solution 0.125 % (Sodium Hypochlorite) Apply to Rt hip topically every day shift for wound care packing gauze soaked with Dakins and covering with border gauze. -Start Date- 04/21/2022 -D/C Date- 05/16/2022. -Dakins (1/4 strength) Solution 0.125 % (Sodium Hypochlorite) Apply to sacrum topically every day shift for sacral wound packing gauze soaked with Dakins and cover with border gauze -Start Date- 04/21/2022 -D/C Date- 05/16/2022. Continued review of R906's progress notes revealed: -4/18/2022 14:37 (2:37 PM) .Infectious Disease Progress Note .Follow up for sacral [CONDITION(S)] .Sacrum continues to appear clinically infected. Continue with [MEDICATION(S)] (antibiotic) and local wound care .4/01: CT abdomen/pelvis + (positive) sacral ulcer concerning for OM ([CONDITION(S)]) .Continue [MEDICATION(S)] .to complete a total 6 weeks course . A review of R906's May 2022 TAR revealed the following (resident hospitalized on [DATE] and readmitted on [DATE]): -Dakins (1/4 strength) Solution 0.125 % (Sodium Hypochlorite) Apply to Rt hip topically every day shift for wound care packing gauze soaked with Dakins and covering with border gauze. -Start Date- 04/21/2022 -D/C Date- 05/16/2022 - Documented as not completed on 5/3/22 and 5/13/22, and no documentation indicating completion on 5/7/22 and 5/8/22. -Dakins (1/4 strength) Solution 0.125 % (Sodium Hypochlorite) Apply to sacrum topically every day shift for sacral wound packing gauze soaked with Dakins and cover with border gauze -Start Date- 04/21/2022 -D/C Date- 05/16/2022 - Documented as not completed on 5/3/22 and 5/13/22, and no documentation indicating completion on 5/7/22 and 5/8/22. Wound care orders were not initiated for R906's right hip and sacral wounds until 5/19/22, and were not documented on the TAR as completed on 5/20/22 and 5/29/22. Continued review of R906's progress notes revealed: -5/3/2022 13:24:00 (1:24 PM) .Dakins (1/4 strength) Solution 0.125 % Apply to sacrum topically every day shift for sacral wound packing gauze soaked with Dakins and cover with border gauze - Not Completed Endorsed to Unit Manager . Written by Nurse D. No additional documentation was present indicating that the wound treatment was actually completed by the Unit Manager. -5/23/2022 16:19 (4:19 PM) .Infectious Disease Progress Note .Follow up for sacral [CONDITION(S)] .Sacrum with improvement. More granulation is present, some malodor .Continue with [MEDICATION(S)] and [MEDICATION(S)] (oral antibiotics). Continue local wound care. May need escalation to IV antibiotic therapy if no improvement on orals . -5/28/2022 20:31 (8:31 PM) .Nursing Progress Note .Writer spoke with ID regarding new onset of odor to Rt hip wound and increased drainage. Orders received to start antibiotic therapy . On 9/7/21 at 12:41 PM, Nurse D was interviewed regarding the note he entered on 5/3/22 related to being unable to complete wound care for R906 per order. Nurse D explained that he and another nurse were the only ones working on the unit that day and had 30 patients a piece (give or take) to take care of. Nurse D explained that normally three nurses would have been working that day. A review of R906's TAR for June 2022 revealed that the resident's wound treatments for the sacral and right hip wounds were not documented as completed on 6/4/22, 6/5/22, and 6/22/22. R906 was hospitalized on [DATE] and readmitted on [DATE]. The resident signed onto hospice services upon their re-admission. The last noted wound measurements present in R906's record were as follows: 7/6/2022: -(R) post (posterior) shoulder abrasion Length x Width x Depth: 5.0 x 4.0 x 0.1 (cm) -(L) breast abrasion 5.0 x 9.5 x 0.1 -sacrum 4 (Stage IV) 16.2 x 28.5 x 6.2 -(R) Hip 4 (Stage IV) 7.5 x 15.2 x 9.0. A review of R906's TAR for July 2022 revealed that the resident's wound treatments for the sacral and right hip wounds were not documented as completed on 7/2/22, 7/3/22, 7/4/22, 7/5/22, 7/10/22, 7/12/22, and 7/16/22. Wound care was also not provided on 7/20/22 per the following notes: -Note Text: Dakins (1/4 strength) Solution 0.125 % Apply to to (R) hip and Sacrum topically every day shift related to PRESSURE ULCER OF SACRAL REGION,STAGE 4 .PRESSURE ULCER OF RIGHT HIP,STAGE 4 .and PRN (as needed) .Wound care not rendered please render wound care per orders .[and] .Unable to render wound care please render wound care per doctor orders medicate prior thank you . Additional progress notes for R906 in July 2022 included: -7/14/2022 14:16 (2:16 PM) .Nurse in to do resident wound care this A.M noted to be in distress prior to wound care crying out and moaning. Wound nurse notified resident primary nurse requested medication prior to wound care; resident was medicated and tolerated well. Wound nurse in to do wound care and noted that resident continued to moan and mumble a little; incoherently. The moment the wound nurse started to talking to the resident to introduce self and CNA (Certified Nurse Aide) and why we were present resident began crying and grabbing for the nurse. 1:1 provided with some success wound care rendered during this assessment it has been noted that resident is crying out in pain when (R) L/E (right lower extremity) is touched. (R) L/E is Swollen, tender to touch, warm/hot, this has been brought to the attention of the primary nurse. The ID doctor contacted .Nurse has also called [hospice] .the ID doctor called and wanted to know if Hospice was ok with the resident receiving abt (antibiotic) therapy . -7/21/2022 19:51 (7:51 PM) .Nurse to resident room several times this tour to assess resident ability to tolerate wound care, resident has been in more pain this tour than day's prior. Primary nurse asked to medicate resident for pain prior to wound care. Nurse stated hospice nurse in and is writing new orders for resident pain management. Wound nurse agreed to f/u (follow up) later to check resident status and assess if pain is managed enough for wound care. On f/u resident continue moaning at rest, there are order changes noted but medication has not yet arrived. The medication available for resident has been given and has a noted decrease with pain but not enough to render any wound care at this time; AEB (as exhibited by) moaning, with eyes closed and what sounds like crying .wound care has been held wound nurse does not believe that this is in the best interest of the resident [at] this time pain must be managed prior to wound care and be managed following wound care before it can be rendered to ensure optimal outcome for the resident . Written by Nurse C. -7/24/2022 21:15 (9:15 PM) .Note Text: Pt has maggots coming from wound which is in both legs pt also has dark green thick drainage coming from peg tube site saturated abd pad less than 5 mins contacted hospice nurse and alos (sic) contacted doctor and left voice message. (Written by Nurse B) No follow-up documentation addressing maggots was found prior to R906's passing on 7/29/22. On 9/7/22 at 11:39 AM, Nurse A was interviewed and indicated that she had filled in as the facility's wound care nurse in March, part of April, and some time in May 2022. When queried regarding R906's wounds, Nurse A indicated that the resident did have multiple wounds and a huge wound to the sacral area and right hip. Nurse A explained that R906 had very heavy wound treatments and wounds with a lot of drainage, and was also prescribed antibiotics several times. Nurse A also explained that R906's wounds were very painful, and that's why R906 went on hospice, because R906, Was just suffering at that point. When queried regarding expectation for completing wound treatments, Nurse A indicated that the floor nurses are responsible for completing the treatments if the wound care nurse is not at the facility and/or another nurse is not assigned to do treatments. When queried if she encountered problems with wound care being completed when it was supposed to, Nurse A stated, Kinda sorta .We desperately need staffing .we are sometimes very short-staffed. On 9/7/21 at 1:47 PM, Nurse C, the facility's current wound care nurse, was asked if the resident having maggots on their legs was reported to her. Nurse C indicated that it was, but she was off at the time and did not come back to work until July 27th. Nurse C explained that she had wrapped R906's legs previously because they were grossly edematous but did not have any open areas the last time she saw them. When queried if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse C was queried if she had seen the resident after returning to work and prior to the resident's death in the facility and responded, I believe I saw [R906] a couple times. When asked if she saw R906's leg, Nurse C said that she had, and the resident had what, Maybe would've been blisters and drainage from the [CONDITION(S)] . Nurse C indicated she had wrapped R906's legs and done an assessment on the resident when she returned but an additional assessment was not found. On 9/8/22 at 8:43 AM, Nurse B was interviewed regarding her assessment of maggots on R906's legs. Nurse B explained that the resident aide came out and said maggots were coming from [R906's] leg. Nurse B stated the resident had their two legs wrapped, so she cut the wraps open and found maggots on both legs. Nurse B was asked if the wraps were dated. Nurse B indicated they were but could not remember with what date. Nurse B did deny that R906's legs were draining any fluid but indicated that they were very edematous and wrapped due to the [CONDITION(S)]. Nurse B stated that she and another staff member cleaned the resident's legs and did not re-wrap them so they could air out and dry. Nurse B indicated that she reported her findings to the physician and to the hospice nurse. A review of the hospice notes scanned into the resident's medical record did not reveal any reference to a report of maggots. On 9/8/22 at 11:20 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed and queried if the expectation is that wound care treatments are initiated in a timely manner after a resident is admitted (or readmitted ) to which the DON responded, Absolutely .within 24 hours. The DON indicated that she also expects wound care orders to be details, and to specify the location the treatment is to be applied. When queried, the DON indicated that she expects wound care treatments to be carried out per order by staff, and that documentation should be present explaining if/why a treatment was not done. When queried regarding the maggots assessed on R906, the DON indicated that she did not necessarily expect follow-up related to that because the dressings were thrown away, legs left open to air, and there was nothing further (documentation was not found to reflect this). A review of the facility's policy titled, Wound Treatment Management and Documentation, revised 07/21, revealed, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment .1. Wound treatments will be provided in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Wound treatments are documented at the time of each treatment .

This Citation Pertains to Intake MI 65. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to prevent willful Resident to Resident physical and/or verbal aggression for five (#508, 507, 509, 510 and 511) of nine Residents reviewed, resulting in Resident #508 running into Resident #510's wheelchair and threatened them by saying, You bit#h ni#ger, get out of my mother fuc#ing way, threatening Resident #509 by telling them they were going to kick their ass and then attempting to kick them, striking Resident #511's hand, and physically assaulting Resident #507 by grabbing their hair, repeatedly punching them in the head and face, and biting them resulting in Resident #507 experiencing physical injuries including two black eyes and a human bite and Resident #509 and Resident #510 experiencing psychosocial distress and verbalization of fear. The Administrator was notified of the Immediate Jeopardy on 8/20/20 at 8:35 AM. A plan to remove the immediacy was requested. The IJ begin on 8/16/20, identified on 8/20/20 and was removed on 8/17/20 at 12:21 am, based on the facility's implementation of the plan removal as verified on 8/20/20. Although the IJ was removed, the facility's deficient practice remained at pattern. Actual harm that is not immediate jeopardy. Findings include: Review of submitted Facility Reported Incident (FRI) intake documentation revealed the following, On 8/16/2020 at approximately 2:30 PM there was an alleged altercation between (Resident #507) and (Resident #508) Per eye witness reports . (Resident #508) repeatedly bumped their wheel chair into (Resident #507's) wheelchair. (Resident #507) was attempting to move out of (Resident #508's) way. (Nursing Assistant B) asked (Resident #508) to stop and (Resident #508) came close to (Resident #507) and in doing so knocked (Nursing Assistant B) to the floor, then punched (Resident #507) from behind 4-5 times in the head, blackening their right eye. (Resident #508) then pulled (Resident #507's) hair and they both fell out of their wheelchairs to the floor and again (Nursing Assistant B) went down with them. (Resident #508) also bit (Resident #507) in the right rib cage. (Resident #508) removed both their (lower extremity) prosthesis and attempted to hit (Resident #507) with them. They were immediately separated as other staff members came . The (local) police were called and came to the facility, they (police) wanted to take (Resident #508) (into custody) but . do not have the capability or means to care for(Resident #508 in jail). On 8/19/20 at 9:30 AM, Resident #507 was observed in their room. The Resident appeared un-groomed with a large, dark purple tinged bruise surrounding their right eye and lighter colored discoloration around their left eye. An interview was completed with the Resident at this time. When asked what occurred on 8/16/20 with Resident #508, Resident #507 stated, (Resident #508) rolled up behind me and locked my wheelchair in and started hitting me. Resident #508 then stated, I was trying to get out but (Resident #508) kept hitting me. When asked how Resident #508 was hitting them, Resident #507 revealed Resident #508 was punching them with a closed fist. Resident #507 further revealed Resident #508 was hitting them in the back of the head and both sides of their head and face. Resident #507 indicated they both fell to the ground and started wrestling on the floor. Resident #507 stated, I started hitting (Resident #508) back to try to make them stop and that is when they bit me. Resident #507 proceeded to pull up their shirt to show where they were bitten on their right upper side. The area was round and red in color with bruising and visible areas that appeared to be teeth marks. A small open area was noted. When asked if Resident #508 broke their skin when they bit them, Resident #507 replied, Yeah. When queried regarding their location when Resident #508 started hitting them, Resident #507 disclosed they were in the hallway with about 20 other people waiting in line to go outside and smoke. When asked if there were facility staff present in the area, Resident #507 revealed they were waiting in line for someone to come but no facility staff were present in the area until (Nursing Assistant B) came and tried to break it up. When asked what happened when Nursing Assistant B attempted to intervene, Resident #507 stated, From what I understand, she fell . I heard (Resident #508) tried to bite them too. Resident #507 revealed after other staff came, the staff assisted them back into their wheelchair. When asked if anything else had occurred, Resident #507 revealed after both Residents were back in their wheelchairs, Resident #508 told them they knew where I lived (room in facility) was going to wait until I was sleeping and stab me in the neck. Resident #507 was then asked if they had any interaction with Resident #508 prior to the incident and stated, (Resident #508) was always going down the hall yelling racial slurs like 'Nigg#r' and saying things like 'When a cracker do it, it get done because they to goody two-shoes'. Resident #507 was asked if that had bothered them and replied, Yes, but not as much as it bother my roommate (Resident #509). Resident #507 revealed Resident #509 has [MEDICAL CONDITION] (medical condition involving abnormal brain development or damage creating deficits in muscle movements and speech). Resident #507 stated, (Resident #508) was making fun of (Resident #509), making noises and stuff. When asked, Resident #507 did not elaborate what they meant when they said, and stuff but stated, (Resident #509) was scared of (Resident #508). Resident #507 then stated, I told (Resident #508) to leave (Resident #509) alone and I guess that was the opening in (Resident #508's) head. When asked when they told Resident #508 to leave Resident #509 alone, Resident #507 indicated it was approximately a week prior to Resident #508 attacking them. With further inquiry, Resident #507 revealed since they had intervened to stop Resident #508 from picking on Resident #509, Resident #508 had been saying things about them. When asked if staff were aware of what Resident #508 was saying, Resident #507 indicated they were and stated, Everyone could hear (Resident #508). Resident #507 was then asked if they had any other interactions with Resident #508 and stated, No. I didn't want any issues with (Resident #508) and I knew (Resident #508) would do something because of their attitude. Resident #507 then stated, To tell you the truth, I'm glad it happened to me and not one of the older Residents here or my roommate. We could all see it was coming. Record review revealed Resident #507 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, displayed no behaviors, and required supervision to limited assistance to perform Activities of Daily Living (ADLs). An interview was conducted with Nursing Assistant D on 8/19/20 at 9:55 AM. When queried if they were working on 8/16/20, Nursing Assistant D indicated they were not but were aware of the incident between Resident #508 and Resident #507. When asked about Resident #507, Nursing Assistant D stated, (Resident #507) is very quiet and easy going. When queried regarding Resident #508, Nursing Assistant D stated, (Resident #508) is very aggressive and vulgar. When asked what they meant, Nursing Assistant D revealed Resident #508 was rude and negative. Nursing Assistant D was asked about Resident #508's interactions with other Residents and stated, (Resident #508) would walk past (other Residents) and say things like, 'You ain't nothing but a mother [***] i#g crybaby' and stuff like that. Nursing Assistant D then stated, (Resident #508) would run into other people's wheelchairs on purpose and then say 'Get your mother [***] i#g honkie a#s' or 'nigg#r a#s' out of the way. When asked if Resident #508 had a roommate, Nursing Assistant D revealed the Resident did not have a roommate before they left but did when they were in the transition unit. When asked about Resident #508's roommate on the transition unit, Nursing Assistant D disclosed the Resident was no longer at the facility and stated, (Resident #508) was really, really mean to them. When queried regarding interventions related to the Residents behavior, Nursing Assistant D stated, I told (Resident #508) to not be so rude and they said they were going to have their (sibling) come up here and put a hit out on my a#s. On 8/19/20 at 10:10 AM, an interview was completed with Licensed Practical Nurse (LPN) E. When asked if they were working on 8/16/20, LPN E indicated they were working but did not witness the incident. LPN E stated, I saw (Resident #507) and their eyes were swollen and then I took (Resident #508) out to smoke (after it happened). When queried regarding Resident #508, LPN E replied, They were not the most pleasant person. LPN E was then asked what they meant and revealed the Resident was mean and verbally aggressive to other Residents and facility staff. LPN E then revealed Resident #508 had threw their food tray in the hall, breaking dishes because they said they 'didn't want that sh#t'. An interview was conducted with LPN Unit Manager F on 8/16/20 at 10:20 AM. When queried regarding Resident #508, Unit Manager F stated, (Resident #508) would curse me out all the time. With further inquiry, Unit Manager F detailed an incident involving Resident #508. Unit Manager F stated, (Resident #508) threw their plate into the hall and I went down to their room to talk to them. Unit Manager F detailed the plate had broken and it was a safety concern for other Residents. When asked what happened, Unit Manager F stated, (Resident #508) said that I 'sell my p#ssy on the corner' and 'fu#k you'. Unit Manager F further revealed if Resident #508 was offered a shower by staff, the Resident would respond with vulgar comments including, 'You ain't getting no free D' and the Resident #508 told staff that 'their crew were the female body snatchers'. Unit Manager F was asked if Resident #508 spoke to other Residents in that manner and replied, Yes, (Resident #508) would make fun of them for their problems. (Resident #508) messed with all of them- always. When queried if any Residents had said anything to them regarding Resident #508, Unit Manager F replied, Yeah, they didn't like (Resident #508). With further inquiry regarding Resident #508's behavior, Unit Manager F stated, (Resident #508) would just propel themselves fast (up and down the hall) and curse. When queried regarding Resident #508's room placement, Unit Manager F conveyed Resident #508 said You better not be putting me in a room with no cracker when they were being moved out of the Transition unit of the facility and they had been able to put them in a private room. On 8/16/20 at 10:30 AM, an interview was completed with Resident #510. When queried regarding interactions with other Residents in the facility, Resident #510 indicated there had been a Resident who was very disruptive and provided a physical description. When queried if the Resident they were describing was Resident #508, Resident #510 revealed it was and stated, (Resident #508) was a terrible person and caused chaos. Resident #510 further stated, (Resident #508) was a constant threat to everyone. When asked what they meant, Resident #510 revealed Resident #508 would curse all the time and would run into other people on purpose. Resident #510 was asked if Resident #508 had ever ran into them and stated, Yeah, (Resident #508) ran into my wheelchair and said, 'You bit#h nig#er get out of my mother fuc#ing way. When asked if that had scared them, Resident #510 replied, Yeah, I'm too weak. If I saw (Resident #508) coming, I would get out of their way. Resident #510 then stated, Everybody was scared of (Resident #508) and tried to avoid them. When asked if they were aware of the incident that occurred on 8/16/20, Resident #510 indicated they were and stated, (Resident #507) is nice, ain't never had a disagreement. (Resident #507) was just defending somebody (Resident #509). Record review revealed Resident #510 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to limited assistance to perform Activities of Daily Living (ADLs). An interview was completed with Housekeeping Staff G. When queried, Housekeeping Staff G revealed they worked on the unit where Resident #507 and Resident #509 resided. Housekeeping Staff G was asked about Resident #508 and stated, (Resident #508) was just mean and would throw things. Resident #508 called me 'white trash' and threw the bathroom garbage can full of garbage at me. Housekeeping Staff G further revealed the garbage can hit them in the leg. When asked, Housekeeping Staff G revealed it hurt and they were upset after the incident occurred. When asked if they had reported the incident, Housekeeping Staff G indicated they told their manager. On 8/19/20 at 11:30 AM, an interview was completed with Nursing Assistant B. When queried, Nursing Assistant B revealed they had observed the incident on 8/16/20 involving Resident #508 and #507. When asked what happened, Nursing Assistant B revealed they were coming around the corner of the hall when they saw Residents sitting in the hall around at the smoking door waiting for a staff member but nobody was there to take them out to smoke. Nursing Assistant B stated, (Resident #508) was in a wheelchair and they were backing into (Resident #507's) wheelchair. (Resident #507) told (Resident #508) to stop. When asked what happened next, Nursing Assistant B stated, (Resident #508) punched (Resident #507) in their face and wrapped (Resident #507's) hair around their hand and was repeatedly punching (Resident #507) in the face. (Resident #508) was holding them by their hair and like wailing on (Resident #507). When asked, Nursing Assistant B revealed both Residents were in their wheelchairs at this time. Nursing Assistant B then stated, I tried to separate them and (Resident #508) pushed me down on my chest. Then (Resident #511) tried to help and got punched in the hand by (Resident #508). Nursing Assistant B continued, Then they were both on the floor and (Resident #507) hit (Resident #508) back and (Resident #508) totally went crazy. When asked, Nursing Assistant B indicated the Residents ended up on the floor when Resident #508 pulled Resident #507 from their wheelchair by their hair and that Resident #508 was still holding onto Resident #507's hair once they landed on the floor. Nursing Assistant B then stated, (Resident #508) took off both prosthetics off to hit (Resident #507) with them and then (Resident #508) bit (Resident #507) and drew blood. When asked for clarification, Nursing Assistant B confirmed that Resident #507 was bleeding from where they had gotten bit by Resident #508. Nursing Assistant B further revealed that after Resident #508 bit Resident #507, (Resident #508) even stood on their stumps after that. When asked about the Resident's injuries, Nursing Assistant B stated, You heard the impact of (Resident #508) hitting (Resident #507) in the head and (Resident #507's) eye immediately swelled up. When queried regarding how staff intervened to stop the altercation, Nursing Assistant B replied, The nurses finally came over. Nursing Assistant B was asked the length of time for other staff to respond and replied, I don't know, a long time. I think it wouldn't have got that far if they (other staff) would have gotten there quicker. I was yelling but nobody came. Nursing Assistant B then stated, Even after it was done and they were going away, (Resident #508) said 'Bit#h, I know where you live and I'm gonna stick you when you sleep' to (Resident #507). When queried regarding what occurred after the altercation, Nursing Assistant B revealed the police were called and stated, (Resident #507) pressed changed but they (police) couldn't take (Resident #508) to jail so (Resident #508) was petitioned out. Nursing Assistant B revealed when Resident #508 was petitioned out of the facility, they told them that the court documents would have Resident #507's address and that they would find them (Resident #507). Nursing Assistant B was then asked if Resident #508 had other altercations while in the facility and replied, Yes, all the time with other Residents and staff. (Resident #508) is a horrible individual. When queried regarding interactions between Resident #508 and Resident #509, Nursing Assistant B revealed Resident #508 would pick on Resident #509 for the way they talked. When queried regarding the time Resident #507 left the facility, Nursing Assistant B replied, Maybe 9:00 PM. Nursing Assistant B was asked what interventions were implemented by the facility until Resident #508 left and replied, Moved rooms (different room on same hall). When asked, Nursing Assistant B revealed Resident #508 was out in the hall of the facility on their phone after the incident and continued to make verbal threats towards others including saying they were going to stab (Resident #507) in their neck while they sleep'. Nursing Assistant B was asked if the Resident had a one to one staff with them following the incident and stated, No. When asked if Resident #508 ever had increased or one on one staff supervision ordered while at the facility, Nursing Assistant B replied, No, never that I know of. On 8/19/20 at 12:05 PM, Resident #511 was observed in their room in bed. An interview was completed at this time. When queried, Resident #511 revealed they were in line to go outside and smoke on 8/16/20 when the altercation occurred between Resident #508 and Resident #507. When asked what happened, Resident #511 revealed Resident #508 was going up and down the hallway and got their wheelchair hooked on Resident #507's wheelchair. Resident #511 stated, (Resident #507) tried to unhook the wheelchair and (Resident #508) got mad. (Resident #508) hit (Resident #507) right in the head then they grabbed (Resident #507's) hair. When asked what happened next, Resident #511 indicated Resident #508 pulled Resident #507 out of their wheelchair to the ground by their hair. Resident #511 stated, (Resident #508) fell on top of (Resident #507) with their hand still in (Resident #507's) hair. They tussled back and forth and (Resident #508) kicked off their prosthetic legs and hit (Resident #507) in the head. Resident #511 additionally stated, (Resident #508) bit (Resident #507) too. When asked about staff intervention, Resident #511 revealed (Nursing Assistant B) had attempted to intervene but was knocked to the floor and said, I was trying to help (Nursing Assistant B) and (Resident #508) hit me in the left hand. When asked what happened after additional staff arrived to assist, Resident #511 stated, Even after it was broke apart, (Resident #508) was trying to reach through the door (to get to Resident #507). Resident #511 was then asked about other interactions with Resident #508 and replied, (Resident #508) is very verbal and racist, non-stop talking and threatening people. You couldn't say anything to them without being threatened. When asked if they were fearful of Resident #508 hurting someone prior to the incident on 8/16/20, Resident #511 replied, Oh yeah. Record review of Resident #511's medical record revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited assistance to perform Activities of Daily Living (ADLs). Review of Resident #508's medical record revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the Resident required supervision to limited assistance to perform Activities of Daily Living (ADLs) and had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderately impaired cognition. The MDS further revealed the Resident displayed Verbal behavioral symptoms directed toward others (threatening, screaming, cursing). Review of Resident #508's medical record revealed the following progress note documentation related to behaviors: -7/19/20: Behavior Note . Lab tech on unit to draw blood from resident. Lab tech reported to nurse that resident was masturbating during the blood draw. Will continue to monitor behavior. -7/24/20: Behavior Note . Resident approached nursing station from the observation unit - resident presented lunch in Styrofoam container & stated 'I need to have my food warmed up' . Nursing staff explained that we could get a fresh lunch from dietary but we would not be able to warm said food in microwave. Resident became upset and stated I don't know why ya'll are acting so stupid Just warm the damn tray up! . Resident proceeded to throw said food container on floor . resident continued to yell down the hallway I don't need to be here Ya'll are some stupid bitc#es Social work, DON (Director of Nursing) & doctor were notified . -7/25/20 at 9:19 AM: Behavior Note . Resident approached desk . RCS (Nursing Assistant) , resident . 'I am tired of you bitc#es playing games with me'! 'You can suck a big dog di#k' 'I don't know why the fu#k you getting smart with me for' . Reported to social work . -7/25/20 at 11:50 AM: Behavior Note: RCS reported to writer; when entering resident's doorway; asked if resident would like some ice water; resident replied 'I didn't fu#king ask you for water'; 'get the fu#k outta my room' . -7/29/20 at 3:16 AM: Behavior Note: Resident observed in hallway calling staff inappropriate names and threatening staff of bodily harm. writer attempt to redirect resident non-compliant and threatens both writer and staff stating 'he will kill us' and continues to call staff names such as bit#hes, whor#s, slu#s tells staff to suck his penis, calls staff dykes, and other inappropriate names while standing in the hallway yelling . -7/29/20 at 7:21 AM: Behavior Note: Resident observed in hallway threatening making sexual advances towards staff when attempt to redirect resident became aggressive and verbally threatening others. -8/4/20 at 10:42 AM: Behavior Note . Writer asked resident what was it that has blocking door entry because staff can't enter. Resident replied don't tell me what the fu#k to do with my room, fu#k you and suck my di#k . Resident constantly observed daily cursing and being verbally aggressive and resistive to care. -8/5/20 at 3:11 AM: Behavior Note . Resident requested some pain medicine. Nurse gave resident 2 Tylenol ES (Extra Strength) med cup. Resident took med cup and looked in it and said this ain't no God da#n Tylenol you bit#h. You trying to give me some mother fu#king [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION]) you dumb bit#h! Then threw the medicine at nurse -8/5/20 at 5:37 PM: Nursing Note . refused [MEDICATION NAME] medication. Also, patient threw dinner plate out onto the hallway floor from his room. During shift, client is aggressive and verbally disrespectful to other clients and employees. -8/6/20 at 8:40 PM: Nursing Note . Patient constantly using verbal language that is offensive to women and racist to employees/patients. -8/10/20 at 12:20 PM: Social Services Note . Resident made a verbal threat to another resident stating would beat his a#s. Resident was put on increased supervision through the weekend to ensure there would be no issues . -8/12/20 at 6:20 AM: Nursing Note . At approx. 0500 (5:00 AM) pt (patient) . immediately started cursing and calling the writer a Bit#h while hollering about the unit not having any towels and where is the MF (Mother Fuc#ing) towels. As I closed the door to the conference rm (room) (Resident #508) tried to hit me with their phone, but dropped it so I was able to back up into rm 103 doorway, then after picking it up (Resident #508) came at me again swinging at me unexpecting to where I had to run from him backwards, more profanity spewing, F--- You Bit#h. I noticed how angry (Resident #508) was that they missed and cursed at me some more but they finally turned the corner toward their unit . -8/12/20 at 7:05 AM: Nursing Note . All the previous mentioned incident was relayed to (Administrator) . -8/16/20 at 3:21 AM: Nursing Note . Resident has been in hallway cussing at staff and resident, resident informed to not do these things and should return to room if upset -8/17/20 at 12:21 AM: Behavior Note . Resident was petition out for tx and evaluation -8/17/20 at 12:27 AM: Behavior Note . Resident did indicate . was going to take a knife and stab another resident in the throat while slept. (Resident #508) indicated that they knew exactly where (other Resident) slept. Record review of Resident #508's care plans revealed the Resident had two care plans which mentioned behaviors but did not have a care plan in place related to their [DIAGNOSES REDACTED]. -When I get frustrated, I will become loud, and over talk others. I will curse, be disrespectful to others, and threaten other staff and residents. I am non-compliant at times and am not easily redirectable (Initiated: 7/17/20; Revised: 8/17/20). The care plan included two interventions: When I get frustrated, it helps me if you don't ask me a lot of questions (Initiated:7/17/20) When I get frustrated, it helps me to be in my room with the door closed (Initiated:7/17/20) -Potential for alteration in mood due to new admission into the facility. I will use profanity and become irritable at times (Initiated and Revised: 7/17/20). Interventions included: Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) (Initiated: 7/17/20) Observe/record/report to MD prn (as needed) acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills. (Initiated: 7/17/20) Interventions in both care plans had not been updated since the Resident's admission to the facility. Review of social services documentation in Resident #508's medical record revealed a Social Services - Initial Assessment and History dated 7/17/20 and locked 7/22/20. The assessment revealed Resident #508 was homeless prior to being hospitalized and then transferred to the facility. The assessment further detailed Resident #508 was alert and orientated to self, family, time, place and situation . Indicate mood(s) observed/reported . Mood: Angry . Resident is irritable and using profanity . Is a referral for psychosocial or mental health issues indicated? . No . Behaviors Observed / Reported . Defensive . Critical of others . Explain: Resident questioned writer and nurse manager on why was being questioned. Began using profanity. Needed redirection to answer questions . Is resident currently receiving Behavioral Healthcare Services? No Would resident benefit from Behavioral Healthcare Services? Yes . Explain: Psych to follow up for evaluation . Additional review of Resident #508's medical record revealed the Resident was seen by psychiatric health care services provider once, on 8/11/20. Review of psychiatric health care provider documentation detailed, (Resident #508) is irritable, crude, impulsive and disagreeable per (medical record) notes . (Resident #508) tells writer they are not crazy and do not need to be on that '[MEDICATION NAME] sh#t' . states does not need any of that psycho babble sh#t, and continued to tell writer what they could use (sexually, vulgar material) . Demeanor: Impulsive, resistant . Orientation: Orientated to person, time, and place . Judgement: Impaired . Insight: Impaired . Mood: Irritable . Affect: Labile . The documentation did not specifically address assessment related to Resident #508 threatening Resident #509. An interview was conducted with Social Worker I and Social Worker J on 8/19/20 at 12:38 PM. When queried regarding Resident #508, Social Worker I replied, We seen (Resident #508) upon admission. When queried regarding Resident #508's behaviors and participation when the admission assessment was completed, Social Worker I reviewed the Resident's medical record and replied, (Resident #508) did not want to participate. Their (sibling) was their guardian. At this time, Social Worker J revealed that Resident #508 had been living with their sibling before becoming homeless and stated, (sibling) couldn't trust (Resident #508). The (sibling) thought (Resident #508) would get angry and try to ruin their property. With further inquiry regarding Resident #508's behavior, Social Worker I stated, The way (Resident #508) was speaking would be potentially threatening. Social Worker J added, (Resident #508's) language was very vulgar. When asked if Resident #508 had ever physically harmed or threatened to harm another Resident, Social Worker I reviewed Resident #508's medical record and stated, Did on 8/10. When queried who Resident #508 threatened, Social Worker J replied, (Resident #509), (Resident #507's) roommate. When queried what interventions were implemented following Resident #508 threatening to physically harm Resident #509, Social Worker J revealed Resident #508 was placed under increased supervision over the weekend. With further inquiry regarding their statement of supervision over the weekend when 8/10/20 was a Monday, Social Worker J stated, It happened on Friday (8/7/20. When asked why the note in Resident #508's medical record was dated 8/10/20, Social Worker J revealed that is when they put it in (documented in medical record). No further explanation was provided. Social Worker J was then asked what increased supervision meant and stated, We did a form to make sure staff was doing a visual. When asked how frequently staff were checking on Resident #508, Social Worker J replied, I believe every hour or so. When queried regarding the length of time increased supervision was in place for Resident #508, Social Worker I replied, Just through the weekend. Then seen by psych on 8/11/20. Documentation of increased supervision for Resident #508 was requested at this time. When queried if psychiatric services addressed Resident #508 threatening Resident #509, Social Worker I reviewed the documentation and stated, It is not written in (psychiatric services note) that they addressed that with (Resident #508). When asked about Resident #508's care plan interventions not being updated since admission and documentation of behaviors, Social Worker I revealed the care plan and confirmed that the care plan interventions had not been updated. Social Worker I was asked why the interventions had not been updated and Social Worker I indicated the interventions were appropriate. When asked if the interventions were effective, related to documentation of Resident #508's behaviors and interactions with staff and other Residents, Social Worker I revealed Resident #508's behaviors were normal for them and not really a threat. When queried regarding what occurred on 8/16/20, Social Worker I stated, I

Based on observation, interview and record review, the facility failed to safely provide activities of daily living (ADLs) care per the resident's documented assessed needs for one (#37) of four residents reviewed for falls, resulting in a skin tear injury, and the likelihood further serious injury. Findings include: On 2/03/19 at 10:15 AM, Resident #37 was observed in bed watching television. During the interview Resident #37 was asked if they had any falls in the facility. Resident #37 stated, I was being moved and fell out of the bed. Resident #37 was asked if they were hurt when they fell . Resident #37 stated, Yes. I fell on my bottom and scraped my lower back. On 2/04/19 at 3:31 PM, a record review revealed that Resident #37 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) dated (MONTH) 26, (YEAR) noted, intact cognition and extensive assistance of two person physical assist with bed mobility, transfers, toileting, dressing, and hygiene. Review of Care Plan: I need assist with my adls and care due to my impaired mobility, muscle weakness, obese, DM HF,[MEDICAL CONDITION](Diabetes, Heart Failure, Hypertension), [MEDICAL CONDITIONS] [MEDICAL CONDITION], Comm (Communication) Deficit, Diff (Difficult) walking, [MEDICAL CONDITIONS], varicose veins, [MEDICAL CONDITION], aneurysm, [MEDICAL CONDITIONS], joint pain, [MEDICAL CONDITIONS], feeding diff, pain, [MEDICAL CONDITIONS]. Goals: I want to be kept clean and well groomed on a daily basis and to improve my current functional status through next review Intervention: BED MOBILITY: The resident is totally dependent on 2 staff members for repositioning and turning in bed Q 2 hrs (every two hours) and as necessary. Created 8/26/15. Review of a Progress Note dated 8/5/18 at 17:08 (5:08 PM) Nursing Note Text: RCS (resident care specialist) giving resident care, asked resident to roll over to her right side and resident rolled out of bed and onto floor. Fall was witnessed, resident stated she felt no new pain, approximately 10 cm (centimeters) skin tear to left flank . physician notified, management notified. Care plan updated. Will continue to monitor. Review of an Incident Report: Date 8/5/18, Description of Incident. RCS was changing resident. When asked resident to roll over, resident rolled too far and fell on to floor. Resident Outcome: Skin Tear. Was initial treatment provided? Yes. Cleanse, applied border gauze to left flank . Incident/Accident Investigation follow-up: Resident is to have 2 RCS for personal hygiene care including brief changes for safety. Review of a Written statement: To whom it may concern. I was doing my last change on (R37) in room (R37's room). When (R37) turned over to much as I was changing (R37) and fell on the floor. (signed CNA O). On 2/05/19 at 12:56 PM, during an interview, CNA O was asked about the incident with Resident #37. CNA O stated, I really don't remember. In the process of turning (R37) to (their) side, (R37) resident kept turning and fell out of bed. On 2/05/19 at 1:34 PM, during an interview, the Director of Nursing was asked, how many aides were assessed for bed mobility or brief change. The DON stated, I believe (R37) was a one person and after this fall (they) became a two person. At that time the Resident #37's care plan was reviewed and verified with the DON, that Resident #37 was a two person assist. The DON called the MDS Nurse M into the office. Nurse M was asked what was the assistance that was required at the time of the fall. Nurse M stated, (R37) bed mobility and hygiene was two person assist. A review of the facility's policy titled, Comprehensive Care Plan dated (MONTH) (YEAR), noted, Policy: The facility will develop a comprehensive person-centered care plan that identifies each resident's medical, nursing, mental, and psychosocial needs . The plan includes measurable objectives and timetables agrees to by the resident to meet such objectives .

This Citation Pertains to Intake Number MI 387. Based on observation, interview and record review , the facility failed to provide monitoring and supervision to prevent elopement from the front door at approximately 8:00 PM for 1 (#704) of 3 residents reviewed for elopement risk, from a total sample of 5. An Immediate Jeopardy (IJ) was identified when the Resident actual elopement from the facility and facility staff were unaware of the Resident's whereabouts for approximately 1 hour and 45 minutes on 5/3/18 in which the Resident propelled themselves in a wheelchair across a busy intersection to an unknown destination and was returned to the facility by an unidentified male, resulting in the potential for serious harm, injury, or death. The facility also failed to ensure adequate assessment, monitoring, and care planning for elopement risk for two (#'s 702 and 705) of 5 sampled residents, resulting in the potential for elopement. The Administrator was notified of the Immediate Jeopardy on 5/16/18 at 4:28 PM. A plan to remove the immediacy was requested. The IJ was removed on 5/4/18 based on the facility's implementation of the plan removal as verified onsite on 5/16/18. Although the IJ was removed, the facility's deficient practice remained at isolated. No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Resident #704 Record review on 5/16/18 at 8:45 AM revealed that Resident #704 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired, required supervision to extensive assistance to perform Activities of Daily Living (ADL's), and displayed wandering behaviors four to six of seven days. Review of Resident #704's facility Investigation documentation on 5/16/18 at 9:00 AM revealed the following documentation: -A handwritten statement dated Saturday 5/5/18: On Thursday 5/3 working as a floor monitor. There smokers were in line to go out got for 8 PM smoke break. I told (Resident #704) along with 5 other smokers that there weren't any other extra cigarettes and they were asked to leave out the line. I took the smokers out and upon entering the building (at 8:22- added to document), the alarm in the lobbing was sounding. I asked another resident did anybody go out and they said (resident #704) went out. I opened the door to see if I could locate (resident #704), but I didn't see them. I went to the nursing station to inform the nurse that a resident said (resident #704) went out the building. Code green was called and the facility was swept, looking in every room and bathroom. Some staff went outside looking by foot and by car. I contacted (Director of Nursing) to let them know what was going on . (Statement not signed, and author not indicated) Review of an Incident/Accident Report authored by Nurse C revealed, Date of Incident/Accident: 5/4/18 . Time of Incident/Accident: 8:00 PM . Elopement . Resident is missing from facility at 8 PM . Cognitive state prior to incident/accident . Confused Equipment involved . No . Safe Smoking Evaluation dated 5/4/18 at 10:28 AM Elopement Risk assessments dated 2/25/18, 3/16/18, and 5/4/18 all stating, Elopement Risk Score: AT RISK Review of Social Services Note authored by Social Worker F, dated 5/4/18 at 3:10 PM: Writer and psych NP (Nurse Practitioner) met with Resident . Resident is A&O x 2 (Alert and Orientated to person and place) with forgetfulness and confusion. Resident knew (where they were); however they thought the month was March, the year was (YEAR) and did not know the day of the week. Resident was unable to name the President of the United States. (The Resident's) general awareness and judgment for safety are both impaired. Resident was asked to recall an incident that occurred last night; however was unable to recall the events until writer asked if they went outside . Review of a Care Plan Conference Summary dated 7/11/17: Summary of care plan conference discussion . Per (family member/guardian), Resident #704 is fine to smoke. However, (family member/guardian) will not provide cigarettes . On 5/16/18 at 9:10 AM, the Director of Nursing (DON) was queried regarding Resident #704's elopement from the facility and the investigation. The DON stated, We have floor monitors (Nursing Assistants) who take Residents out to smoke. We usually keep a complimentary pack but there weren't any more. The floor monitor told(Resident #704) there weren't anymore cigarettes. The floor monitor heard the alarm when they came back in from taking other resident's out to smoke and asked another resident who was sitting there, then they looked outside. The floor monitor didn't see (Resident #704) so they called a code green. A guy was pushing (the Resident) back from the direction of the gas station. When queried regarding the handwritten statement that did not indicate who wrote it, the DON indicated Nursing Assistant B was the floor monitor/Nursing Assistant on 5/3/18 who had written the statement. Unit Manager Nurse A was interviewed on 5/16/18 at 10:10 AM and was queried regarding facility policy/procedure related to Resident's with elopement risks. Nurse A stated, We have a book. When asked about Resident #704, Nurse A stated, (Resident #704's) is on their wheelchair because they cut it off. We've put it on (the Resident's) arms and legs before. Tried everywhere so we put it on their wheelchair this time. When queried regarding the Resident's cognitive status, Nurse A replied, (Resident #704) has behaviors and short-term memory loss. Review of the Resident's progress note on 5/16/18 at 10:30 AM revealed the Resident had previously eloped from the facility as well as made elopement attempts. Documentation revealed the following: Review of a nursing note dated 7/8/17 at 3:34 PM: Another Resident informed writer that resident went out the back gate. Resident was last seen at approx. (approximately) 2 PM when given medication. Code green initiated, the building and surrounding area searched for resident. Residents family informed of situation. Administrator notified, and DON notified. Police called . Nursing Note dated 7/8/17 at 4:08 PM: Resident returned to the facility by the Police Department, Resident states went out of the building to get fresh air, Resident was found walking back to the facility . A nursing note dated 7/9/17 at 6:03 PM: Resident attempted walked out of the front door at 17:15. A nurse brought resident back into the facility without incident. Resident placed on 1:1 and given prescribed PRN (as needed) 0.5 [MEDICATION NAME] (prescription medication used to treat anxiety) . A nursing note dated 1/9/18 at 2:45 AM: Resident left building's front door at 2:45 am, writer and several staff member went to get resident and bring back in building. Resident states they are sorry, they just did not want to miss Christmas with their family. Resident was taken back to room, wander guard put on Resident, DON notified and guardian notified, via v/m (voicemail). Review of a Behavior Note dated 1/30/18 at 9:09 AM: Housekeeping staff witnessed and reported to writer that Resident use a butter knife from breakfast tray to remove wander guard from left leg. When interviewed resident stated using loud words Why do I need this? I am a wheelchair! I am not suppose to be here! A nursing note dated 2/1/18 at 4:14 AM: Resident attempting to elope from building at 3:35 am. Resident redirected via RCS (Resident Care Specialist) Monitor. Resident began using profane language and yelling loudly at 3:40 am. Next, resident went into the dining room and began asking staff and Residents to give them a dollar to buy a pop . Monitoring behavior, [MEDICATION NAME] .5 mg (milligram) administered. [MEDICATION NAME] .5 mg therapy not effective. Resident displaying inappropriate behavior with Bi-Polar tendencies and [MEDICAL CONDITION]. Resident also c/o (complain of) the inability to sleep . A nursing note dated 5/4/18 at 12:04 AM: Resident came back @ 9.45 PM with one cigarette, Pt (patient) said they went(NAME)rd with wheelchair, somebody pushing them back to facility, and gave them one cigarette . Review of facility policy entitled, Resident Elopement (Dated (MONTH) 2012) on 5/16/18 at 10:40 AM revealed, It is the responsibility of all personnel to report any Resident attempted to leave the premise or suspected of being missing, to the Director of Nursing and the Administrator and to document the occurrence . Wander/Elopement Alarm Activation: 1. If an employee hears a door alarm, he or she should: a. Immediately go to the site of the alarm; b. If a Resident is observed attempted to elope, follow the steps outlined below for Attempted Elopement; c. If no Resident is found to be exiting the facility, the employee should: i. Exit the facility., walk about the building and ensure that a Resident has not already exited the facility; ii. Notify the Director of Nursing and the Administrator immediately; and iii. Complete a head count to ensure that all Residents are accounted for . 2. Upon return of the Resident to the facility, the Director of Nursing and the Administrator should: a. Examine the Resident for injuries (Director of Nursing) . d. Complete and file an Incident/Accident Report; e. Make appropriate notations in the Resident's medical record (Director of Nursing) . The Administrator was interviewed on 5/16/18 at 10:50 AM and was queried regarding facility policy/procedure regarding the frequency of Elopement assessments for residents. The Administrator stated, They should be completed upon admission, readmission, and quarterly. When queried further regarding Resident #704 not having elopement assessments completed at those intervals, the Administrator was unable to provide an explanation. When asked why facility staff searched inside the facility before looking for Resident #704 outside, the Administrator stated, They had to be sure that was the Resident that left. With further inquiry related to documentation of Resident #704's prior elopement and elopement attempts, the Administrator indicated they would need to review the Resident's medical record and facility documentation. Additional facility Incident and Accident Reports for Resident #704 were requested at this time. An interview was conducted with Resident #704 on 5/16/18 at 11:45 AM. When queried regarding leaving the facility on 5/3/18, Resident #704 replied, Yes. I went down 10 Mile road, past(NAME) and got to a street (Resident was unable to recall street name). The Resident then indicated they saw a man who gave them a cigarette. With further inquiry, Resident #704 stated, They (unidentified man) told me to be calm, cool, and collected so we turned my wheelchair around and I came back. On 5/16/18 at 12:20 PM, an interview and record review of the facility provided investigation was completed with the facility Administrator. When queried regarding the handwritten, un-signed statement present in the facility investigation folder, the Administrator replied, That is (Nursing Assistant A)'s statement. When queried regarding additional staff interviews and/or statements related to the elopement, the Administrator reviewed the investigation folder and stated, The Social Work progress note is their statement. When asked about additional staff interviews, no further explanation was provided. An interview was completed with Nursing Assistant E on 5/16/18 at 1:20 PM. When queried, Nursing Assistant E indicated they monitor Residents during facility smoking times. When asked about facility smoking policy/procedures, Nursing Assistant E stated, We have extra cigarettes that we give Residents (if they do not have their own). With further inquiry, Nursing Assistant E indicated the facility provides one pack of cigarettes (20 cigarettes/pack) per day and that Residents who do not have their own cigarettes are limited to three smoking breaks per day. When asked, Nursing Assistant E revealed there are Seven smoke breaks (supervised cigarette breaks) per day at 7:00 AM, 9:30 AM, 1:00 PM, 3:30 PM, 5:00 PM, 8:00 PM, and 10:00 PM. Record review with Nursing Assistant E at this time of Resident's Cigarettes Log dated 5/3/18 revealed Resident #704 did not have their own cigarettes on 5/3/18 and went out to smoke at 1:00 PM and 5:00 PM. The log further revealed the facility provided 12 cigarettes to Residents on 5/3/18. When queried why Resident #704 was not able to smoke at the 8:00 PM smoking break when eight cigarettes would have been available in the daily facility provided pack of cigarettes, Nursing Assistant E was unable to provide an explanation. An interview was conducted with Nurse D on 5/16/18 at 2:05 PM. When queried regarding Resident #704's elopement from the facility on 5/3/18, Nurse D indicated they did not speak to the Resident prior to the elopement and stated I was doing an admit (admission). I saw (Resident #704) in their room and then (Nursing Assistant B) called for a smoke break. With further inquiry, Nurse D stated, I talked to (Resident #704) when they got back. (Resident #704) said it was cold, dark and they saw a man and asked him for a cigarette. The man brought (Resident #704) back. Nurse D then stated, The guy brought (Resident #704) back to the back door because they rang the doorbell. When asked about actions taken to locate the Resident, Nurse D stated, We looked all over inside and then started looking outside. When asked what the Resident was wearing when they left the building, Nurse D replied, A jacket and a gown. When queried if the Resident had made previous attempts to leave the facility, Nurse D replied, Yes. An interview was conducted with Nurse C on 5/16/18 at 2:25 PM. When queried regarding Resident #704's elopement from the facility on 5/3/18, Nurse C stated, (Resident #704) was upset and then they were going to smoke. When queried further regarding the Resident being upset before going to smoke, Nurse C replied, I don't know, I didn't hear. Nurse C further indicated (Resident #704) didn't have any cigarettes. When asked if the resident had a history of [REDACTED]. When queried regarding the nursing assessment completed when the Resident returned to the facility, Nurse C did not provide a response. When asked who organized the search for the Resident, Nurse C indicated facility Administration and the Police were notified. On 5/16/18 at 2:30 PM, an interview was completed with Social Worker F. With inquiry pertaining to Resident #704's elopement from the facility, Social Worker F indicated they were informed of the elopement on 5/4/18 at the facility morning meeting. Social Worker F stated, I heard there was an incident where (Resident #704) left out of the front door. With further inquiry, Social Worker F indicated they interviewed the Resident regarding the elopement and stated, (Resident #704's) cognitive function is declining. (The Resident) was not able to recall the incident, their story was conflicting. When asked if they interviewed other Residents and/or facility staff regarding the incident, Social Worker F replied, No, I did not do the investigation. That would have been the Director of Nursing (DON) and the Administrator. An interview was conducted with the facility Administrator and DON on 5/16/18 at 3:12 PM. When asked what time the Resident exited the building, the Administrator replied, I don't know what time the alarm went off. It was between 8:00 and 8:25 PM. When queried when they were notified Resident #704 had left the facility, the Administrator replied, I didn't get notified until the next day. When queried who orchestrated the search for the Resident, the DON replied (Nurse C) and (Nurse G). With further inquiry, the DON indicated four staff members left the facility to search for the Resident. When asked, the DON was unable to provide the names of the staff that searched for the Resident outside of the facility and/or where they searched. When queried again regarding Incident and Accident Reports for Resident #704's elopement/elopement attempts from the facility, the DON stated, We don't have any more (Incident and Accident Reports). When asked if an Incident and Accident Report should be completed for elopement/elopement attempts from the facility, the Administrator replied, Yes. No further explanation was provided. On 5/16/18 at 3:20 PM, an interview was completed with Nursing Assistant B. When queried regarding Resident #704's elopement from the facility on 5/3/18, Nursing Assistant B replied, I was outside with the smokers (Residents) and when I came back in the front door was alarming. I opened the door, looked both ways. I didn't see (the Resident). I asked another Resident who was sitting there, and they told me (Resident #704) left out the door. I went back the (Resident #704's) room and checked. They weren't there so I let the nurse know and we started looking for (Resident #704) inside. We searched the whole building and notified the DON. Then we went outside to look for (Resident #704). With further inquiry regarding the alarm and if other staff were able to hear the alarm, Nursing Assistant B replied, I don't know. That's a good question. You could definitely hear it. When asked if Resident #704 was upset prior to the 8:00 PM smoke break, Nursing Assistant B replied, Yes before when I told them 5:00 PM there were no more cigarettes for extra and they couldn't go out at 8:00 PM. Nursing Assistant B further revealed the Resident was in line for the 8:00 PM smoke break but was not allowed to go out due to not having cigarettes. An interview was conducted with Nurse G on 5/16/18 at 3:30 PM. When queried regarding Resident #704's elopement from the facility on 5/3/18, Nurse G replied, I didn't have (the Resident) but I did help to look for them. With further inquiry, Nurse G stated, We looked in the building first. In all the rooms and then one nurse went one way, and another went the other way in their cars. When asked who was in charge of the search, Nurse G replied, It would have been the nurse that was assigned to (Resident #704). When asked about when the Resident returned to the facility, Nurse G indicated they were unaware of the time or the door the Resident entered upon their return. When queried regarding events prior to Resident #704's elopement from the facility, Nurse G stated, One of the Resident's said (Resident #704) had gotten some money but that was after they were already gone. Review of Resident #704's care plans on 5/16/18 at 4:00 PM revealed a care plan related to risk of elopement entitled, I am an elopement risk and attempt to leave the facility r/t (related to) smoking, going home, anger at (family) keeping them here. History of attempts to leave facility unattended, Impaired safety awareness. I am noncompliant with allowing the staff to place wander guard on my person, so wander guard in place on my wheelchair (Initiated and Revised: 5/4/18). Care plan interventions included: -Check placement and function of safety monitoring device every shift (Initiated: 5/4/18) -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (pop, skittles, drawing, listening to music) (Initiated and Revised: 5/4/18) -Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is Resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate (Initiated: 5/4/18) -Observe location at regular and frequent intervals. Document wandering behavior and attempted diversion interventions (Initiated: 5/4/18) Additional review at this time revealed a care plan entitled, I need assist with my adls and care because I have cognitive impairment, disease process, unsteady gait, limited mobility and I have had a decline, [MEDICAL CONDITIONS], muscle weakness and personal care assist (Initiated and Revised: 3/21/18). The care plan included the intervention, Wanderguard placed on wheel chair due to consistently ripping it off on my leg or hand (Initiated and Revised: 3/21/18). Review of facility policy entitled, Incident/Accident Reporting for Residents (Dated (MONTH) (YEAR)) revealed, All incidents, accidents, and unusual occurrences involving a Resident are investigated, documented and reported . Definitions . Adverse Event: An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Adverse events include but are not limited to . All elopements . Reporting for All Incidents, Accidents, or Unusual Occurrences . 2. The facility documents all Incidents . d. Relevant facts regarding the Incident are recorded in the Progress Notes 3. The facility investigates the Incident in accordance with OP2 General Investigation Guidelines . Documentation . 2. Incident/Accident Report . 4. Progress Notes . The facility submitted a Plan of correction to remove the immediacy: Element 1 On 5/3/18, Resident #704, exited the front lobby door at approximately 8 PM and returned to the facility with no visible signs of distress same day approximately at 9:45 PM. A skin assessment was completed by the charge Nurse and no signs of injury were noted. The physician, guardian and law enforcement was notified of his return. After his return he was placed on 1:1 supervision with the floor monitor for the remainder of the shift and every 15 min checks thereafter. 5/16/18, the identified resident was placed on 1:1 supervision. Element 2 A QAPI and Safety meeting was held on 5/4/18, the elopement, Wanderguard and smoking policies were reviewed and deemed appropriate. All of the residents in the facility were reassessed for elopement risks, from 5/4/18-5/17/18, their care plans were updated as needed, as well as the elopement books. Their Wanderguard bands continue to be checked q-shift for placement and daily for functionality. Element 3 The Door Alarm company installed a new sounding alarm in the resident care area on 5/7/18 with the staff receiving education on the new sounding alarm. Starting On 5/4/18-5/12/18, The facility staff were reeducated on the elopement policy. All remaining staff will be re-educated prior to start of their shift. On 5/4/18, extended hours were put in place for the receptionist to start from 8:30 am-10 PM. The Receptionist will turn exit door alarm on prior to leaving daily. On 5/4/18, the Qapi team instituted a new agreement for courtesy cigarettes to be available for those who do not have at the moment. Element 4 Maintenance will continue to do ongoing daily check of alarm system on the day shift. The Smoking monitor will complete the cigarette audit sheet after each smoke break, at 7:30 am, 9:30 am, 1 PM, 3:30 PM, 5 PM, 8 PM and 10 PM. and report need of cigarettes to receptionist or administrator. The Admin/designee will do random checks 3 x weekly for 4 wks, then weekly x 4, and then monthly x 3 of the alarm system, with all findings reported to the QAPI committee. Resident #702 Record review on 5/16/18 at 9:10 AM revealed Resident #702 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required supervision to extensive assistance to perform Activities of Daily Living (ADL's). On 5/16/18 at 12:00 PM, Resident #702 was observed in the assisted dining room area of the facility. The Resident was observed speaking loudly to other Resident's in the dining room and swearing at facility staff. The Resident then left the dining room unassisted in their wheelchair and went to the front lobby area of the facility. On 5/16/18 at 12:10 PM, Resident #702 was observed in the front lobby area of the facility staring out the front window. An interview was conducted with the Resident at this time. When queried, Resident #702 stated they were waiting for their Mom. The Resident then stated, I want to get the h*** out of here and asked, Is this Holly? With further inquiry, Resident #702 stated, I think my Mom is by Holly. I want to find her. Resident #702 indicated their mother had not visited them recently and they wanted to see her. Record review of Resident #702's medical record on 5/16/18 at 1:00 PM, revealed the Resident had two Elopement Risk assessments completed while a Resident at the facility dated 8/10/17 ant 5/10/18. The Elopement Risk assessment dated [DATE] indicated the Resident was At Risk for elopement. Review of the Resident's care plans at this time revealed the Resident did not have a care plan in place related to elopement risk. On 5/16/18 at 1:50 PM, an interview was completed with the facility Administrator. When queried regarding Resident #702's statement indicating they wanted to leave the facility, assessment indicating the Resident was a risk for elopement, and lack of care plan, the Administrator was unable to provide an explanation and indicated they would review the Resident's chart. An interview was completed with Nurse G on 5/16/18 at 1:45 PM, when queried regarding Resident #702's risk for elopement, Nurse G stated, I haven't heard anything. Resident #705 Record review on 5/17/18 revealed Resident #705 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment revealed the Resident was severely cognitively impaired, required supervision to extensive assistance to perform Activities of Daily Living (ADL's) and displayed disorganized thinking and wandering behaviors daily. Record review of Resident #705's medical record revealed the Resident had Elopement Risk Assessments completed on 12/28/17, 4/3/18, 4/8/18, and 5/10/18 which all indicated the Resident was At Risk for elopement. Review of Resident #705's progress note documentation within the medical record revealed the following: -5/10/18; Social Services Note: Writer submitted resident's referral to the Skilled nursing facility. Resident was denied acceptance to the nursing facility due to resident being an elopement risk . -5/7/18 at 1:16 PM; Nursing Note: Resident still attempting to leave facility, checking doors . -4/8/18 at 4:07 PM; Behavior Note: Resident eloped out of A wing rear door was immediately brought back in the door by RCS (Resident Care Specialist) . -1/26/18 at 12:48 AM; Behavior Note: Resident attempting to elope out of A wing exit nurse redirected him . -1/23/18 at 8:56 AM; Nursing Note: In shift report per off going nurse, resident awake during the night, exit seeking . -1/8/18 at 6:10 PM; Behavior Note: Resident seen by writer trying to break the window out with walker in room and then tried to exit out of the back door on A-Wing . Review of Resident #705's care plans at this time revealed the following care plans: -I have the potential for alteration in behavior due to my hx (history) of being verbally agitated and aggressive at other facilities. I have attempted to throw my walker out the window. I attempt to elope from the facility and am not easily re-directable (Revised: 4/2/18). -I am at increased risk for falls r/t (related to) weakness, impaired mobility, h/o (history of) falls, gait/balance problems, possible medication side effects, wandering, impaired cognition (Initiated and Revised: 4/3/18). The care plan included the intervention, The Resident uses Wanderguard. Ensure the device is in place as needed (Initiated and Revised: 4/3/18). An interview was completed with Nurse H on 5/17/18 at 12:56 PM. When queried regarding Resident #705, Nurse H stated, Today was the first time that I know of (Resident #705) actually got out. They went into the courtyard. When asked how the Resident got into the courtyard, Nurse H indicated the door will open if someone pushes on it for a specific number of seconds and an alarm will sound. With further inquiry, Nurse H stated, (Resident #705) is always wandering and going by the doors. They talk about leaving all the time. A tour of the exterior facility doors was completed on 5/17/18 at 2:15 PM. Resident #705 was observed standing next to the C-Hall exterior facility entrance door and attempting to open the exterior door. An interview and record review of Resident #705's medical record documentation was completed with the facility Administrator and Director of Nursing (DON) on 5/17/18 at 4:25 PM. When queried regarding documentation of Resident #705's exit from the building today, 5/17/18, the Administrator and DON indicated they were unaware of the Resident attempting to leave the building. When queried regarding documentation of prior elopement, attempted elopements, and exit seeking behavior and facility Incident and Accident Reports/investigations, the DON stated, We don't have any I and A's (Incident and Accident Reports) about it. When asked if an Incident and Accident Report should have been completed per facility policy/procedure, the DON replied, Yes. When queried why the Resident's care plan was not updated to include elopement risk until 4/2/18 when prior elopement attempts and wandering behaviors had been identified, the DON and Administrator were unable to provide an explanation.

Based on observation, interview and record review, the facility failed to monitor and complete weekly skin assessments for one sampled resident (#49) of 2 reviewed for pressure ulcers in a total sample of 31, resulting in an acquired unstageable pressure ulcer on the heel, delay in treatment, and potential worsening of a pressure ulcer. Findings include: On 01/10/18 at 8:53 a.m., a review of the medical record for resident #49 revealed: Resident #49 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated [DATE] indicated cognitive impairment and the need for extensive/total assistance of one to two persons for bed mobility, transfer, dressing, eating, hygiene, and bowel/bladder care. Further review of Resident #49's clinical record revealed the following: MDS Section M. Skin: 3/18/17 resident at Risk for Pressure Ulcer, No Pressure Ulcer, No unhealed Pressure Ulcer. 6/1/17 resident at Risk for Pressure Ulcer, No Pressure Ulcer, No unhealed Pressure Ulcer, Were pressure ulcers present on the prior assessment, No. 9/1/17 resident at Risk for Pressure Ulcer, No Pressure Ulcer, No unhealed Pressure Ulcer, Were pressure ulcers present on the prior assessment, No. 10/28/17 M0210. Unhealed Pressure Ulcer(s) Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? Yes. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. 1. M0610. Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar. A. Pressure ulcer length: Longest length from head to toe. 06.1, B. Pressure ulcer width: Widest width of the same pressure ulcer, side-to-side perpendicular (90-degree angle) to length 04.3, C. Pressure ulcer depth: Depth of the same pressure ulcer from the visible surface to the deepest area. 00.0. Were pressure ulcers present on the prior assessment, No. Progress Note: 6/22/17 Nurse was asked by RCS (facility name for certified nursing assistant) to please check this resident('s) heel. A large necrotic area was noted. New tx (treatment) ordered & applied, along with foam boot. Care Plan for Skin: Created 9/29/15, revised 4/10/17, 6/2/17, 9/18/17: Skin checks weekly per facility protocol, document findings. Resident has Potential Skin Issues related to disease process, and non-ambulatory. 6/22/17: Resident has potential skin issues related to disease process, bowel and bladder incontinence, and non-ambulatory & (and) at this time has a necrotic area to her R (right). heel. Head to Toe Skin Checks: Weekly 2/16/17: Intact skin No other Skin assessments documented as completed, until 6/23/17. Wound care note: Weekly Pressure Ulcer Record 6/23/17 Right heel, existing, acquired at facility, Pressure Length 4.0 Width 6.0 Unstageable, Description of Site:100% eschar. No odor or drain, undermining-none, Wound bed Black eschar, no drainage, no odor. foam boot. On 1/12/18 at 2:45 p.m., during wound care observation with Nurse P, Resident #49 right heel was an area of pink in color, with no drainage or bleeding. On 1/12/18 at 11:26 a.m., during a review of the medical record with Unit Manager H, Unit Manager H, verified that skin assessments were not completed during the months of March, April, and May and no progress note related to skin until 6/22/17. Unit Manager H was asked if Resident #49 was supposed to be getting weekly skin assessments, Unit manager H said, Yes, if that is our policy she should have been getting weekly skin assessments. Order: Resident to wear ankles PRAFOs (back of the heel, alleviating pressure and preventing heel ulcers) for 4-6 hours daily . Check for skin integrity before and after application of PRAFOs. 6/22/17 Foam Boot on at all times 7/14/17: LAL (low air loss) mattress at #5 for positioning and comfort. On 1/12/18 at 4:00 p.m., during an interview, the Director of Nursing (DON) was questioned about Resident #49's missing skin assessments. The DON said, When I took this position we identified assessments as being a problem. The nurse that was in charge was not being consistent on the documentation of wounds. The DON was asked the facilities expectation for the completion of skin assessments, The DON said, The policy is to complete skin assessments weekly. A policy specifically pertaining to the facilities skin assessments was requested, but not received by the conclusion of this survey.

Based on observation, interview, and record review, the facility failed to provide sufficient and adequate medically- related social services to identify and ensure the needs of one (#31) of one Residents reviewed for social services were met, of a total sample of 31, resulting in a lack of timely follow up and documentation of legal guardianship as well as a dependent Resident with communication barriers being unaware of the status of their family, being unable to contact their family, and suffering emotional and psychosocial distress. Findings include: On [DATE] at 4:48 PM, Resident #31 was observed in their room lying in bed. When asked questions, the Resident did not verbally respond but was observed unsuccessfully attempting to open the drawer of a dresser. The dresser was positioned directly to the left of the top of the Resident's bed and had a TV sitting on top of it. With staff assistance, Resident #31 obtained two communication boards from the top drawer of the dresser. One communication board included the alphabet and the other communication board included pictures of common items. After obtaining the communication boards, Resident #31 pointed to letters on the board and spelled the words, Mom, Dad, Wife, and died . When queried if their wife had died , Resident #31 shook their head yes and gave the thumbs up signal. Resident #31 then pointed to letters on the board and spelled, Son. With additional inquiry, Resident #31 indicated they wanted to know where their son was. Resident #31 then pointed to letters on the board and spelled, Help. On [DATE] at 9:55 AM, record review revealed, Resident #31 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] indicated the Resident did not speak and did reveal assessment of the Resident's mental status. Additional review of the MDS indicated the Resident required extensive assistance to perform Activities of Daily Living. Review of the Resident's paper medical record at this time revealed the following documentation: -Letters of Guardianship dated [DATE]. The document was signed by a judge and revealed Resident #31 was a legally incapacitated individual. The document indicated the Resident's spouse was appointed by the court as Successor guardian of (Resident #31) . The document further revealed a non-relative guardian was appointed by the court system. The document indicated, These letters of guardianship expire on [DATE]. -Letters of Guardianship dated [DATE]. The document was signed by a judge and revealed Resident #31 was a legally incapacitated individual. The document indicated the Resident's spouse was appointed by the court as Successor guardian of (Resident #31) . The document indicated, These letters of guardianship expire on [DATE]. -Order: Suspending(NAME)of Fiduciary dated [DATE]. The document was signed by a judge and revealed (Resident #31's spouse), fiduciary in this matter has: Failed to file an Annual Report on Condition of Ward . It is ordered: The powers of fiduciary are suspended. On [DATE] at 10:50 AM, Resident #31 was observed lying in their bed in the facility with their eyes open and the TV on. When asked how they were doing, the Resident obtained the communication board and began pointing at letters. The Resident spelled the words, Mom, Dad, Wife, died , and Son. With additional questions, Resident #31 indicated their wife died and they did not know if their son was alive. The Resident became tearful and continued to point at letters to spell the word, Son. On [DATE] at 11:12 AM, an interview and record review was conducted with Social Services Staff K. When queried regarding Resident #31, Staff K stated, (Resident #31) had a guardian who was their wife. I recently informed (the Resident) that their wife passed in September. With further inquiry regarding the Resident and who was their legal guardian, Staff K replied, We were not aware (Resident #31's wife) passed until recently so we will have to work on that now. When asked if the Resident has other family members, Staff K stated, (The Resident) has a Mom and we have been trying to reach out to her but we cant reach her at this time. When queried regarding the Resident having a son, Staff K replied, (Resident #31) does have a son. I met him months ago but when the wife was diligently coming. When asked how old Resident #31's son is, Staff K replied, He appeared to be 11 or 12. When queried how the facility became aware Resident #31's wife had died , Staff K stated, We reached out to the Social Security office. Resident #31's facesheet and emergency contact information was reviewed with Staff K at this time. The only contact and phone number listed on the documentation was for the Resident's wife. When asked how the facility was attempting to reach Resident #31's Mom when the only phone number listed on the Resident's facesheet was for their wife, Staff K stated, (Social Worker F) will probably reach out to Social Security regarding finding (the Resident's) Mom. We don't have a phone number. When asked if the facility knew the Resident's Mothers name, Staff K replied, No, not at this time. With further inquiry as to how the facility was searching for the Resident's mother when they did not know their name, Staff K was unable to provide an explanation. When asked about Letters of Guardianship and the Order: Suspending(NAME)of Fiduciary documentation in Resident #31's paper medical record, Staff K stated, As far as I know, (Resident #31's) wife was their guardian. No further explanation was provided. With further inquiry, Staff K stated, (Resident #31) had been asking for their wife for a while. We were reaching out but we couldn't get a hold of her. When queried regarding documentation of attempts to contact the Resident's wife, Staff K stated, Just there in PCC (medical record). With further inquiry, Staff K stated, It would be in the notes. Review of Resident #31's medical record at this time revealed the following documentation: -[DATE] at 11:05 AM, Social Services Note: Resident was informed on today that his wife has passed in the month of [DATE]. Resident appeared to be sad and dismayed in regards to wife passing. Resident did ask about the well-being of his son and mother. Writer informed resident that writer would continue to search for resident's son as well as, resident's mother diligently. Resident was unable to inform writer of any pertinent information pertaining to his mother such as, an address or phone number at this time. SW to remain available prn (as needed). -[DATE] at 11:25 AM, Care Conference Note: Care Conference Held, resident and family invited, resident and IDT members present, resident has concerns of wanting family to come see them, Social Worker to address concerns . -[DATE] at 11:40 AM, Activities Note: Activity Annual Care Conference Note: . .Resident is able to make hand gestures and communication board to respond when questions and statements are phrased appropriately. Resident at times is visited by his spouse who is concerned with care . -[DATE] at 2:45 PM, Social Services Note: Quarterly Assessment: Resident is A&O x 2 (person and place) scoring ,[DATE] on BIMs with ,[DATE] recall. Resident is non-verbal; however is able to communicate needs and concerns to the staff with communication board. Resident uses gestures to communicate (i.e. a thumbs up sign if you are guessing correctly). Resident knows where they are at. (Resident) is able to communicate with a picture communication board or the alphabet communication board where he can spell things out . Resident is able to communicate very basic needs; however staff to anticipate and meet resident needs. Resident's spouse is guardian. (Facility) sent a certified letter since she does not return phone calls and has not been in to see resident in over 5 months. Resident's current mood appears stable . SW to remain available to resident and family prn. Resident's AD (Advance Directives) were reviewed and is a full code. -[DATE] at 12:06 PM, Activities Note: .Resident is able to make hand gestures and communication board to respond when questions and statements are phrased appropriately. Resident at times is visited by his spouse who is concerned with care . -[DATE] at 3:23 PM, Social Services Note: Writer sent a certified letter to resident's spouse/guardian regarding the lack of communication or return phone calls when the facility leaves messages. The facility is requesting a response from guardian; otherwise SW to apply for modification of guardianship. SW to remain available to resident and family prn. On [DATE] at 1:08 PM, an interview was completed with Resident #31. When queried regarding their parents' names, the Resident started smiling and gave the thumbs up gesture. The Resident proceeded to spell their Mother and Father's names utilizing the communication board. The Resident then spelled the words Son and spelled their son's name. After this, the Resident then spelled Wife, died followed by Son and Alive. When asked if they were asking if their son was alive, the Resident shook their head indicating, Yes. The Resident was observed to have tears in their eyes. When queried if any facility staff had asked what their parents and/or son's name were, the Resident shook their head to indicate no. On [DATE] at 10:16 AM, an interview was completed with the facility Administrator and Social Worker F. When queried regarding Resident #31 and action taken by the facility related to the death of the Resident's spouse/guardian, Social Worker F indicated the facility found out in December the Resident's wife passed away in September. When asked how long it had been since the Resident's spouse had visited the facility, Social Worker F was unable to provide a response but indicated a certified letter had been sent to the spouse/guardian by the facility in June. When queried regarding steps taken to locate the Resident's family including their wife and son as indicated in the Social Services note dated [DATE], Social Worker F indicated they were attempting to locate the family. When queried what the Resident's Mother, Father, and Son's names were, Social Worker F replied, I don't know. When asked how they were attempting to locate the Resident's family if they did not know their names, Social Worker F was unable to provide an explanation. When queried regarding the emotional distress and concern the Resident had expressed related to their wife's death and not being aware if their son was alive, Social Worker F indicated they were not aware the Resident was experiencing emotional distress or worry. When queried if they had assessed the Resident after they were informed of their wife's death and documented their assessment, Social Worker F stated, There is no documentation. When asked why they had not begun looking for the Resident's family and why they did not ask the Resident their family member's names, Social Worker F was unable to provide an explanation. When queried, the facility Administrator replied, There is nothing I can say. We will work on it. An interview was completed with the facility Administrator and Business Office Manager M at 3:30 PM. When queried regarding Resident #31 and communication with the guardian, Manager M stated, We sent the deficiency notice in June and termination was sent [DATE]. When queried further, regarding facility actions, Manager M stated, We didn't do anything through December when we found out (Resident #31's) spouse died . Record review of facility policy entitled Social Services Program (Dated February 2017) on [DATE] revealed, General services, with which a social service department may assist, oversee, or manage, could include: . Maintaining contact with Resident's family or legal representative . Specific conditions to which the facility should respond with social services staff or referrals include, but are not limited to: Lack of an effective social support system; . Presence of legal or financial problems; . Need for emotional support . Documentation: Interdisciplinary Progress Notes: Document any interaction or visits with the Resident, their family members, and/or outside providers working with the resident .

This citation pertains to intake MI 821: Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided when it was determined that one to one supervision was needed for one (#804) out of 3 residents reviewed for falls out of a total of 7 sampled residents, resulting in multiple falls, a fall that resulted in a hematoma (a collection of blood outside of a blood vessel. Source: MedicineNet.com) on the forehead, and a black eye. Findings included: On 1/24/17 at 3:18 PM, a review of the clinical record revealed that Resident #804 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #804 had severely impaired cognition, and required extensive physical assistance from staff to complete activities of daily living. The Fall Risk Assessment, dated 10/7/16, revealed that Resident #804 was at High Risk for potential falls. The nursing care plan, initiated 9/6/16, documented that Resident #804 Has a behavior problem of impulsiveness and combativeness at times related to his [DIAGNOSES REDACTED]. 8/27/16 unavoidable for falls due to poor cognition and impulsiveness . On 1/24/17 at 5:00 PM, during an interview, Family Member D stated, I was told that he would have a one to one (supervision), but that was a lie. He has had so many falls while he's been here. He had a fall where he was so bruised .this was taking in December (2016). Family Member D revealed on her cell phone a photo of Resident #804 with a black/purple bruising that covered the right forehead and a right black eye. They told me that he was going to have someone with him. I had been visiting and when I got ready to leave I told Nurse I I was going, but before I could get where I was going, they (facility staff) called me to say he had fallen and was at the hospital. I flew back here and asked 'What the h-- happened?' They just looked at me. During the interview, Resident #804 was observed lying in a low bed. Resident #804 repeatedly attempted to sit up and get up and Family Member D had to repeatedly reassure the resident that everything was ok and to lay back down in the bed. Resident #804 would mumble nonsensically, lay down and then try to get up again. On 1/25/17 at 12:00 PM, a review of Incident/Accident Reports revealed Resident #804 had sustained the following falls/incidents: 10/25/16 at 8:45 AM - Unattended no injury - hallway - no injury - Patient was observed getting up from his chair in the hallway, when trying to sit back down he dropped int the floor due to wheelchair was not locked. Patient has a small skin tear on his right hand. 11/3/16 at 3:30 (no AM/PM documented) - Fall - hallway - Observed resident on floor with small skin tear left posterior arm. 11/12/16 at 8 AM, Fall - dining room - Observed resident on floor with no apparent injuries . 11/13/16 1:30 AM - Skin tear - resident's room - Patient stated he wanted to use the restroom and opened the door, trying to go in the restroom. On the way in, he accidently scrapped his right hand in the door way. 11/17/16 at 11:00 PM - Fall - resident's room - Observed on knees in front of wheelchair with skin tear right forearm . 11/18/16 at 11:20 PM - Fall - hallway - Observed resident on floor in hallway with no apparent injuries. 11/20/16 at 12:30 PM - Abrasion to right hand - hallway - Patient stood up out of wheelchair and fell , did not hit head . 11/21/16 at 3:30 PM - Unattended with injury - hallway - Patient was observed reaching forward and fell over hitting his right side of the head. Redness and swelling observed .Witnessed by the maintenance manager. On 1/25/16 at 12:40 PM, the Director of Nursing (DON) was asked about Resident #804's falls and interventions that had been put in place. The Interdisciplinary Post Fall Reviews were reviewed. The Post Fall Review for 11/21/16 documented that Resident #804 was to be started on 1:1 supervision. However, the DON stated, Resident #804 had been on a 1:1 supervision for a few months. We asked Hospice to provide a 1:1 sitter, but they said they didn't do that. The Nursing Care Plan documented, 11/18/16 Hospice called to provide a volunteer sitter. However, hospice unable to do at this time. Resident unavoidable for falls due to cognition thus will continue POC (Plan of Care). The DON was asked to review the 1:1 documentation forms for October to present. At 13:37 PM, the DON revealed she only had 1:1 forms for 12/17-12/18/16, 1/18/17, 1/20/17, 1/21/17, 1/22-1/23/17, and 1/24/17. The DON revealed she was not sure where the other forms were. Further review of the post fall assessments had staff interview forms stabled to them that were blank. The DON was asked if post fall investigations had been completed and what new interventions had been attempted. The DON reviewed the post fall assessments and stated, The staff failed to follow protocol. When a resident has a fall, they are supposed to assess for injury, if the person is on the floor and can't get up, use the lift to get them up, do an assessment. They are supposed to document the circumstances in the electronic medical record, notify the physician, guardian or responsible party, do neuro checks if the fall was unwitnessed, and put interventions in place to assure another fall does not occur. When that does not work, they should be put on a 1:1. The documentation does not support what I believe in my heart we have done. The DON was asked about Resident #804's injury after the 11/21/16 fall. The DON stated, He was black and blue. On 1/25/17 at 3:01 PM, Nurse I was asked about Resident #804's fall on 11/21/16. Nurse I stated, He fell on the right side of his head .I was in the medication room and was told the resident had a fall. Nurse I was asked if Resident #804 was on 1:1 supervision that evening. Nurse I stated, The 1:1 was off and on. He was supposed to have a 1:1, but he did not have a 1:1. Nurse I was asked about Resident #804's injury. Nurse I stated, He had a hematoma (a collection of blood outside of a blood vessel. Source: MedicineNet.com) on his head. There was a cut on the hematoma (a collection of blood outside of a blood vessel. Source: MedicineNet.com) and some blood on the floor. I sent him to the hospital. Because of the inconsistency of the 1:1, I suggested we have an activity table. They (facility staff) asked Hospice if they could do the 1:1 and they said they couldn't do it . On 1/25/17 at 4:03 PM, Hospice Nurse L was asked about Resident #804's 11/21/16 fall. Hospice Nurse L stated, They called our line to report it .They initiated the 1:1 after that fall. He was on 1:1 before that fall, but it was intermittent. On 1/25/17 at 4:30 PM, the Assistant Director of Nursing (ADON) was asked about Resident #804's 11/21/16 fall and the 1:1 supervision. The ADON stated, He's been on it. I did a clarification order in December prior to that he was on it as well. I called Hospice on 11/18/16 to see if they would provide a sitter. They told me they couldn't do that. The ADON revealed the nursing care plan entry, dated 11/18/16, and stated, That is the day I called Hospice to see if they could provide the 1:1. The ADON was asked if it was determined on 11/18/16 that Resident #804 required 1:1 supervision to keep him safe, what was implemented. The ADON stated, We continued with the plan of care in place, a sensor pads. The ADON revealed there was no documentation that 1:1 supervision had been provided by facility staff on 11/18/16. The ADON was asked about Resident #804's injury. The ADON stated, He had a hematoma on his forehead and a black eye. On 1/25/17 at 4:45 PM, a review of the facility's policy titled Fall Management, revised August 2012, stated, If a fall occurs, the Interdisciplinary Team (IDT) conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls . ( )

This citation pertains to MI 871. Based on observation, interview and record review the facility failed to monitor, accurately assess, and treat one resident (#701) with a [MEDICAL CONDITION] that resulted in an Anaerobic Right Foot Infection and subsequent right above the knee amputation and and failed to monitor and assess the feet of one resident (#702) which resulted in right foot [MEDICAL CONDITION] from a total sample to three residents all reviewed for infections. Findings include: Resident #701 On 10/26/16 at 9:15 am, Resident #701 was observed laying in bed. The head of the bed was up at an approximately 40 degree angle. Resident #701 was observed to be alert, looking out into the hallway, and intermittently calling out to passers-by in the hallway shouting, Help me! Help me! Resident #701 was observed to have a bandage that covered her right leg stump. At 10:15 am, Resident #701 was observed and shouted, Help me! Help me! What am to do with this? At that time Resident #701 looked down at her right leg stump and touch her upper thigh with both hands. On 10/26/16 at 9:30 am, clinical record review revealed Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set ((MDS) dated [DATE], Resident #701 had impaired cognition and required extensive to total physical assistance with all activities of daily living (ADLs). The assessment also noted that Resident #701 was noted to have a [MEDICAL CONDITION] and it documented the application of dressings to the feet. Further clinical record review revealed the following: The Acute Care Facility Assessment, dated 10/23/16, documented the following when Resident #701 was interviewed, Why did I lose my leg? An Acute Care Facility document, dated 10/23/16, noted that Resident #701 presented to the hospital with inflammation changes and crepitus (a crackling sensation when touched) of the right leg. Further review of the Acute Care Facility record, dated 10/23/16, revealed the following, admitted to hospital from nursing home for right heel wound with malodorous and necrotic site with tendon showing, the patient is been on antibiotic at nursing home, patient has multiple decubitus ulcers .x-ray noted gas extending into the mid and lower leg concerning for gangrene infection. Resident #701 was subsequently taken for emergency surgery where a right above the the knee amputation was performed. However, further record review revealed that Resident #701 did not receive antibiotic therapy for the right heel wound while a nursing home resident for the months of September 2016 and October 2016. A care plan related to Potential/Actual Skin Issues initiated on 7/23/15 documented, Contact Doctor if changes in wound is noted (revised on 8/4/16). If odor develops to foot/heel wound, contact Dr. for orders (initiated on 9/19/16). Skin checks weekly (initiated 1/29/16). However, further review revealed that the Wound Care Physician was aware of the worsening right heel wound condition (interventions were not reviewed or revised), an odor was observed to have developed on 9/13/16 (interventions were not reviewed or revised), and no weekly skin checks after May, 2016 were performed by licensed nursing staff. A care plan titled, Resident has Potential/Actual Infection related to: Wound/Skin to Right Heel (initiated/revised on 10/7/16), revealed the following goal, Resident's infectious process will resolve with treatment ordered/provided by next review. However, there was no treatment nor antibiotic therapy ordered. The care plan included the following interventions, Observe and Report changes to right heel, provide antibiotic therapy as ordered, and treatment as ordered. However, review of the Physician Orders revealed that no antibiotic therapy was ordered per the Medication Administration Record for October 2016, Resident #701 did not receive any antibiotics related to the right heel wound and per the Treatment Administration Record the treatment was not reviewed or modified. Physician order review revealed: A physician order dated 8/3/16, Followed by wound care here at the facility. A physician's order dated 9/6/16 to crush a 500 milligram tablet of [MEDICATION NAME] (antibiotic) and add to Santyl (debridement) every day shift for odor to foot wound. The order was administered once on 9/8/16 and discontinued on 9/11/16. [MEDICATION NAME] is used to decrease odors emitted from wounds. A physician's order dated 9/9/16 documented, Infectious Disease (ID) consult related to antibiotic resident pulled PICC (IV line that extends into the right side of the heart) line did not complete course of ABT (antibiotic). Refuses PICC line. However, review of the ID Physician 'D' note dated 9/15/16, documented that Resident #701, Is seen in follow-up status [REDACTED]. Patient has a history of bilateral feet ulcers, urinary tract infections. Patient has been maintained off of antibiotics and remains in stable condition. Plan. Keep patient off antibiotics and monitor from a distance. A physician's order dated 9/19/16, revealed X-ray right foot and ankle to rule out osteo[DIAGNOSES REDACTED] (bone infection). According to the Radiology (X-ray) Report dated 9/19/16, the word ALERT' was noted across the report and documented, The bones appear diffused, demineralized. Large heel ulcer seen with erosive change of posterior calcaneous (heel bone) concerning for osteo[DIAGNOSES REDACTED]. Consider MRI. On the report, Nurse Practitioner 'C' documented that the results were discussed with Wound Care Physician 'B' and there were no new orders. The treatment ordered on [DATE] of Dakins Solution 0.4-0.5%, apply to right heel topically every day shift for open area. Cleanse area with normal saline, apply and wrap with abdominal pad and Kerlix. Review of Wound Care Nurse Notes revealed the following: Weekly Head To Toe Skin Checks (a nurse assessment) were reviewed from May 2016 through October 2016. There were no weekly Head to Toe Skin Checks performed for Resident #701 after 5/5/16. Skin-Weekly Non-Pressure Condition Record signed on 9/13/16 by Nurse 'A' documented Right heel. 7.6 centimeters (cm) x 7.5 cm, depth utd (unable to determine) Description of Site- 20% necrosis (dead tissue), 50% (softened dead tissue), 30 % granular (tissue). Odor is present at times, with new order for Dakin's. Moderate serous (fluid with red blood cells) drainage. Skin-Weekly Non-Pressure Condition Record signed on 9/29/16 by Nurse 'A' documented Right heel. 7.6 cm x 7.5 cm, depth utd. 20% necrotic, 50 % slough, 30% granular, without odor and moderate serous drainage. There was no change in the right heel wound status. Skin-Weekly Non-Pressure Condition Record signed on 9/29/16 by Nurse 'A' documented, Right heel. 7.3 cm x 7.5 cm, depth utd. 30% necrotic, 70% slough, [DIAGNOSES REDACTED] noted all around, without odor, & heavy serous drainage. There was an increase in necrotic tissue and slough with no granular tissue indicating deterioration of the wound. Weekly Non-Pressure Skin Assessment dated 10/10 noted, Right foot [DIAGNOSES REDACTED] (redness), [MEDICAL CONDITION], condition deteriorated. Skin-Weekly Non-Pressure Condition Record signed 10/13/16 by Nurse 'A' documented, Right heel. 8.0 cm x 7.8 cm, depth utd. 30% granular, 70% slough, moderate serosanguinous drainage, without odor. However, admission records to the acute care hospital dated 10/13/16 (same day the note was signed) noted that Resident #701 was admitted with a malodorous and necrotic right heel wound. Skin/Wound Note date 10/13/16 documented, While doing resident's wounds to right heel today, a tendon was showing to back of right leg. Very odorous. Review of Wound Care Physician 'B's note, dated 10/3/16, documented that Resident #701 has a transmetatarsal amputation (removal of toes). The right heel diabetic ulcer, measures 8.4 cm x 7.6 cm, unable to determine depthness, 30% necrotic, 60% slough, 10 % granular. Moderate serosanguinous drainage. Review of Wound Care Physician 'B's note, dated 10/10/16, documented that Resident #701 had a right heel diabetic ulcer that measured 10.5 cm x 7.8 cm but unable to determine the depthness. Has some mild [DIAGNOSES REDACTED] around. There is [MEDICAL CONDITION], 60% necrotic tissue, 40% slough, moderate serous drainage. Wound Care Physician 'B' also documented, Multiple comorbidity's and very high risk of further amputation of the foot due to the patient's noncompliance and the severity of her disease. However, Resident #701 had to have emergency surgery to remove the entire right lower leg (including the knee). In addition, the note did not address treatment after the wound deteriorated over the last 4 nurse assessments and after the last 2 physician assessments. There was no consult made to Infectious Disease (ID) as Resident #701 began to exhibit signs and symptoms of infection (redness and inflammation). Review of the Medication Administration Record (MAR) for the month of September 2016 revealed a physician order for [REDACTED]. The reason for use documented on the MAR was [MEDICAL CONDITION] and confirmed by the ID note dated 9/15/16, that Resident #701 was administered the [MEDICATION NAME] for a urinary tract infection [MEDICAL CONDITION] and not for the diabetic wound to the right heel. There was no documented evidence that Resident #701 received any antibiotic therapy related to the right heel diabetic ulcer. On 10/26/16 at 12:15 p.m., Infectious Disease Physician 'D' was interviewed regarding Resident #701's right heel treatment. Physician 'D' explained that he did see Resident #701 and then stated, I don't see her on a regular basis. I defer to the wound care team to tell me if I need to see (Resident #701). Physician 'D' then explained Resident #701 had been on and off antibiotics for a while because she had a chronic wound to her right foot. Physician 'D' then explained that he was aware of the right leg above the knee amputation and that, The extent of the amputation has to do with vascular supply (not infection). On 10/26/16 at 1:15 p.m., Wound Care Nurse 'A' was interviewed. Nurse 'A' explained that Resident #701 had a right heel diabetic ulcer that would get better and then it would get worse. When asked about the odor that emitted from the right heel wound, Nurse 'A' stated, It was odorous for a while, but it was the dressing. After you clean the wound and remove the bandages and 'sniff' the area, it didn't have an odor. Nurse 'A' added, The staff was always telling me that the wound was odorous but I explained to them that it was the bandages and not the wound. When asked why was the [MEDICATION NAME] ordered to be crushed and placed into the wound, Nurse 'A' stated, For a wound that stinks. Nurse 'A' was then queried as to where the tendon was visible as she stated in her nurses note and pointed to the area below her right ankle and stated, The skin was gone. When asked about antibiotic therapy, Nurse 'A' stated, I was not aware that she was on any antibiotics for the right heel wound. Once she pulled the PICC line out (September 10, 2016) I don't know what they decided to do. However, review of the record documented that Resident #701 did not receive ABT therapy for the right heel wound. On 10/26/16 at 1:45 p.m., Wound Care Physician 'B' was interviewed via telephone regarding Resident #701. Physician 'B' explained that she had seen Resident #701 on 10/10/16 and stated, (Resident #701) had an infection. When asked how did she know, Physician 'B' stated, From the odor of the wound. It had a little redness and moderate drainage. On 10/13/16 I was informed of the tendon showing. That can happen within 24 hours. When asked were antibiotics or some intervention implemented after she noted that Resident #701 had an odor emitting from her right foot wound on 10/10/16, Physician 'B' stated, I don't have a note on Antibiotics. I thought she was done with the antibiotics. On 10/26/16 at 2:00 p.m., Nurse Practitioner (NP) 'C' was interviewed and explained that Resident #701 required IV antibiotics. On 9/9/16 she had a few doses left and there was an attempt to initiate another PICC line. She refused it. I wrote the consult for ID to see if she needed any more antibiotics. When queried regarding the follow-up for the Radiology report that recommended an MRI, NP 'C' reviewed the report and stated, I discussed that (MRI) with them (Wound Care Team). They handle the wound, we do not. On 10/26/16 at 2:40 p.m., Nurse 'E,' whose medication cart is usually posted outside of Resident #701's room, was queried. Nurse 'E' explained that she used to be a wound care nurse. When asked if she noted any odors that would be indicative of infection, Nurse 'E' stated, No. However, Nurse 'E' explained that during the last few days prior to Resident #701 being discharged on [DATE], there was a lot a blood/drainage and frequent dressing changes like 3-4 times a day. That is a sign of infection. On 10/26/16 at 3:00 p.m., Nurse 'F,' who regularly provided medication and performed intermittent wound care for Resident #701 was queried. When asked about antibiotic therapy for Resident #701's [MEDICAL CONDITION] that was deteriorating Nurse 'F' stated, It was my understanding that (Physician 'D') did not want to continue with any antibiotics. When asked about any odors observed from Resident #701's diabetic ulcer to the right foot Nurse 'F' explained, The wound has been odorous since mid September (2016). The odor from the wound was abnormal. It wasn't the odor you expect from a dressing change. I've been a nurse for some time and I know what is abnormal. On 10/26/16 at 3:00 p.m., record review of the United States National Library of Medicine (4/2016) regarding Anaerobic (Gas Gangrene) Infection noted the following signs and symptoms of the infection; swelling, gas that can be felt as a crackly sensation (crepitus), edges of the area (wound) grow quickly, and a foul-smelling brown-red or bloody fluid (serosanguinous discharge). According to the web site the condition can by diagnosed using X-ray or MRI; X-ray, CT scan or MRI may show gas in the tissues. Treatment includes IV Antibiotic therapy or surgery to remove dead, damaged, and infected tissue. On 10/26/16 at 3:35 p.m., review of the facility policy titled Skin Management revised August 2012 revealed, The nurse will assure treatments, interventions, Care Plan, and the appropriate skin documentation records are initiated in a timely manner according to Practice Guidelines. The policy also noted that for lower extremity ulcers, monitor the area closely during treatment to evaluate appropriateness of treatment regime. Consult with Certified Wound Care Nurse or surgeon may be appropriate. Resident #702 On 10/26/16 at 10:00 am, Resident #702 was observed to have a PICC line inserted into her right arm. On 10/26/16 at 11:50 am, a skin assessment of Resident #702's (who was seated on the side of her bed) was performed with Nurse 'G. Resident #702's entire right foot was observed to be reddened from the tips of the toes to the ankle. The right foot was approximately twice the size of Resident #702's left foot. A pea-sized, blackened, raised area in the middle of the right second toe was also observed. When queried, Resident #702 stated, It doesn't hurt but I'm not sure how I'm going to walk on it. That may be hard to do. On 10/26/16 at 11:00 am, clinical record review revealed Resident #702 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/25/16 Resident #702 was diagnosed with [REDACTED].#702 had severely impaired cognition, was able to walk independently and required supervision for hygiene and bathing needs. According to the assessment, Resident #702 had no skin impairments or skin treatments. Review of the care plans revealed no care plan for Activities of Daily living, no non-compliant care plan related to the provision of care, and no care plan for potential or actual wound care prior to 10/25/16. Further record review revealed a physician order dated 8/2015 to perform Weekly head to to assessment on Tuesdays. Review of the Skin-Head to Toe Skin Checks dated 5/5/16 noted, Skin intact, need podiatry consult. Review of the Skin- Head to Toe Skin Checks revealed no weekly Skin- Head to Toe Skin Checks for the months of June, July, August, September or October 2016. A nurses note dated 10/12/16 documented, Resident shoes too small. Resident has scab on her right foot, second toe. Is wearing non-skid socks and is walking fine. There was no follow-up assessment or monitoring of the 'scab' implemented. An SBAR (change in condition report) dated 10/24/16 documented, Right foot with redness and area weeping. Was wearing shoes with no socks. Podiatry here .new orders for antibiotics for right foot [MEDICAL CONDITION]. On 10/26/16 at 2:00 p.m., the Director of Nursing (DON) was interviewed and acknowledged that there were no Skin - Head to Toe Skin Checks performed on Resident #702 since May of 2016. When asked how did staff know to look at Resident #702's foot, the DON explained that a staff nurse noticed that her gait changed because her shoes were too small. When asked if Resident #702's feet were monitored and assessed on a regular basis to prevent the right foot [MEDICAL CONDITION] the DON was unable to explain or provide documentation that Resident #702's feet were monitored prior to the discovery of the scab on 10/12/16 nor was the DON able to provide evidence that Resident #702's feet were monitored and assessed after the scab was discovered. When asked if a care plan related to the right foot scab was implemented the DON stated, No. When asked if Resident #702 had an ADL care plan, the DON was unable to provide an ADL care plan for Resident #702. On 10/26/16 at 3:35 p.m., review of the facility policy titled Skin Management revised August 2012 revealed that weekly skin checks are to completed and documented as completed by the Licensed Nurse's initials. Note: Alterations or change(s) in skin integrity, any break in the resident's skin .are to be recorded on the Head to Toe Skin Check form. On 10/26/16 at 3:30 p.m., review of the facility policy titled, Wound Care/Treatment Guidelines revised 9/2015, documented, A weekly assessment should be done on all wounds requiring treatment. This should include measurement and a description .so nurses will be aware of the progress. The care plan should reflect the current status of the wound and appropriate goals. ( )

Based on observation, interview, and record review the facility failed to monitor the use of [MEDICATION NAME] (an antipsychotic medication) for one (Resident #501) of three residents reviewed for the use of an antipsychotic medications from a total sample of three residents resulting in the development of involuntary muscle movements and a decline in physical function. Findings include: On 3/19/15 at 10:00 am, Resident #501 was observed in seated in a reclining chair with Certified Nurse Assistant (CNA) 'F." CNA 'F' placed one hand on Resident #501's left shoulder while her body was positioned to prevent Resident #501 from rising up and out of the chair. CNA 'F' stood in front of Resident 'F' while CNA 'A' gathered supplies to change Resident #501's brief and while Treatment Nurse 'D' gathered supplies to perform Resident #501's wound care. During the time from 10:00 am until 10:20 am Resident #501 was observed to have involuntary movements in both arms. The muscles in the arms were observed to flex and release with intermittent jerking movements. Resident #501 was observed to intermittently attempt to move forward in the chair with occasion periods of forward hip thrusts. At 10:20 am Resident #501 was assisted into bed and positioned onto his left side by Treatment Nurse 'D' and CNA 'A.' Resident #501's pants were pulled down to expose the wound and both thighs. During the treatment there were spontaneous and intermittent times when Resident #501's thigh muscles could be seen to abruptly contract and release, there were intermittent and forward moving pelvic thrusting and both arms were observed to suddenly and abruptly flail about without purpose followed by periods of rest. When asked what the intermittent muscle contractures and movements were related to, Treatment Nurse 'D' did not provide an explanation. CNA 'A' was queried regarding the jerky movements exhibited by Resident #501 and stated, "(Resident #501 jumps in his sleep like he is having nightmares." Nurse 'D' or CNA 'A' were unable to report if these movements have worsened since Resident #501's admission. On 3/19/15 at 12:30 pm, Resident #501 was observed seated in the dining room exhibiting pelvic thrusting. On 3/19/15 at 1:00 pm, Resident #501 was observed seated in the dining room. A towel with food droppings was removed from Resident #501's chest area by CNA 'I." CNA 'I' was queried regarding the amount eaten by Resident #501. CNA 'I' said that Resident #501 ate 25% of the noon meal and reported that Resident #501 was difficult to feed because "(Resident #501) is asleep, and he keeps moving himself forward in his chair and he drools." On 3/19/15 at 2:05 pm, Resident #501 was assisted to walk by Restorative Aides (RA) 'G' and 'H." Resident #501 stood up from the reclining chair with RA 'G' and 'H' holding him up by the arms. Resident #501 was observed ambulating while leaning to the right. When queried, RA 'H' stated, "(Resident #501) is definitely a two-person maximum assist with ambulation." RA 'G' added that Resident #501 drools and has tremors that makes it difficult for him to receive restorative care. On 3/19/15 at 2:30 pm, Resident #501's clinical record was reviewed and revealed the following: An Admission Nurse Note date 3/2/15 at 5:30 pm. The section titled "Musculoskeletal" indicated that Resident #501 was ambulatory, could bear full weight (stand on his own), had poor balance and "stumbles, walks aimlessly." The note indicated that Resident #501 was independent with bed mobility and transfer, when walking limited assistance was required. The note also documented that Resident #501 "wanders in rooms" "climbs into others beds." Review of Incident and Accident Reports for the month of March 2015 were reviewed and revealed no evidence of falls. According to the face sheet Resident #501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], Resident #501 had severely impaired cognition, required extensive two-person physical assistance with bed mobility, transfers and ambulation. In addition Resident #501 received [MEDICAL CONDITION] medication daily. The MDS revealed that after 13 days, Resident #501 exhibited a decline in mobility function. A "[MEDICAL CONDITION] Medication Evaluation" dated 3/3/15, noted no adverse reactions. The "Abnormal Involuntary Movement Scale (AIMS)", dated 3/3/15 documented that there were no irregular, spontaneous or purposeless upper arm movements and there were no squirming or pelvic gyrations observed. The "Nursing Facility Psychiatric-Evaluation," dated 3/3/15 documented the following: Resident #501 had [DIAGNOSES REDACTED]. The treatment included to continue [MEDICATION NAME] 4 milligrams (mg) by mouth every six hours for agitation, anxiety, and adjustment behavior disorder. The treatment plan also included to monitor and report behaviors and for psychiatric services to follow Resident #501 as necessary. The "History and Physical," signed and dated by the Attending Physician on 3/3/15 indicated poor balance when standing and drooling however there were no involuntary jerking movements observed during the assessment. The "Care Plan For [MEDICAL CONDITION] Med(medication) Use," dated 3/3/15 noted, "Monitor for side effects, adverse effects and notify physician and Interdisciplinary Team." The "Care Plan For Behaviors," dated 3/3/15 documented, "Resident exhibits inappropriate behavior as evidenced by confusion, climbing into others beds and agitation." Review of Acute Care Hospital records dated 2/23/15, note that Resident #501 was ordered [MEDICATION NAME] 4 milligrams every 6 hours to be administered as needed. Further review noted that Resident #501 received [MEDICATION NAME] 4 mg once or twice each day. Resident #501 did not receive [MEDICATION NAME] 4 mg every six around around the clock. A Speech Therapy note dated 3/4/15 diagnosed Resident #501 with Dysphagia (difficulty swallowing). A physician's orders [REDACTED]. A "Social Service Progress Notes," dated 3/11/15 documented that Family Member 'E' "wanted to know why he was on [MEDICATION NAME]" and that the doctor be contacted to take (Resident #501) off [MEDICATION NAME] because "[MEDICATION NAME] is messing him up." Review of "Nursing Notes" dated 3/3/15 through 3/19/15 did not address any involuntary movements or jerking movements. On 3/19/15 at 2:20 pm, the Director of Nursing (DON) reviewed Resident #501's clinical record and was interviewed. The DON explained that Resident #501 was prescribed [MEDICATION NAME] because he was difficult to redirect. The DON further explained that Resident #501 required a one-to-one (close physical monitoring) upon admission because he was getting up, ambulating and getting into other resident beds. The DON was asked about the monitoring of the side effects of Resident #501's [MEDICATION NAME]. The DON was unable to provide evidence that Resident #501's was monitored for adverse effects of [MEDICATION NAME] especially after an increase from 4-8 milligrams daily to a scheduled dose of 24 milligrams daily. When queried about the onset of the involuntary movements exhibited by Resident #501, the DON was unable to explain why there was no documentation by nursing staff regarding Resident #501's involuntary jerky movements and pelvic thrusting. The DON was unable to explain why [MEDICATION NAME] was continuously administered by nursing staff when Resident #501 was observed to drool and exhibit involuntary jerky movements. When asked if Resident #501 was followed by the facility's contracted Psychiatric services, the DON explained that Resident #501 was seen by NP 'B' on 3/5/15 but was unable to provide documentation of any psychiatric service follow-up for the monitoring of [MEDICATION NAME] administered to Resident #501 and its side effects between 3/6/15 through 3/19/15. On 3/20/15 at 8:50 am Physician Assistant (PA) 'B' was interviewed regarding Resident #501. PA 'B' reported that upon the admission observation of Resident #501 there were no jerking movements observed nor were any observed on of 3/5/15. PA 'B' added that upon admission, Resident #501 would continuously get up and try to walk, he was resistant to help from staff and that Resident #501 was observed walking with one staff member with a gait belt. When asked why on 3/3/15 he prescribed [MEDICATION NAME] 4 mg every 6 hours for Resident #501 instead of every 6 hours as necessary, PA 'B' reported that Resident #501 received it every six hours prior to admission. When it was explained that Resident #501 was only administered [MEDICATION NAME] on an as necessary basis prior to admission, PA 'B' stated, "I will have to review the record." When queried PA 'B' then reported that 3/5/15 was the last time Resident #501 was assessed by him and that the facility should have had someone to fill in for him to monitor Resident #501 for medication ([MEDICATION NAME]) use, its effectiveness, and any adverse effects. When PA 'B' was asked if it was a concern that Resident #501 was treated for [REDACTED]. PA 'B' agreed that aspiration is a concern with the administration of [MEDICATION NAME]. Record review revealed that there was no documented evidence that addressed Resident #501's inhalation infiltrate or that it was reported to the Interdisciplinary Team for further review. On 3/19/15 at 3:00 pm, review of a facility policy titled "[MEDICAL CONDITION] Management," dated 2/2011, revealed, "An unnecessary drug is any drug when: used in excessive dose; for excessive duration; without adequate monitoring; in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the above." The policy also documented, "Initial antipsychotic doses should be low, with longer intervals between dosage increases. A significantly increased risk for stroke and/or death has been noted when an antipsychotic is used in elderly patients with dementia. Antipsychotics should also be used cautiously in patients with dysphagia. [MEDICAL CONDITION] dysmotility and aspiration have been associated with other antipsychotic drugs." Review of an additional facility policy titled "[MEDICAL CONDITION] Management," dated 8/2012, revealed that antipsychotic medications are not used for wandering, poor self care, restlessness, anxiety, fidgeting, or uncooperativeness." The policy does not address how facility staff will monitor for immediate adverse reactions to [MEDICAL CONDITION] medications. On 3/20/15 at 9:30 am, review of the "Drug Information Handbook for Nursing" (2007), revealed that when using [MEDICATION NAME] for dementia behaviors increase dose at four to seven day intervals, monitor for side effects, monitor for extrapyramidal symptoms, report altered gait or balance, excessive sedation, and unusual movements. EPS symptoms include spasms, muscle contractions, motor restlessness, irregular and jerky movements. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 268. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE A SAFE ENVIRONMENT FOR 1 (#101) OF 5 RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL SAMPLE OF 5, WHEN RESIDENT #101 WAS ROLLED OUT OF THE BED BY A CAREGIVER DURING REPOSITIONING, fell TO THE FLOOR AND SUSTAINED A RIGHT HIP FRACTURE. FINDINGS INCLUDE: ACCORDING TO AN INCIDENT/ACCIDENT (I/A) REPORT DATED 04/03/12, RESIDENT #101 ROLLED OUT OF BED ONTO FLOOR ON 04/03/12 AT 9:05 PM WITH BED IN THE LOW POSITION DURING PATIENT CARE. THIS I/A REPORT SAID THERE WAS NO EQUIPMENT INVOLVED AND CERTIFIED NURSE AIDE (CNA) #4 WAS THE ONLY IDENTIFIED WITNESS. ACCORDING TO A NURSE'S NOTES DATED 04/03/12 AT 10:00 PM, RESIDENT #101"ROLL(ED) ONTO FLOOR DURING PT (PATIENT) CARE." REVIEW OF THE MEDICAL RECORD REVEALED AN X-RAY REPORT DATED 04/04/12 AT 10:08 AM THAT RESIDENT #101 HAD AN ACUTE FEMORAL NECK FRACTURE OF THE RIGHT HIP. ACCORDING TO PHYSICIAN ORDERS [REDACTED]." REVIEW OF THE MEDICAL RECORD REVEALED A FACE SHEET DATED 04/12/12 THAT SAID RESIDENT #101 WAS A [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE HISTORY AND PHYSICAL DATED 10/07/11, RESIDENT #101 had a history of [REDACTED]. ACCORDING TO AN INVESTIGATION SUMMARY DATED 04/04/12 WRITTEN BY THE DIRECTOR OF NURSING (DON), CERTIFIED NURSE AIDE (CNA) #4 WAS RENDERING CARE TO RESIDENT #101AND "ASKED FOR HELP BUT COULD NOT FIND ANYONE TO HELP HER OR REMEMBER WHO SHE ASKED." THIS SUMMARY SAID CNA #4 "WASHED AND CHANGED" RESIDENT #101 AND "ROLLED HIM BACK TOWARDS THE DOOR (AWAY FROM CNA #4) AND HE (RESIDENT #101) ROLLED OFF OF THE BED (TO THE FLOOR) NEXT TO HIS BED" AND WAS "LYING ON HIS LEFT SIDE." NURSE #3 WAS NOTIFIED THAT RESIDENT #101 WAS ON THE FLOOR AT 9:05 PM BY CNA #4 WHEN CNA #4 CALLED NURSE #3 TO ASSIST. THE INVESTIGATION SUMMARY NOTED THAT NURSE #7, NURSE #9, AND CNA #8 ALL DENIED THAT CNA #4 HAD ASKED THEM FOR ASSISTANCE BEFORE RENDERING CARE TO RESIDENT #101. ACCORDING TO THE INVESTIGATIVE SUMMARY, AFTER RESIDENT #101'S FALL TO FLOOR, NURSE SUPERVISOR #5 SPOKE TO CNA (#4) "ABOUT WHY SHE (CNA #4) TOOK CARE OF (RESIDENT #101) HERSELF," TO WHICH CNA #4 SAID, "BECAUSE SHE COULD NOT FIND HELP." A FALL RISK EVALUATION DATED 03/21/(2012), DOCUMENTED THAT RESIDENT #101 HAD A FALL RISK SCORE OF 14. ACCORDING TO THIS ASSESSMENT, A SCORE OF 10 OR ABOVE REPRESENTS HIGH RISK. THIS EVALUATION NOTED THAT RESIDENT #101 WAS DISORIENTED X 3 (TO PERSON, PLACE AND TIME) AT ALL TIMES, WAS CHAIR-BOUND, NOT ABLE TO PERFORM GAIT/BALANCE FUNCTIONS, AND HAD 3 OR MORE PREDISPOSING DISEASES THAT INCREASED HIS FALL RISK. A RESIDENT TRANSFER EVALUATION DATED 03/21/12 THAT SAID RESIDENT #101 HAD SCORE OF 21. ACCORDING TO THIS ASSESSMENT A SCORE OF 15 OR GREATER INDICATES THE CAREGIVER PERFORMS 100% OF THE TASK. THIS ASSESSMENT NOTED THAT RESIDENT #101 WAS NON-AMBULATORY, UNABLE TO FOLLOW DIRECTIONS, AND UNABLE TO SIT ON BEDSIDE WITHOUT FULL BACK AND HEAD SUPPORT. REVIEW OF THE MEDICAL RECORD REVEALED A MINIMUM DATA SET (MDS) ASSESSMENT WITH AN ASSESSMENT REFERENCE DATE OF 03/27/12 THAT SAID RESIDENT #101 RARELY/NEVER UNDERSTANDS OTHERS, HAD SEVERELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING, AND REQUIRED TWO PLUS PERSON PHYSICAL ASSIST FOR SUPPORT DURING BED MOBILITY AND TRANSFER. THIS MDS ALSO SAID RESIDENT #101 HAD RANGE OF MOTION IMPAIRMENTS ON BOTH UPPER AND LOWER EXTREMITIES. THE DIRECTOR OF NURSING (DON) PROVIDED THE SURVEYOR WITH THE CNA RESIDENT CARE GUIDE, UNDATED AND KNOWN AS A "RIS" (RESIDENT INSTRUCTION SHEET) THAT THE DON STATED WAS IN EFFECT ON THE DAY OF RESIDENT #101'S FALL, 4/3/12. ACCORDING TO THIS RIS, RESIDENT #101 WAS "TOTAL" (CARE) FOR TRANSFERS AND ADLS (ACTIVITIES OF DAILY LIVING) AND WAS AT-RISK FOR FALLS. DURING AN INTERVIEW WITH NURSE #3 ON 04/26/12 AT 10:30 AM, NURSE #3 SAID SHE DID NOT WITNESS RESIDENT #101'S FALL BUT ASSESSED HIM ON 04/03/12 AT APPROXIMATELY 9:05 PM AFTER CNA #4 REPORTED THE FALL. NURSE #3 SAID SHE OBSERVED RESIDENT #101 ON FLOOR NEAR LEFT SIDE OF BED. NURSE #3 SAID CNA #4 TOLD HER SHE WAS REPOSITIONING RESIDENT #101 IN BED PUSHING HIM "AWAY" FROM HER AND RESIDENT #101 ROLLED OFF THE EDGE OF THE BED ONTO THE FLOOR. NURSE #3 SAID HER INITIAL ASSESSMENTS WERE UNREMARKABLE BUT LATER X-RAY REPORTS SHOWED RESIDENT #101 HAD A FRACTURED RIGHT HIP. NURSE #3 SAID CNA #4 WAS RENDERING CARE TO RESIDENT #101 WITHOUT THE ASSISTANCE OF OTHER STAFF PRIOR TO THE FALL. NURSE #3 SAID RESIDENT #101 WAS A TWO PERSON ASSIST FOR BED MOBILITY AND SHOULD HAVE HAD TWO STAFF ASSISTING DURING THE REPOSITIONING. NURSE #3 SAID RESIDENT #101 NEEDED TWO STAFF FOR BED MOBILITY ASSISTANCE BECAUSE HE HAS CONTRACTURES OF EXTREMITIES, IS LARGER IN SIZE, HAS GENERAL WEAKNESS AND IS UNABLE TO ASSIST IN TRANSFERS OR BED REPOSITIONING. DURING AN INTERVIEW WITH CERTIFIED NURSE AIDE (CNA) #4 ON 04/26/12 AT 2:20 PM, CNA #4 SAID, ON 04/03/12 AT APPROXIMATELY 9:00 PM, SHE REPOSITIONED RESIDENT #101 IN THE BED WITHOUT ASSISTANCE FROM OTHER FACILITY STAFF. CNA #4 SAID SHE ROLLED RESIDENT #101 "AWAY FROM ME" AND HE ROLLED OFF THE BED ONTO THE FLOOR. CNA #4 SAID, AT THE TIME OF FALL, RESIDENT #101'S BED WAS ELEVATED TO HER NAVEL/MIDDLE ABDOMEN AREA (APPROXIMATELY 2 ? TO 3 FEET IN THE AIR). CNA #4 SAID, IMMEDIATELY AFTERWARD, NURSE #5 COUNSELED HER FOR ROLLING RESIDENT #101 "AWAY FROM HER." CNA #4 SAID, AT THE TIME, SHE WAS UNSURE IF RESIDENT #101 NEEDED TWO PERSON ASSISTANCE FOR REPOSITIONING. DURING AN INTERVIEW WITH NURSE #5 ON 04/26/12 AT 3:05 PM, NURSE #5 SAID ON 04/03/12 AROUND 9:00 PM, CNA #4 WAS REPOSITIONING RESIDENT #101 IN BED WITHOUT THE ASSISTANCE OF OTHER STAFF AND RESIDENT #101 fell OFF BED TO FLOOR. NURSE #5 SAID HE DID NOT WITNESS THE FALL. NURSE #5 SAID HE COUNSELED CNA #4 AFTERWARD FOR ROLLING RESIDENT #101"AWAY FROM HER, NOT TOWARD HER." NURSE #5 SAID RESIDENT #101 WAS NON-VERBAL AND DID NOT HAVE THE ABILITY TO ASSIST IN REPOSITIONING. NURSE #5 SAID CNA #4 DID NOT ASK HIM OR ANY OTHER STAFF FOR ASSISTANCE PRIOR TO REPOSITIONING RESIDENT #101 ON 04/03/12. MULTIPLE ATTEMPTS WERE MADE TO INTERVIEW NURSE #7, NURSE #9, AND CNA #8, BUT THE ATTEMPTS WERE UNSUCCESSFUL. ATTEMPTS TO INTERVIEW RESIDENT #101 ON 04/26/12 AT 9:45 AM WERE UNSUCCESSFUL. RESIDENT #101 WAS UNABLE TO PRODUCE SPEECH AND UNABLE TO FOLLOW VERBAL COMMANDS. THE SURVEYOR OBSERVED RESIDENT #101 HAVING CONTRACTURES TO LIMBS AND UNABLE TO PRODUCE MEANINGFUL MUSCULAR MOVEMENT. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 04/26/12 AT 9:40 AM AND 04/26/12 AT 11:00 AM, THE DON SAID, ON 04/03/12 AT APPROXIMATELY 9:05 PM, CNA #4 REPOSITIONED RESIDENT #101 ALONE WITHOUT THE ASSISTANCE OF OTHER FACILITY STAFF AND THAT WAS THE REASON RESIDENT #101 fell OUT OF HIS BED AND SUSTAINED THE HIP FRACTURE. THE DON SAID CNA #4 SHOULD HAVE HAD ANOTHER STAFF MEMBER TO ASSIST HER DURING THE REPOSITIONING OF RESIDENT #101, TO PREVENT THE FALL. THE DON SAID RESIDENT #101 WAS NOT ABLE TO ASSIST WITH REPOSITIONING. THE DON SAID CNA #4 CLAIMED TO HAVE ASKED OTHER FACILITY STAFF TO ASSIST IN THE REPOSITIONING OF RESIDENT #101 BUT COULD NOT REMEMBER THE NAMES OF THESE STAFF. THE DON SAID OTHER STAFF WORKING IN THE FACILITY DURING THE TIME OF RESIDENT #101'S FALL WERE INTERVIEWED AND ALL DENIED THAT CNA #4 ASKED THEM TO ASSIST IN THE REPOSITIONING OF RESIDENT #101 PRIOR TO THE FALL ON 04/03/12.

REFER TO INTAKE # MI 450 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE CARE FOR PAIN FROM MULTIPLE LEG FRACTURES FOR 1 (RESIDENT #104) OF 3 RESIDENTS REVIEWED FOR PAIN FROM TOTAL SAMPLE OF 5, RESULTING IN SEVERE PAIN FOR AT LEAST 8 HOURS DUE TO MULTIPLE FRACTURES FROM AN UNKNOWN ORIGIN. FINDINGS INCLUDE: RESIDENT #104 WAS [AGE] years OLD WITH HISTORY OF [MEDICAL CONDITION] AND WAS admitted TO HOSPICE CARE ON [DATE] FOR COMFORT AND PALLIATIVE CARE. ACCORDING TO THE HOSPITAL RECORD, RESIDENT #104 PRESENTED TO THE HOSPITAL ON [DATE] AT 2:05 AM, VIA AMBULANCE WITH MULTIPLE FRACTURES (RIGHT FEMORAL NECK FRACTURE AND RIGHT DISTAL FEMUR FRACTURE) FROM AN UNKNOWN ORIGIN. HOSPITAL RECORDS ACQUIRED ON [DATE], SHOWED EVIDENCE THAT DURING PHYSICAL ASSESSMENT AT THE emergency room , AT [DATE] AT 3:45 AM, "RIGHT LOWER EXTREMITY WAS INTERNALLY ROTATED (180 DEGREE ROTATED) TENDER TO PALPATION, PAIN WITH MOVEMENT AND UNABLE TO MOVE. HOSPITAL X-RAYS CONFIRMED MULTIPLE FRACTURES LOCATED AT 1.) RIGHT DISTAL FEMUR FRACTURE, 2.) RIGHT [MEDICAL CONDITION] AND 3.) RIGHT ANKLE FRACTURE." ACCORDING TO THE AMBULANCE RUN SHEET DATED [DATE], PRIMARY IMPRESSION: "TRAUMATIC INJURY CLOSED FRACTURE IN MULTIPLE SITES (FEMUR FRACTURE/ RIGHT FIBULA/TIBULAR FRACTURE)." NARRATIVE NOTES STATED: "(NURSING HOME) STAFF DID NOT KNOW HOW ALL THE FRACTURES HAPPENED. PATIENT SCREAMS OUT IN PAIN WHEN MOVED AROUND. left the faciity on [DATE] AT 1:55 AM, AND ARRIVED THE HOSPITAL emergency room AT 2:05 AM." HOSPICE admission orders [REDACTED]. 1 SUPPOSITORY PR (PER RECTUM) EVERY ,[DATE] HOURS PRN (AS NEEDED) FOR FEVER. ACCORDING TO THE AFTERNOON CERTIFIED NURSE AIDE (CNA) #6, INTERVIEWED ON [DATE] AT 1:20 PM, RESIDENT #104 WAS FOUND POSITIONED "AWKWARDLY" IN BED AT 4:30 PM ON [DATE]. NURSE AIDE #6 FURTHER EXPLAINED THAT BOTH LEGS WERE FOUND ON TOP OF THE BOLSTERS WITH THE LEFT LEG ON TOP OF THE RIGHT. HE SAID: "IT LOOKED LIKE SOMEONE STARTED GETTING RESIDENT #104 UP BECAUSE THE WHEELCHAIR WAS POSITIONED RIGHT NEXT TO THE BED BUT DID NOT FINISH THE TASK AND LEFT". THE AFTERNOON NURSE AIDE # 6 EXPLAINED THAT HE ARRIVED AT 4:00 PM THAT DAY BUT THE SHIFT STARTED AT 3:00 PM. OTHER NURSES AIDES COVERED HIS SET (ASSIGNMENT) FROM 3:00 PM UNTIL HE ARRIVED AT 4:00 PM. RESIDENT #104 WAS MOANING AND WAS IN PAIN BUT HE THOUGHT IT WAS RESIDENT #104'S USUAL BEHAVIOR. NURSE AIDE #6 admitted THAT HE CONTINUED TO TRANSFER HER FROM BED TO CHAIR WITHOUT USING THE GAIT BELT BEFORE DINNER AND NOTICED THAT HER RIGHT LEG "DID NOT LOOK RIGHT." ACCORDING TO NURSE AIDE #6, HE ASKED NURSE #3 TO HELP HIM TO PLACE THE FOOT REST TO SUPPORT THE RESIDENT'S RIGHT LEG, THAT DID APPEAR TO BE NORMAL. AS NURSE #3 ATTEMPTED TO ASSESS THE RESIDENT'S LEG, RESIDENT #104 STARTED HITTING AND SCRATCHING THE NURSE. ANOTHER STAFF (NURSE AIDE #9) CAME AND TOOK HER (RESIDENT #104) TO THE DINING ROOM TO EAT. AFTER DINNER, AT AROUND 6:30 PM, AFTERNOON CHARGE NURSE #5 TOLD NURSE AIDE #6 TO PUT RESIDENT #104 TO BED SO SHE COULD ASSESS HER LEG. BETWEEN 6:00 PM TO 6:30 PM, NURSE AIDE #9 HELPED NURSE AIDE #6 TRANSFER RESIDENT #104 INTO BED. AFTERNOON NURSE AIDE #6 STATED THAT HE DID NOT USE A GAIT BELT DURING THE TRANSFER. RESIDENT # 104 WAS CRYING AND YELLING IN PAIN. RESIDENT #104 WAS GRABBING AND HITTING WHEN THEY ATTEMPTED TO TOUCH HER LEG. NURSE AIDE #6 LEFT THE ROOM AND CONTINUED ON TO OTHER RESIDENTS. NURSE AIDE #9, DURING AN INTERVIEW ON [DATE] 2:30 PM, STATED THAT SHE HELPED NURSE AIDE #6 DURING THE TRANSFER. RESIDENT #104 WAS SCREAMING, CRYING, HITTING AND WAS GRABBING STAFF. NURSE AIDE #9 RECALLED THE TRANSFER AND DESCRIBED THAT SHE (NURSE AIDE #9) GRABBED RESIDENT #104'S LEFT ARM AND HELD ON TO THE BACK OF RESIDENT #104'S PANTS. NURSE AIDE #6 WAS ON THE RIGHT SIDE GRABBING RESIDENT #104'S RIGHT ARM AND THE BACK OF HER PANTS. NURSE AIDE #9 admitted THAT THEY DID NOT USE A GAIT BELT DURING THE TRANSFER. NURSE AIDE #9 COMMENTED THAT NURSE AIDE #6 WAS "A TALL MAN" AND SHE WAS VERY SHORT, BUT SHE WAS GLAD THAT THE TRANSFER "WENT WELL." SHE REMEMBERED THAT RESIDENT #104 WAS CRYING AND SCREAMING DURING THE ENTIRE HER SHIFT. ACCORDING TO AFTERNOON CHARGE NURSE #5 DURING A TELEPHONE INTERVIEW ON [DATE] AT 1:00 PM, SHE WAS THE NURSE IN CHARGE OF RESIDENT #104 DURING 3:00 PM TO 11:00 PM. SHE admitted RECEIVING A REPORT FROM THE NURSE AIDE #6 AND NURSE #3 THAT RESIDENT #104'S LEG "LOOKED FUNNY." AFTERNOON CHARGE NURSE#5 STATED THAT SHE ATTEMPTED TO ASSESS THE RIGHT LEG IN THE DINING ROOM BUT RESIDENT #104 WAS SCREAMING AND SCRATCHING. BETWEEN 6:30 TO 7:00 PM, AFTERNOON CHARGE NURSE #5 INSTRUCTED CNA #6 TO PUT RESIDENT #104 BACK TO BED SO SHE COULD FURTHER EVALUATE THE LEG. RESIDENT #104'S RIGHT LEG LOOKED "PECULIAR." RESIDENT #104 CONTINUED TO RESIST AND WAS SCRATCHING STAFF. THE NURSE SUPERVISOR #7 WAS NOTIFIED AND CAME BETWEEN 7:30 AND 8:00 PM. NURSE SUPERVISOR # 7 ORDERED AN XRAY BECAUSE IT WAS IMPOSSIBLE TO ASSESS RESIDENT #104 AS SHE WAS UNCOOPERATIVE. AFTERNOON CHARGE NURSE #5 admitted THAT SHE DID NOT GIVE ANYTHING FOR PAIN DURING THE ENTIRE SHIFT. AFTERNOON NURSE #5 admitted THAT SHE WAS AWARE OF THE RESIDENT #104'S CHANGE IN CONDITION AT 4:30 PM THAT DAY BUT DID NOT GIVE RESIDENT #104 ANY PAIN RELIEF. AFTERNOON NURSE RECALLED GIVING RESIDENT #104 [MEDICATION NAME] GEL AT AROUND 11:30 PM. MIDNIGHT NURSE #8, DURING A TELEPHONE INTERVIEW ON [DATE] AT 10:00 AM, STATED THAT RESIDENT #104 WAS OBSERVED CRYING OUT SHAKING THE HAND RAILS AT AROUND 11:30 PM ON [DATE]. "RESIDENT #104 WAS IN A LOT OF PAIN." MIDNIGHT NURSE # 8 FOUND OUT THAT RESIDENT #104 HAD NOT BEEN GIVEN ANY MEDICATION FOR PAIN AT ALL DURING THE AFTERNOON SHIFT. THE RESIDENT DID NOT HAVE PAIN MEDICATION ORDERS OTHER THAN THE HOSPICE STANDING ORDER, MIDNIGHT NURSE #8 WENT AHEAD WITH GIVING TYLENOL SUPPOSITORY 650 MG TO RESIDENT # 104, PER HOSPICE STANDING ORDERS. RESIDENT #104 CALMED DOWN AFTER THAT AND AT 2:00 AM ON [DATE], RESIDENT #104 WAS TRANSFERRED TO THE HOSPITAL FOR MULTIPLE FRACTURES. THE CLINICAL RECORD SHOWED NO EVIDENCE THAT ANY CALLS WERE MADE TO THE PHYSICIAN FOR NOTIFICATION OF THE LEG PROBLEM OR FOR PAIN MEDICATION UNTIL THE MIDNIGHT NURSE# 8 DOCUMENTED THAT A CALL WAS MADE TO THE PHYSICIAN AT 2:00 AM WHEN THE XRAY RESULTS CAME. NO NEW PAIN ORDERS WERE RECEIVED AT THAT TIME. ACCORDING TO THE NURSES NOTES DATED [DATE] AT 2:00 PM, X-RAY RESULTS RECEIVED REVEALED "RIGHT KNEE ACUTE MODERATE DISPLACED FRACTURE, FRACTURE SHAFT OF FEMUR AND RIGHT TIB FRACTURE ACUTE FEMORAL NECK. " NURSES NOTES DATED [DATE] AT 6:00 AM, NOTED THAT TYLENOL 650 MG SUPPOSITORY HAD BEEN ADMINISTERED FOR PAIN, BUT THE TIME THAT THIS MEDICATION WAS GIVEN WAS NOT DOCUMENTED. FURTHER REVIEW OF THE MAR (MEDICATION ADMINISTRATION RECORD) REVEALED THAT TYLENOL WAS GIVEN AT 12:30 AM ON [DATE] AS SIGNED BY THE MIDNIGHT NURSE #8. THE PRN (AS NEEDED) PAIN Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THERE WAS NO EVIDENCE OF PAIN ASSESSMENT AND MONITORING IN THE DOCUMENTATION ON [DATE] STARTING AT 4:30 PM UNTIL THE MIDNIGHT NURSE (#8) ADMINISTERED TYLENOL SUPPOSITORY ON ,[DATE] AT 12:30 AM. WHEN HOSPICE PHYSICIAN #13 WAS INTERVIEWED BY TELEPHONE ON [DATE] AT 1:05 PM, HE STATED THAT HE DID NOT RECEIVE ANY NOTIFICATION OF CHANGE IN CONDITION OR REQUEST FOR ANY PAIN MEDICATION FROM THE FACILITY ON [DATE]. HOSPICE CARE NURSE #11, DURING A TELEPHONE INTERVIEW ON [DATE] AT 2:15 PM, STATED THAT ON [DATE], SHE WAS IN AND OUT OF THE ROOM (OF RESIDENT #104) TO PERFORM THE INITIAL HOSPICE NURSING EVALUATION FROM 10:00- 2:00 PM. DURING THIS EVALUATION, THERE WERE NO OBVIOUS SIGNS AND SYMPTOMS OF PAIN. SHE COMMENTED: RESIDENT #104 "LOOKED PLEASANTLY COMFORTABLE DURING THE ENTIRE EVALUATION." HOSPICE NURSE # 11 DENIED GETTING A CALL FROM THE FACILITY AFTER THE INITIAL EVALUATION. SHE DENIED RECEIVING ANY CALL OR REFERRAL FOR PAIN MANAGEMENT AND CHANGE OF CONDITION THAT DAY ([DATE]). HOSPICE MANAGEMENT STAFF #12 ON [DATE] AT 9:25 AM PER TELEPHONE INTERVIEW STATED THAT THERE WAS NO RECORD OF ANY CALL FROM THE FACILITY ON [DATE] FOR PAIN MANAGEMENT OR CHANGE IN CONDITION NOTIFICATION. HOWEVER, A CALL WAS MADE TO THE HOSPICE AGENCY ON [DATE] AT 8:11 AM NOTIFYING HOSPICE THAT RESIDENT #104 WAS TRANSFERRED TO THE HOSPITAL. RESIDENT #104 EXPIRED AT THE HOSPITAL ON [DATE], UNDER HOSPICE/ PALLIATIVE CARE. 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