Every finding on record at Harold and Grace Upjohn Community Care Center

Based on observation, interview, and record review, the facility failed to maintain an overall effective pressure ulcer prevention program to prevent the development and worsening of pressure ulcers, implement interventions for pressure injuries and effectively assess and monitor for new or worsening pressure injuries for 7 residents (Resident #41, #53, #61, #45, #7, #18 and #4) of 7 residents reviewed for pressure ulcers, resulting in Resident #41's pressure ulcer on the sacrum (coccyx, tailbone) worsening to a Stage 4, Resident #53's Stage 3 pressure ulcer on the sacrum deteriorated, Resident #61 developed a new facility acquired pressure ulcer, and the potential for skin breakdown or continued skin breakdown for Resident's #45, #7, #4, and #18 and overall decline in health status. Findings include: Resident #41 Review of an admission Record revealed Resident #41 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of sacral (coccyx, tailbone) region stage unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #41, with a reference date of 3/11/26 revealed a Brief Interview for Mental Status (BIMS) score of severe cognitive impairment. Review of Behaviors revealed no rejections of care. Review of the Functional Abilities revealed that Resident #41 was completely dependent on staff for toileting and transfers. Review of Resident #41's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 3/20/26 revealed, Sensory perception: slightly limited. Moisture: very moist.Bedfast (does not get out of bed). Resident is very limited. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: Excellent. Friction and shear: problem. Braden Score: 13. This evaluation indicated the resident is at moderate risk to develop a pressure ulcer. Review of Resident #41's Wound Care Plan revealed, .I have wound on my sacral buttock area, left BKA (below the knee amputation) surgical incision, left gluteus (buttocks), right gluteus. Date initiated: 12/19/25. Interventions: .Monitor ulcer for signs of infection, Monitor ulcer for signs of progression or declination, Notify provider if no signs of improvement on current wound regimen, Provide wound care per treatment order. Date initiated: 12/10/25. Additional interventions: .Air mattress DX (diagnosis) sacral decubitus (pressure ulcer). Offload wounds while laying in bed and in chair as tolerated, cushion in wheelchair. Provide wound care per treatment order. Date initiated: 1/6/26. There was no information related to Resident #41's pressure ulcer on the right foot and or the urinary catheter that was ordered to promote wound healing. Review of Resident #41's Skin Care Plan revealed, I am at risk for skin breakdown. Date initiated: 11/26/25. Interventions: Educate resident/representative about primary risk factors and prevention, Monitor for pain and medicate as necessary per physician order. Notify resident/representative of any new areas of skin alteration. Report any changes in skin status to physician. Date initiated 11/26/25. Additional interventions, Roho (air filled pressure reducing) cushion to wheelchair, Turn and reposition every 2 hours as requested and tolerated. Date initiated 1/27/26. There was no indication of why Resident #41 was at risk for skin breakdown. There was no care plan related to Resident #41 incontinence and/or urinary catheter use. Review of Resident #41's Infection Control Care Plan revealed, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO). The resident must be placed in isolation (enhanced) due to risk of spreading MDRO's via an indwelling device, chronic/non-healing wound. Date initiated: 1/6/26. Interventions: .Staff are to wear PPE (gown and gloves) before entering room if they are providing high contact care. Date initiated: 1/6/26. In an interview on 04/14/2026 at 10:17 AM, Family Member (FM) VV reported that Resident #41 was on an antibiotic for a bad infection in her sacral wound and had recently been hospitalized for the wound. FM VV reported that the resident's family had not been visiting due to their fear of getting sick due to Resident #41's infection. During an observation and interview on 04/14/2026 at 11:03 AM Resident #41 was lying in her bed and Hospice Nurse (HN) M was performing wound care and a wound dressing change for Resident #41's sacral wound. Resident #41 verbalized that the wound was painful. Observed a foley catheter bag hanging from the bed frame. HN M was not wearing a gown. In an interview on 04/14/2026 at 11:20 AM, HN M reported that he had just finished wound dressing changes for Resident #41. HN M reported that Resident #41 had recently signed onto hospice services and that day was Resident #41's first wound visit. Review of Resident #41's Hospice Progress Note dated 4/14/26 revealed, .Communicates verbally very effectively.Rates sacral wound pain 8/10.Wound care provided: Sacrum – stage 4 pressure wound – 6 x 6 x1 cm, right heel – stage 1 pressure wound 2 x 2 cm, right lateral foot – stage 1pressure wound 0.3 x 0.3 cm. At end of lengthy visit, patient confirms that her pain is unimproved. It was noted that Resident #41's pressure ulcer on her sacrum had worsened since previous observations. There was no documentation to indicate the pressure ulcers were unavoidable. During an observation and interview on 04/15/2026 at 11:39 AM Resident #41 was lying in her bed with the head of bed (HOB) elevated to approximately 45 degrees (an upright position) and slightly turned to her left side. There was a pillow in place behind her back. Resident #41 reported that she was uncomfortable, had been vomiting earlier that day and had not been cleaned up yet. Observed Resident #41's chin and gown with dried yellow substance. Resident #41's right foot was covered with a blue protective boot. During an observation on 04/15/2026 at 11:50 AM Resident #41's roommate was observed notifying Licensed Practical Nurse (LPN) KK that Resident #41 needed help. LPN KK replied, they are getting her. In an interview on 04/15/2026 at 12:12 PM, Certified Nursing Assistant (CNA) W reported that Resident #41 does not get out of her bed, was not able to feel when she was incontinent, but was otherwise able to make her needs known. CNA W reported that she had checked on Resident #41 a couple of hours ago, approximately 10:15 AM and she was dry, so she let the resident rest, and did not reposition her. CNA W reported that Resident #41 had big sores on her buttocks and would be repositioned after lunch around 2:00 PM. During subsequent observations on 04/15/2026 from 11:39 AM-1:23 PM when Resident #41 received lunch, she remained in the same position. At 1:23 PM Resident #41's HOB was raised so that she could eat lunch. Resident #41 remained in this position until approximately 2:42 PM (4 1/2 hours) when this surveyor requested to observe Resident #41's wound dressings along with LPN KK. In an interview and observation on 04/15/2026 at 2:42 PM, LPN KK reported that she had changed Resident #41's wound dressing on her sacrum early that morning and flushed her foley catheter. LPN KK reported that the wound did not look good, there was a lot of slough (white dead tissue) and green drainage. LPN KK reported that Resident #41 was on an oral antibiotic for the wound. Observed Resident #41 still lying in bed, positioned on her left side, with the HOB at 45-90 degrees. Observed a large adhesive bandage covering Resident #41's sacrum, and bandages covering her right foot and heel. During observations on 04/15/2026 at 2:49 PM and again at 3:36 PM Resident #41 was observed lying in her bed, in the same position as when first observed at 11:39 AM that day; positioned on her left side with HOB approximately 45 degrees. In an interview on 04/16/2026 at 8:14 AM, Unit Manager (UM) D reported that the facility had been following orders from the wound clinic for Resident #41's sacrum and right foot wounds until yesterday when the hospice nurse saw the resident for the first time and changed the treatment orders. UM D reported that Resident #41's last wound clinic visit was 4/6/26 and an antibiotic was ordered due to Resident #41's sacral wound infection at that time. UM D reported that Resident #41 was hospitalized [DATE]-[DATE] for UTI (urinary tract infection) and returned to the facility with a foley catheter in place to help with sacral wound healing. UM D reported that the facility did not have a wound provider or nurse that specialized in wounds and expected that the floor nurse assigned to daily care for residents, should also be completing the weekly wound assessments when they are due. UM D reported that the nurse that performed the weekly assessments would not be consistent but should be able to determine wound progress by comparing the assessment details from the week prior. After reviewing Resident #41's record, UM D reported that the weekly wound assessments were not being documented as expected by the nursing staff; most of the wound information appeared to be copied and pasted from earlier assessments. UM D could not determine when the last time Resident #41's sacral (coccyx) wound and right foot wounds were formally assessed and measured by facility staff. UM D could not find any documentation to verify that staff were assessing and monitoring Resident #41's wounds, other than the treatment records that were initialed, to indicate they were completed, and the wound clinic notes that were scanned into the record did not include wound measurements and/or characteristics. UM D could not find any documentation related to concerns that Resident #41's wounds were deteriorating and/or having had signs of infection. Director of Nursing (DON) C was present for this interview and could not provide any information to support compliance for Resident #41's wounds management. Review of Resident #41's Weekly Skin Check dated 3/9/26 at 2:24 PM (prior to hospitalization) revealed, .Skin warm and dry, skin color WNL (within normal limits). No new skin issues identified. Skin issue #1: .HAS NOT BEEN EVALUTED. Location left gluteus.Issue type: Pressure ulcer/injury. Wound was present on admission. Skin issue #2: .HAS NOT BEEN EVALUATED. Location: left gluteus. Issue type: Open lesion. Wound was present on admission.Skin issue #3: .HAS NOT BEEN EVALUATED. Location: right gluteus. Issue type: Open lesion. Wound was present on admission. Staged by In-house nursing. Skin issue #4: .HAS NOT BEEN EVALUATED. Location: left gluteus. Additional information: Sacrum. Issue type: Pressure ulcer/injury. Pressure ulcer staging: Stage 3 pressure ulcer/injury full thickness skin loss. Wound was present on admission. Review of Resident #41's Wound Clinic Visit dated 3/9/26 at 11:00 AM revealed, .Her wound has declined today. Please encourage increased repositioning from side to side. Wound Treatment: Wound #1 location: Sacrum.Peri-Wound (skin surrounding the wound) care: Triad Hydrophilic (helps to maintain moisture) wound dressing 1 x per day. Acetic Acid (kills microorganisms) 0.25% 1 x day, apply as directed as a 5-10 minute soak before dressing application. Aquacel Ag Advantage (an antimicrobial wound dressing to reduce risk of infection) . Wound #5 location: Gluteus Right.Triad Hydrophilic wound dressing.apply a thin layer to peri-wound. Review of Resident #41's Hospital Wound Consult Dated 3/12/26 revealed, .consulted for a coccyx, right heel and buttock wounds.Several more wounds that were found. Right buttock, right heel, right lateral foot, left medial thigh and left lateral thigh are all deep tissue wounds. Left buttock is a stage 2, sacral wound is a stage 3.Wound Assessment: 1. Sacral.length 5.5 cm x width 5 cm x depth 0.6 cm. 2. Left medial thigh DTPI (deep tissue pressure injury). length 5.5 cm x width 5 cm. 3. Left upper later thigh DTPI. length 5 cm x width 3 cm. 4. Left Buttock Stage 2 Pressure injury. length 1 cm x width 1 cm. 5. Right heel DTPI (deep tissue pressure injury). length 2 cm x width 1.5 cm. 6. Right lateral foot DTPI. length 2.2 cm x 1.5 cm. 7. Right buttock DTPI. length 5 cm x width 3 cm. Assessment: .General surgery was consulted for chronic sacral decubitus ulcer.There does appear to be superficial necrotic slough at the superior and right lateral aspects of the sacral decubitus ulcer. Review of Resident #41's Hospital After Visit Summary dated 3/19/26 (admitted on [DATE]) revealed, .Transfer Instructions: .Wound Site: Sacrum .Right heel, Right lateral foot, left medial thigh and left upper lateral thigh.Foley in place for maintenance of sacral wound. Review of Resident #41's re-admission Assessment dated 3/19/26 revealed, Arrived by ambulance. Urinary Catheter intact. Skin warm and dry, skin color WNL (within normal limits). No new skin issues identified. Skin issue #1: .HAS NOT BEEN EVALUATED. Location left gluteus, proximal, superior. Issue type: Pressure ulcer/injury. Wound was present on admission. Skin issue #2: .HAS NOT BEEN EVALUATED. Location: left gluteus, distal, inferior. Issue type: Open lesion. Wound was present on admission.Skin issue #3: .HAS NOT BEEN EVALUATED. Location: right gluteus, inferior, distal. Issue type: Open lesion. Wound was present on admission. Staged by In-house nursing. Skin issue #4: .HAS NOT BEEN EVALUATED. Location: left gluteus, middle, inferior, distal. Additional information: Sacrum. Issue type: Pressure ulcer/injury. Pressure ulcer staging: Stage 3 pressure ulcer/injury full thickness skin loss. Wound was present on admission. It was noted that the information was copied from the 3/9/26 skin check and did not include the wounds from the hospital after visit summary. Review of Resident #41's Skilled Nursing Evaluation dated 3/21/26 revealed, .Skin issue #1: .HAS NOT BEEN EVALUATED. Location left gluteus, proximal, superior. Issue type: Pressure ulcer/injury. Wound was present on admission. Skin issue #2: .HAS NOT BEEN EVALUATED. Location: left gluteus, distal, inferior. Issue type: Open lesion. Wound was present on admission.Skin issue #3: .HAS NOT BEEN EVALUATED. Location: right gluteus, inferior, distal. Issue type: Open lesion. Wound was present on admission. Staged by In-house nursing. Skin issue #4: .HAS NOT BEEN EVALUATED. Location: left gluteus, middle, inferior, distal. Additional information: Sacrum. Issue type: Pressure ulcer/injury. Pressure ulcer staging: Stage 3 pressure ulcer/injury full thickness skin loss. Wound was present on admission. It was noted that the information was copied from the 3/19/26 skin check and did not include all of Resident #41's wounds. Review of Resident #41's Wound Clinic Visit dated 3/23/26 at 11:00 AM revealed, Her wound has declined today. Wound Treatment: Wound #1 location: Sacrum.Peri-Wound (skin surrounding the wound) care: Triad Hydrophilic wound dressing 1 x per day. Acetic Acid 0.25% 1 x day, apply as directed as a 5-10 minute soak before dressing application. Aquacel Ag Advantage. Wound #5 location: Gluteus Right.Triad Hydrophilic wound dressing.apply a thin layer to peri-wound. Review of Resident #41's Skilled Nursing Evaluation dated 3/22/26, 3/23/26, 3/24/26, and 3/26/26 all revealed a duplicate of the skin documentation from 3/21/26. Review of Resident #41's Weekly Skin Check dated 3/26/26 revealed a duplication of the skin documentation from the previous weekly skin checks. Review of Resident #41's Wound Clinic Visit dated 4/6/26 revealed, .Based on culture results of the sacrum we would like to begin Ciprofloxin (antibiotic) 500 mg twice a day for 10 days to treat the pseudomonas (bacteria).Her wound on her sacrum has declined today. Please encourage increased repositioning from side to side. If dressings are soiled they need to be changed or risk for infection will increase. Do not wipe them off. New dressings are needed. Wound Treatment: Wound #1 location: Sacrum.Peri-Wound (skin surrounding the wound) care: Triad Hydrophilic wound dressing 1 x per day. Acetic Acid 0.25% 1 x day, apply as directed as a 5-10 minute soak before dressing application. Aquacel Ag Advantage 4 x 5 inch 1 x per day, place directly onto wound bed as directed. Secondary dressing: Abdominal pads 7.5 x 8 inch, place over wound or other dressings as directed for protection and absorption. Wound #5 location: Gluteus Right.Triad Hydrophilic wound dressing.apply a thin layer to peri-wound. Wound #6 location: Calcaneus (heel) right. use skin prep to peri-wound and wound. Mepilex Ag 4 x 4 inch.place directly onto wound bed. It was noted that an additional wound was assessed on the right heel during the visit. Review of Resident #41's most recent Weekly Skin Check dated 4/9/26 revealed, Skin warm and dry, skin color WNL (within normal limits) .Skin issues: Skin issue #1: Skin issue HAS NOT BEEN EVALUATED. Location: left gluteus. Issue type: pressure ulcer/injury. Skin issue #2: .HAS NOT BEEN EVALUATED. Location: left gluteus. Issue type: Open lesion. Skin issue #3: .HAS NOT BEEN EVALUATED. Location: right gluteus. Issue type: Open lesion. Staged by: in-house nursing. Skin issue #4: .HAS NOT BEEN EVALUATED. Location: left gluteus. Additional location information: SACRUM. Issue type: pressure ulcer/injury. Skin issue #5: NEW SKIN ISSUE. Location: Coccyx. Issue type: Pressure ulcer/injury. Progress: Improving. Overall wound characteristics improved. Wound was present on admission. Length 1 (cm), width 1.5 (cm), depth 0 (cm). During an observation on 04/17/2026 at 8:45 AM Resident #41 was lying in bed, positioned slightly to her left with the HOB at approximately 45 degrees. In an interview on 04/17/2026 at 9:16 AM, CNA G reported that she had not been in with Resident #41 since the start of her shift at 7:00 AM (2 hours ago). CNA G reported that she would have to look at Resident #41's care plan to know what care needed to be done. During a subsequent observation and interview on 04/17/2026 at 10:27 AM Resident #41 remained in the same position, lying in bed, positioned slightly to her left with the HOB approximately 45 degrees. Resident #41 reported that she was finished with her breakfast tray and that her bottom was sore and she could not change positions on her own. Review of Resident #41's Physician Orders revealed, Ciprofloxacin HCl Oral Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth two times a day for sacrum infection per wound center for 10 Days. Start 4/6/2026, Stop 4/16/2026. Resident #53 Review of an admission Record revealed Resident #53 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Pressure ulcers of sacral region and heel, both unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #53, with a reference date of 2/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #53 was cognitively intact. Review of the Functional Abilities revealed that Resident #53 required substantial/maximal assistance (>50%) for moving in bed and was completely dependent on staff for toileting needs. Review of Resident #53's Braden Scale for predicting Pressure Ulcer Risk Evaluation dated 2/5/26 revealed, 12 indicating at high risk to develop pressure ulcers. Review of Resident #53's Skin Care Plan revealed, I am at risk for skin breakdown. Date initiated: 10/31/25. Interventions: Monitor for pain and medicate as needed per physician's order. Date initiated: 10/31/25. There was no documentation related to Resident #53's risk for pressure ulcers and/or interventions in place to reduce the risk. There was no care plan related to Resident #53's need for assistance with bed mobility, toileting and or status of bowel and bladder continence. There was no care plan related to Enhanced Barrier Precautions (EBP). Review of Resident #53's Wound Management Care Plan revealed, Bilateral heels, Coccyx. Date initiated: 11/6/25. Interventions: Measure ulcer on regular intervals. Monitor ulcer for signs of infection. Monitor ulcer for signs of progression or declination. Notify provider if no signs of improvement on current regimen. Provide wound care per treatment orders. Date initiated 11/6/25. There were no updates made to this care plan. During an observation on 04/15/2026 at 7:15 AM Resident #53 was lying in bed with her eyes closed and the HOB at approximately 45 degrees. Observed a pillow behind Resident #53 near her back, keeping her positioned slightly on her left side. There was no signage posted for enhanced barrier precautions (EBP). In an interview on 04/15/2026 at 8:36 AM, LPN LL reported that Resident #53 does not get out of bed anymore, her heel sores have completely resolved, but the wound on her buttocks is not doing good at all. LPN LL reported that Resident #53 is incontinent of bowel and bladder, very compliant with cares and repositioning, but the protective boots do not stay on her feet well. LPN LL reported that Resident #53 also has pressure point wounds on the tips of her toes, therefore staff had to constantly watch so that her feet don't press up against the end of the bed. During an observation on 04/15/2026 at 12:50 PM Resident #53 was lying in bed with her eyes closed, and remained positioned slightly to her left side. Observed a pillow behind Resident #53's back and the HOB was 45 degrees. Observed blue protective boots partially in place on Resident #53's feet. In an interview on 04/16/2026 at 9:25 AM, UM D reported that Resident #53 had wounds on her heels and buttocks, and at one time a couple months ago had concerns for osteomyelitis (infection in the bone caused by infected tissue) because the wounds on her feet were not healing. UM D did not know the status of Resident #53's wounds. Reviewing Resident #53's records with UM D and there was no documentation of wound assessments that measured size, no pressure wound interventions listed, and all weekly skin checks were noted as normal. UM D reported that the facility did not have a dedicated wound nurse or provider, and that the floor nurse was expected to complete all wound assessments during the weekly skin check and notify UM D or a provider if there was a concern. UM D reported that the facility also uses a Wound Log to document when a concern was identified. During an observation and interview on 04/17/2026 at 9:49 AM Resident #53 was sitting up in bed eating breakfast. Resident #53 reported that her butt was sore. Resident #53 was not wearing the blue protective boots on her feet. There was no signage observed to indicate that Resident #53 had orders for EBP. Review of the facility Wound Communication Log revealed, (Resident #53) 4/2/26 Sacral wound purulent (liquid substance indicative of infection) drainage 3x2cm, new bruise right upper thigh/hip, new wound to right of current wound .5x.2cm. There was no documentation in the blanks for dressing orders or risk management completed. In an interview on 04/17/2026 at 10:04 AM, UM D reported that she was not aware of the wound communication log note from 4/2/26 related to Resident#53's wounds. UM D reported that Resident #53's orders had not changed since then and there were no progress notes or physician notes to correlate that the wound concern was assessed and being monitored. This surveyor requested to observe Resident #53's wounds and UM D agreed to collect supplies to complete assessments and wound care for all of Resident #53's wounds. During an observation on 04/17/2026 at 10:26 AM Resident #53 was still sitting up in her bed and her breakfast tray was in front of her and her blue protective boots were not in place on her feet. UM D was gathering supplies for wound care. CNA CC was gathering supplies to provide incontinence care for Resident #53. There was still no signage indicating that Resident #53 had EBP in place. At 10:46 AM UM D, CNA CC, and Nurse Practitioner (NP) N were in the room at the bedside, donned gloves and began explaining to Resident #53 that they would be doing incontinence care and looking at her wounds. UM D removed the wound dressings from Resident #53's right and left heels, and NP N assessed the wounds. This surveyor observed nickel size brown scabs on both heels. NP N reported that the right heel wound measured 1 cm x 1 cm and the left heel wound measured 2 cm x 1 cm, and called the wounds deep tissue injuries. This surveyor observed Resident #53's toes on her left foot, they were discolored and scabbed, the staff did not assess that area. CNA CC and UM D rolled Resident #53 to her left side to provide incontinence care and assess her buttocks wound. There was an extra-large bandage covering Resident #53's coccyx area dated 4/17/26 that was visibly soaked with drainage from the wound. UM CC removed the bandage which revealed a large open wound with slough (moist white dead tissue) and eschar (black hard dead tissue) in the center of the wound. NP N reported Resident #53's coccyx wound was 8 cm x 9.5 cm and called it a Stage 3 pressure ulcer and said that it was deteriorating since there was tissue exposed now. There was a large purple discolored wound on Resident #53's right upper thigh that followed the line of an incontinence brief. UM D reported that she was not aware of the wound on the right upper thigh. NP N reported that Resident #53's wound on the right upper thigh appeared to be from shearing (a wound affecting deep tissue layers due to lateral shifts in movement). Resident #53 was soiled with BM and urine and CNA CC completed incontinence care with assistance from UM D. UM D continued with wound care after the incontinence care, cleansing the coccyx wound and applying the wound dressing. It was noted that all staff in the room provided direct care and were not wearing proper PPE (gowns) related to EBP standards for wounds. In an interview on 04/17/26 at 11:10 AM, NP N reported that she did not know how long Resident #53 had the wounds that were observed that day. NP N reported that at this time they would continue the same wound treatment as previously ordered. In an interview on 04/17/26 at 11:11 AM, CNA CC reported that Resident #53 was very compliant with care and would stay in whatever position we place her in; she does not refuse repositioning or the protective boots. CNA CC reported that Resident #53 was always incontinent and that the last time she had completed incontinence care for Resident #53 was the day before. CNA CC noted that the wound on her upper thigh was red yesterday and did not have the purple and black area in it. CNA CC was not aware that Resident #53 should have EBP in place. In an interview on 04/17/2026 at 11:17 AM, Infection Preventionist (IP) E reported that she would expect staff to notify her when there was a concern for wound infection and stated, a lot of the time I don't know until I find out on my own. IP E reported that residents with pressure wounds are not automatically placed in EBP. IP E reported that if a wound is diagnosed as a certain stage or was found to be infectious, then EBP are implemented at that time. IP E reported that Resident #53 wounds were not open and she does not require EBP. In a subsequent interview on 04/17/26 at 11:40 AM, IP E reported that she was informed Resident #53's wounds were deteriorating therefore she would be placed on EBP. In an interview on 04/17/2026 at 12:01 PM, NP N reported that she had not seen Resident #53's toes in the earlier observation and was not aware that she had any wounds on her toes. In an interview and observation on 04/17/2026 at 12:04 PM, Registered Nurse (RN) I reported that they were applying betadine (antiseptic for infection prevention) to Resident #53 toes. Observed Resident #53 lying in her bed; her left great toe had a thick scab covering the tip, and the 2nd and 3rd toes were discolored black at the tips. RN I reported that Resident #53's left great toe was an unstageable pressure injury. Review of Resident #53's Physician Note dated 2/9/26 revealed, .Staff concerned with skin issues on her bilateral feet. Bilateral heel wounds were being treated with Dakins (helps reduce infection and promote healing) solution on bilateral heels while floating and has an air mattress to offload pressure. Now concern with discoloration of toes.Physical exam: .Bilateral heels have stage 3 pressure injury with beefy red wound base and macerated (softening and breaking down of skin) edges surrounding both wounds are individually the size of a nickel, right great toe has deep purple scab to the tip of the toe, right 2nd digit has small area on the pad of the toe which is dark purple, left great toe appears to have gangrene (tissue death) at the tip, left 2nd digit has gangrene nearly to the DIP (distal interphalangeal: closest to tip of toe) joint, bilateral legs have venous insufficiency (lack of blood circulation) with skin color changes.Assessment and Plan: 1. Impaired skin integrity. New orders placed for wounds on bilateral heels and toes. X-ray of bilateral feet. Vascular referral ASAP. Concern with gangrene. Review of Resident #53's X-ray of bilateral feet dated 2/10/26 revealed, .No osteomyelitis (infection of the bone) is seen.Medicine (sic) bone scan are more sensitive for detecting osteomyelitis. Review of Resident #53 Progress Notes&rd

Based on observation, interview and record review, the facility failed to fully implement a policy regarding use and storage of resident foods brought in from outside sources resulting in potentially hazardous foods being held passed their discard date, increasing the risk of contamination and food borne illness among residents who store food in resident refrigerators.Findings Include:On 4/14/26 at 10:06 AM, observation of the East Nourishment room found a plastic bag with containers of leftover dinner and dessert items labeled with a resident's name and dated 4-6-26. Further observation of the unit found an unopened package of yogurt labeled with a resident's name and having best by dates of March 23, 2026. At this time, an interview with Dietary Manager V found that staff come down to this room in the morning and after lunch to check on the snack items but probably get used to only looking at the items dietary regularly stocks. On 4/14/26 at 10:18 AM, observation of the [NAME] Nourishment room found three, four-packs of yogurt, with best by dates of [DATE] and March 6, 2026. A record review of the facility provided policy entitled Use and Storage of Food Brought in by Family or Visitor, revised on 3/11/26, found that, Food brought in by family or other visitors is permitted, provided care is taken to ensure food is handled properly for safe and sanitary storage, as well as consumption. A further review of the policy found that, Foods should be consumed or used by 72 hours or per facility food storage policy. Resident/Patient and family should be informed that if the food is not consumed within the designated storage time the food item will be discarded for food safety concern.

Based on interview and record review, the facility failed to: 1) effectively identify quality deficiencies, develop, and implement appropriate action to correct deficiencies; and 2) sustain a system to ensure corrective measures related to resident rights, bowel/bladder incontinence/catheter care, infection control, monthly medication reviews, pressure ulcers, and quality of care as evidenced by repeated deficiencies on the past three surveys. This deficient practice has the potential to affect all residents that reside in the facility. Findings include: During an interview on 4/17/2026 at 1:01 PM, Nursing Home Administrator (NHA) B reported that the facility was currently working on performance improvement projects (PIPS) related to resident falls and new employee orientation. NHA B reported the facility was not currently working on any performance improvement projects (PIPS) related to the repeat deficiencies that the facility had been cited for on the last three recertification and abbreviated surveys. NHA B confirmed that the facility had repeat deficiencies related to resident rights, bowel/bladder incontinence/catheter care, infection control, monthly medication reviews, pressure ulcers and quality of care, but that all of those areas had not been brought to QAPI as PIPs for the facility to work to improve on. NHA B confirmed that the repeat deficiencies that the facility had been cited for on the past surveys were high priority areas. Review of the facility's Quality Assurance and Performance Improvement Committee policy dated 3/11/26 revealed, Purpose/Objective:(The Facility) will maintain an ongoing and active Quality Assessment and Performance Improvement program . It will also focus on the care of all residents in the facility . 6. PERFORMANCE IMPROVEMENT PROJECTS (PIPs) a. A PIP is a concentrated effort on a particular problem in one area of our facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements. We conduct PIPs to examine and improve care or services in areas that we identify as needing attention. The facility will set priorities for PIPs that focus on high-risk, high-volume, or problem-prone areas; consider incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care .

Based on observation, interview, and record review, the facility failed to effectively implement an effective infection control program to include: 1). ensuring Enhanced Barrier Precautions (EBP) (an infection control intervention that uses targeted gown and glove use during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms (MDROs) were implemented in 3 residents (Resident #41, #45 & #53), 2). ensuring Contact Precautions (Transmission based infection control measure used to prevent the spread of infectious agents through direct or indirect contact) were implemented in 1 resident (Resident #61), 3.) maintain standard infection control measures in 1 resident (Resident #5) and 4.) an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), from a total of 18 resident reviewed for infection control, resulting in the potential for cross-contamination, the development and spread of infection to a vulnerable population, and increased risk of respiratory infection among all residents in the facility. Findings include: Resident #41 Review of an admission Record revealed Resident #41 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of sacral (tailbone) region stage unspecified. Review of Resident #41's Infection Control Care Plan revealed, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO). The resident must be placed in isolation (enhanced) due to risk of spreading MDRO's via an indwelling device, chronic/non-healing wound. Date initiated: 1/6/26. Interventions: .Staff are to wear PPE before entering room if they are providing high contact care. Date initiated: 1/6/26. In an interview on 04/14/2026 at 10:17 AM, Family Member (FM) VV reported that Resident #41 was on an antibiotic for a bad infection in her sacral wound and had recently been hospitalized for the wound. FM VV reported that the resident's family had not been visiting due to their fear of getting sick due to Resident #41's infection. During an observation and interview on 04/14/2026 at 11:03 AM Resident #41 was lying in her bed and Hospice Nurse (HN) M was performing wound care and a wound dressing change for Resident #41's sacral wound. Resident #41 verbalized that the wound was painful. Observed a foley catheter bag hanging from the bed frame. HN M was not wearing a gown. Observed signage outside of Resident #41's room indicating EBP were required. In an interview on 04/14/2026 at 11:20 AM, HN M reported that he had just finished wound dressing changes for Resident #41. Review of Resident #41's Hospice Progress Note dated 4/14/26 revealed, .Communicates verbally very effectively.Rates sacral wound pain 8/10.Wound care provided: Sacrum – stage 4 pressure wound – 6 x 6 x1 cm, right heel – stage 1 pressure wound 2 x 2 cm, right lateral foot – stage 1 pressure wound 0.3 x 0.3 cm. At end of lengthy visit, patient confirms that her pain is unimproved. In an interview on 04/16/2026 at 8:14 AM, Unit Manager (UM) D reported that Resident #41's last wound clinic visit was 4/6/26 and an antibiotic was ordered due to Resident #41's sacral wound infection at that time. UM D reported that Resident #41 was hospitalized [DATE]-[DATE] for UTI (urinary tract infection) and returned to the facility with a foley catheter in place to help with sacral wound healing. Review of Resident #41's Wound Clinic Visit dated 4/6/26 revealed, .Based on culture results of the sacrum we would like to begin Ciprofloxin (antibiotic) 500 mg twice a day for 10 days to treat the pseudomonas (bacteria).Her wound on her sacrum has declined today. Please encourage increased repositioning from side to side. If dressings are soiled they need to be changed or risk for infection will increase. Do not wipe them off. New dressings are needed. Resident #45 Review of an admission Record revealed Resident #45 was originally admitted to the facility on [DATE]. Review of Resident #45's Skin Care Plan revealed, I am at risk for skin breakdown.Date initiated: 4/19/21. Interventions: .Report any changes in skin to physician. Date initiated: 5/10/23. There was no mention of skin breakdown on buttocks, wound on chin, and/or pressure ulcer prevention. There was no care plan related to infection prevention. During an observation on 04/14/2026 at 11:27 AM Resident #45 was lying in his bed, his gown was soiled with flakes of dried blood and there was a large open wound on his left chin/neck. There was no signage that indicated Resident #45 had Enhanced Barrier Precautions (EBP) in place. In an interview on 04/15/2026 at 1:40 PM, LPN KK reported that the wound on Resident #45's chin/neck was a skin cancer that he elected not to get treatment for several years ago. LPN KK reported that there are no orders for wound care and/or a dressing. During an observation on 04/15/2026 at 4:09 PM Resident #45 was lying in his bed. UM D and LPN KK entered the room to complete a wound assessment. Observed a large deep open wound on his right chin/neck area that was beefy red and crusted along the edges. There were flakes of crusted blood covering the front of Resident #45's gown and his fingernails had blood underneath them. UM D measured the chin/neck wound; 5.5 cm x 5.5 cm. In an interview on 04/16/2026 at 7:32 AM, CNA GGG reported that Resident #45 had open areas on his bottom on and off. CNA GGG reported that direct care staff did not perform any type of wound care or cleansing of the open wound on Resident #45's chin. In an interview on 04/16/2026 at 7:44 AM, UM D reported that she had just completed a thorough skin check and wound assessments for Resident #45. UM D reported that she would also be adding EBP for Resident #45 due to the chronic open wound on his chin/neck. In an interview on 04/17/2026 at 9:12 AM, CNA G reported that she was not familiar with Resident #45's wounds and to CNA G's knowledge Resident #45 was not on any type of infection control precautions. Resident #53 Review of an admission Record revealed Resident #53 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Pressure ulcers of sacral region and heel, both unspecified. Review of Resident #53's Wound Management Care Plan revealed, Bilateral heels, Coccyx. Date initiated: 11/6/25. Interventions: Measure ulcer on regular intervals. Monitor ulcer for signs of infection. Monitor ulcer for signs of progression or declination. Notify provider if no signs of improvement on current regimen. Provide wound care per treatment orders. Date initiated 11/6/25. There was no care plan for EBP. During an observation on 04/15/2026 at 7:15 AM Resident #53 was lying in bed with her eyes closed and the HOB (head of bed) at approximately 45 degrees. There was no signage posted for enhanced barrier precautions (EBP). In an interview on 04/16/2026 at 9:25 AM, UM D reported that Resident #53 had wounds on her heels and buttocks, and at one time a couple months ago had concerns for osteomyelitis (infection in the bone caused by infected tissue) because the wounds on her feet were not healing. During an observation and interview on 04/17/2026 at 9:49 AM Resident #53 was sitting up in bed eating breakfast. There was no signage observed to indicate that Resident #53 had orders for EBP in place. During an observation on 04/17/2026 at 10:26 AM Resident #53 was lying in bed in a sitting position. UM D was gathering supplies for wound care. CNA CC was gathering supplies to provide incontinence care for Resident #53. There was still no signage indicating that Resident #53 had EBP in place. At 10:46 AM UM D, CNA CC, and Nurse Practitioner (NP) N were in the room at the bedside, donned (put on) gloves and began explaining to Resident #53 that they would be doing incontinence care and looking at her wounds. UM D removed the wound dressings from Resident #53's right and left heels, and NP N assessed the wounds. CNA CC and UM D rolled Resident #53 to her left side to provide incontinence care and assess her buttocks wound. There was an extra-large bandage covering Resident #53's coccyx area dated 4/17/26 that was visibly soaked with drainage from the wound. UM CC removed the bandage which revealed a large open wound with slough (moist white dead tissue) and eschar (black hard dead tissue) in the center of the wound. NP N reported Resident #53's coccyx wound was 8 cm x 9.5 cm and called it a Stage 3 pressure ulcer and said that it was deteriorating since there was tissue exposed now. Resident #53's brief was soiled with BM and urine and CNA CC completed incontinence care with assistance from UM D. UM D continued with wound care after the incontinence care, cleansing the coccyx wound and applying the wound dressing. It was noted that all staff in the room provided direct care and were not wearing proper PPE (personal protective equipment) related to EBP standards for wounds. In an interview on 04/17/26 at 11:11 AM, CNA CC reported that she was not aware that Resident #53 should have EBP in place. In an interview on 04/17/2026 at 11:17 AM, Infection Preventionist (IP) E reported that she would expect staff to notify her when there was a concern for wound infection and stated, a lot of the time I don't know until I find out on my own. IP E reported that residents with pressure wounds are not automatically placed in EBP. IP E reported that if a wound is diagnosed as a certain stage or was found to be infectious, then EBP would be implemented at that time. IP E reported that Resident #53 wounds were not open and she did not require EBP. In a subsequent interview on 04/17/26 at 11:40 AM, IP E reported that she was informed Resident #53's wounds were deteriorating therefore she would now be placed on EBP. Resident #61 Review of an admission Record revealed Resident #61 was originally admitted to the facility on [DATE]. Review of Resident #61's Infection Control Care Plan revealed, Contact Precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO). Date initiated: 4/16/26. Interventions: .Staff are to wash hands with soap and water before and after providing care. Staff are to wear PPE (gown and gloves) before entering room and discard before leaving room. Date initiated: 4/16/26. During an observation on 04/15/2026 at 1:15 PM Resident #61's door was closed and signage was posted that indicated Contact Precautions. The lunch cart arrived and CNA H delivered Resident #61's lunch tray to her and set the tray up on the table over the bed. CNA H did not don gloves or a gown and did not perform hand hygiene before or after contact with Resident #61. In an interview on 04/15/2026 at 1:26 PM, LPN FF reported that Resident #61 had a urinary tract infection and the culture showed an MDRO (multidrug resistant bacteria) ecoli (a bacteria found in the intestines), was on an antibiotic and had contact precautions in place. During an observation on 04/15/2026 at 1:58 PM CNA W entered Resident #61's room with linens and then came back out to retrieve wash cloths. CNA W did not don a gown or gloves prior to entering and/or exiting the room. At 2:08 PM CNA W entered the room with additional supplies and was not observed donning a gown or gloves. At 2:19 PM this surveyor donned a gown and gloves and entered Resident #61's room. CNA W was at the bedside performing incontinence care for Resident #61. CNA W was not wearing a gown. In an interview on 04/15/2026 at 2:31 PM, CNA W reported that she was not aware that Resident #61 had an infection, and she had not been informed that contact precautions were in place, until she saw this surveyor with a gown on. In an interview on 04/16/2026 at 8:48 AM, UM D reported that Resident #61's lab results from the urine sample were received on 4/15/26 via phone and contact precautions were put in place right away due to culture positive for an MDRO. UM D reported that staff were only required to don a gown when performing direct care and did not need to do such when delivering a meal tray. (It was noted that this information was not consistent with infection control standards of practice.) According to the Centers for Disease Control and Prevention (CDC), use contact precautions for patients with known or suspected infections that represent an increased risk for contact transmission .Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens .Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting patients on Contact Precautions. [NAME] clean PPE to handle the patient at the transport location .If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient .patients on contact precautions ensuring rooms are frequently cleaned and disinfected (e.g., at least daily or prior to use by another patient if outpatient setting) focusing on frequently-touched surfaces and equipment in the immediate vicinity of the patient . www.cdc.gov/infectioncontrol/basics Review of Centers for Disease Control and Prevention (CDC) dated March 20,2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following: o Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or o Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Effective Date: April 1, 2024 . www.cdc.gov/infectioncontrol/basics Review of Centers for Disease Control (CDC) poster for Enhanced Barrier Precautions, revealed, .Enhanced Barrier Precautions: Everyone Must .Clean Their Hands, including before entering and when leaving a room .Providers and Staff Must Also .Wear Gown and Gloves for the following High Contact Resident Care Activities .Dressing .Bathing/Showering .Transferring .Changing linens .Providing hygiene .Changing briefs or assisting with toileting .Device care or use: central line, urinary catheter, feeding tube, tracheostomy .Wound Care: any skin opening requiring a dressing . www.cdc.gov/infectioncontrol/basics Resident #5: Review of an admission Record revealed Resident #5 was a female with pertinent diagnoses which included altered mental status, diabetes, peripheral vascular disease (circulation disorder involving narrowed or blocked vessels), anxiety, heart failure, dementia, and muscle weakness. Review of Orders for Resident #5 revealed, .Monitor foley catheter 16fr/30cc (a device that drains urine from bladder to a collection bag outside of your body) r/t (related to) Urine retention. Change PRN (as needed) for obstruction every shift for infection control/hygiene AND as needed for infection control, hygiene Review of Orders for Resident #5 revealed, .Enhanced Barrier Precautions are in place to prevent the spread of MDRO's (multi drug resistant organisms) every shift for Safety All staff are to wear Gown and Gloves when providing high contact care. During an observation on 04/14/2026 at 4:01 PM, Resident #5 was seated in her recliner in her room. The catheter bag was partially lying on the floor with the bottom one third on the floor. During an observation on 04/15/2026 at 12:04 PM, Resident #5 catheter bag had bottom 1one third on the floor while she was seated in the recliner. It was located on the left front side of the recliner. In an interview on 04/17/2026 11:55 AM, Certified Nursing Assistant (CNA) T reported a resident's catheter bag should not be on the floor as there was dirt, debris, and could cause the bag to be contaminated. In an interview on 04/17/2026 at 12:15 PM, CNA TT reported the catheter bag should not be touching the floor as to ensure to keep it clean and prevent damage to the bag and it should have a dignity bag. In an interview on 04/17/2026 at 11:51 AM, Registered Nurse (RN) HH reported a catheter bag should not be on the floor due to infection control concerns as all the bacteria on the floor would contaminate the bag. In an interview on 04/17/2026 at 12:43 PM, Infection Preventionist (IFP) E reported a catheter bag should never be on the floor unless there was a barrier underneath of it due to the potential contamination. On 4/14/26 at 9:45 AM, observation of the three-compartment sink found that the cold-water handles for both faucets and the overhead spray were removed from the fixtures. When asked why they did not have handles, Dietary Manger V stated that staff only use hot water at these fixtures. On 4/14/26 at 10:50 AM, an interview with Facility Director (FD) Q, found that staff flush some unused and minimal use fixtures in the facility, but were not aware that kitchen staff were not using those cold-water fixtures in the kitchen and will add them to a flushing schedule. On 4/14/26 at 11:10 AM, observation of the housekeeping closet on the East South wing, found a chemical dispense system no longer in use. At this time, an interview with Housekeeping Lead UU found that her staff use the main housekeeping area in the basement with the chemical dispense and do not use the sinks on the floor anymore. At this time, the surveyor turned on the handles to the mop sink faucet in the closet and found that discolored water momentarily dispensed from the faucet when the hot water handle was turned on. On 4/14/26 at 11:16 AM, observation of the East North soiled utility room found a hopper with the fixture's hot water line off, and the hoppers sprayer turned off, both of which would leave stagnant lines if left unattended. On 4/14/26 at 11:40 AM, observation of the [NAME] South soiled utility room found that the hopper and hopper spray was not operable, making the fixtures stagnant water lines. At this time, an interview with FD Q found that he was unaware the janitor sinks and hoppers were not getting some regular use and would need to be on the flushing schedule. On 4/14/26 at 11:46 AM, observation of the [NAME] South housekeeping closet found that the hot water handle had been removed and the cold-water handle dispensed discolored water momentarily when turned on. On 4/14/26 at 1:50 PM, observation of the [NAME] North nurses station supply room found hot and cold-water lines protruding from the back wall and running to the room next door. Observation of the medical records room, next door, found the water lines capped off behind a short filing cabinet positioned in the corner of the room. On 4/14/26 at 2:27 PM, a review of Water Management Plan documentation found that the facility tests for free chlorine in the domestic water system. When asked if the facility ever tests the domestic hot water system, FD Q stated that they only test free chlorine in the cold-water system. A record review of the facility provided document entitled, Water Management Program, last revised on 1/31/2022, found that, The WMP will include the following elements: .The identification of situations that can led to Legionella growth, such as: .7. Water stagnation. 8. Inadequate disinfection. A further review of the document found that it states, Quarterly Free chlorine monitoring will include, but not limited to: .4. Monitor water leaving the boiler. (the hot water supply).

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) employed by the facility received at least 12 hours of annual in-service education, resulting in the potential for inadequate care and unmet needs of residents. This had the potential to affect all residents who reside in the facility. Findings include:In an interview on 04/17/2026 at 1:46 PM, Staff Scheduler (SS) L reported that she was not familiar with CNA in-service hour requirements. In an interview on 04/17/2026 at 1:59 PM, Director of Nursing (DON) C reported that CNA's were assigned monthly trainings through an online platform and the HR (Human Resource) person tracked those. In an interview on 04/17/2026 at 2:25 PM, Interim-Chief Executive Officer (I-CEO) B reported that he was not able to provide tracking information for CNA in-service hours. I-CEO B reported that Infection Preventionist (IP) E was also responsible for staff education but the task was not being completed. I-CEO B reported that he would provide a report to show the lack of in-service tracking. Review of CNA In-service Reports provided by the facility failed to confirm that all CNA's employed by the facility received the required 12 hours of annual in-service. Numerous CNA's that were listed did not complete the assigned monthly trainings.Review of The Importance of Continuing Education Credits in Healthcare, www.leaderstat.com, 2024, revealed: According to The Institute For Health Care Improvement, CE (continuing education) is a vehicle for spreading best practices and how to improve patient outcomes.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 8 of 18 residents (Resident #41, #45, #53, #61, #7, #81, #18 and #4) reviewed for complete and accurate documentation, resulting in the potential for staff and providers mismanaging care for residents. Findings include:Resident #41 Review of an admission Record revealed Resident #41 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of sacral (tailbone) region stage unspecified. Review of Resident #41's Wound Care Plan revealed, .I have wound on my sacral buttock area, left BKA (below the knee amputation) surgical incision, left gluteus, right gluteus. Date initiated: 12/19/25. Review of Resident #41's Hospice Progress Note dated 4/14/26 revealed, .Communicates verbally very effectively.Rates sacral wound pain 8/10.Wound care provided: Sacrum – stage 4 pressure wound – 6 x 6 x1 cm, right heel – stage 1 pressure wound 2 x 2 cm, right lateral foot – stage 1pressure wound 0.3 x 0.3 cm. At end of lengthy visit, patient confirms that her pain is unapproved. In an interview on 04/16/2026 at 8:14 AM, Unit Manager (UM) D reported that Resident #41's last wound clinic visit was 4/6/26 and an antibiotic was ordered due to Resident #41's sacral wound infection at that time. UM D reported that Resident #41 was hospitalized [DATE]-[DATE] for UTI (urinary tract infection) and returned to the facility with a foley catheter in place to help with sacral wound healing. UM D reported that the facility did not have a wound provider or nurse that specialized in wounds and expected that the floor nurse assigned to daily care for residents, should also be completing the weekly wound assessments when they are due. UM D reported that the nurse that performed the weekly assessments would not be consistent but should be able to determine wound progress by comparing the assessment details from the week prior. After reviewing Resident #41's record, UM D reported that the weekly wound assessments were not being documented as expected by the nursing staff; most of the wound information appeared to be copied and pasted from earlier assessments. UM D could not determine when the last time Resident #41's sacral (coccyx) wound and right foot wounds were formally assessed and measured by facility staff. UM D could not find any documentation to verify that staff were regularly assessing and monitoring Resident #41's wounds, other than the treatment records that were initialed, to indicate they were completed, and the wound clinic visit notes that were scanned into the record did not include wound measurements and/or characteristics. UM D could not find any documentation related to concerns that Resident #41's wounds deteriorating and or having had signs of infection prior to her being started on an antibiotic on 4/6/26. Director of Nursing (DON) C was present for this interview and could not provide any information to support compliance for Resident #41's wounds management. Review of Resident #41's Weekly Skin Check dated 3/9/26 at 2:24 PM (prior to hospitalization) revealed, .Skin warm and dry, skin color WNL (within normal limits). No new skin issues identified. Skin issue #1: .HAS NOT BEEN EVALUATED. Location left gluteus.Issue type: Pressure ulcer/injury. Wound was present on admission. Skin issue #2: .HAS NOT BEEN EVALUATED. Location: left gluteus. Issue type: Open lesion. Wound was present on admission.Skin issue #3: .HAS NOT BEEN EVALUATED. Location: right gluteus. Issue type: Open lesion. Wound was present on admission. Staged by In-house nursing. Skin issue #4: .HAS NOT BEEN EVALUATED. Location: left gluteus. Additional information: Sacrum. Issue type: Pressure ulcer/injury. Pressure ulcer staging: Stage 3 pressure ulcer/injury full thickness skin loss. Wound was present on admission. The wound assessments were not completed. Review of Resident #41's Wound Clinic Visit dated 3/9/26 at 11:00 AM revealed, .Her wound has declined today. Please encourage increased repositioning from side to side. Wound Treatment: Wound #1 location: Sacrum. Wound #5 location: Gluteus Right. The document did not include assessments of the wounds. Review of Resident #41's Hospital After Visit Summary dated 3/19/26 (admitted on [DATE]) revealed, .Transfer Instructions: .Wound Site: Sacrum .Right heel, Right lateral foot, left medial thigh and left upper lateral thigh.Foley in place for maintenance of sacral wound. Review of Resident #41's re-admission Assessment dated 3/19/26 revealed, Arrived by ambulance. Urinary Catheter intact. Skin warm and dry, skin color WNL (within normal limits). No new skin issues identified. Skin issue #1: .HAS NOT BEEN EVALUTED. Location left gluteus, proximal, superior. Issue type: Pressure ulcer/injury. Wound was present on admission. Skin issue #2: .HAS NOT BEEN EVALUATED. Location: left gluteus, distal, inferior. Issue type: Open lesion. Wound was present on admission.Skin issue #3: .HAS NOT BEEN EVALUATED. Location: right gluteus, inferior, distal. Issue type: Open lesion. Wound was present on admission. Staged by In-house nursing. Skin issue #4: .HAS NOT BEEN EVALUATED. Location: left gluteus, middle, inferior, distal. Additional information: Sacrum. Issue type: Pressure ulcer/injury. Pressure ulcer staging: Stage 3 pressure ulcer/injury full thickness skin loss. Wound was present on admission. It was noted that the information was copied from the 3/9/26 skin check and did not include all of the wounds listed on the hospital after visit summary that same day. Review of Resident #41's Skilled Nursing Evaluation dated 3/21/26 revealed, .Skin issue #1: .HAS NOT BEEN EVALUATED. Location left gluteus, proximal, superior. Issue type: Pressure ulcer/injury. Wound was present on admission. Skin issue #2: .HAS NOT BEEN EVALUATED. Location: left gluteus, distal, inferior. Issue type: Open lesion. Wound was present on admission.Skin issue #3: .HAS NOT BEEN EVALUATED. Location: right gluteus, inferior, distal. Issue type: Open lesion. Wound was present on admission. Staged by In-house nursing. Skin issue #4: .HAS NOT BEEN EVALUATED. Location: left gluteus, middle, inferior, distal. Additional information: Sacrum. Issue type: Pressure ulcer/injury. Pressure ulcer staging: Stage 3 pressure ulcer/injury full thickness skin loss. Wound was present on admission. There was no current assessment of Resident #41's wounds. It was noted that the information was copied from the 3/19/26 skin check and still did not include all of Resident #41's wounds. Review of Resident #41's Skilled Nursing Evaluation dated 3/22/26, 3/23/26, 3/24/26, and 3/26/26 all revealed a duplication of the skin issues documentation from 3/21/26. Review of Resident #41's Weekly Skin Check dated 3/26/26 revealed a duplication of the skin issues documentation from the previous weekly skin checks. Review of Resident #41's Wound Clinic Visit dated 4/6/26 revealed, .Based on culture results of the sacrum we would like to begin Ciprofloxin (antibiotic) 500 mg twice a day for 10 days to treat the pseudomonas (bacteria).Her wound on her sacrum (coccyx) has declined today. Please encourage increased repositioning from side to side. If dressings are soiled, they need to be changed or risk for infection will increase. Do not wipe them off. New dressings are needed. Review of Resident #41's most recent Weekly Skin Check dated 4/9/26 revealed, Skin warm and dry, skin color WNP (within normal limits) .Skin issues: Skin issue #1: Skin issue HAS NOT BEEN EVALUATED. Location: left gluteus. Issue type: pressure ulcer/injury. Skin issue #2: .HAS NOT BEEN EVALUATED. Location: left gluteus. Issue type: Open lesion. Skin issue #3: .HAS NOT BEEN EVALUATED. Location: right gluteus. Issue type: Open lesion. Staged by: in-house nursing. Skin issue #4: .HAS NOT BEEN EVALUATED. Location: left gluteus. Additional location information: SACRUM. Issue type: pressure ulcer/injury. Skin issue #5: NEW SKIN ISSUE. Location: Coccyx. Issue type: Pressure ulcer/injury. Progress: Improving. Overall wound characteristics improved. Wound was present on admission. Length 1 (cm), width 1.5 (cm), depth 0 (cm). There was no documentation that wounds #1-4 were assessed and wound #5 (coccyx) was not an accurate description of the infected Stage 3 pressure wound noted in the wound clinic visit on 4/6/26. Resident #45 Review of an admission Record revealed Resident #45 was originally admitted to the facility on [DATE]. Review of Resident #45's Skin Care Plan revealed, I am at risk for skin breakdown.Date initiated: 4/19/21. Interventions: .Report any changes in skin to physician. Date initiated: 5/10/23. There was no mention of skin breakdown on buttocks, wound on chin, and/or pressure ulcer prevention. During an observation on 04/14/2026 at 11:27 AM Resident #45 was lying in his bed, his gown was soiled with flakes of dried blood and there was a large open wound on his left chin/neck. Review of Resident #45's Weekly Skin Check dated 4/6/26 revealed, Skin warm & dry, skin color WNL and turgor is normal. No new skin issues identified. Skin Issues: #1 Skin issue has NOT been evaluated. Location: buttocks-generalized.redness. #2 Skin issue has NOT been evaluated. Location: buttocks-generalized.middle.redness. # 3 Skin issue has NOT been evaluated. Location: chin, left.open wound that resident picks at non-stop.Wound is greater than 3 months. #4 Skin issue has NOT been evaluated. Location: genital.testicles.small open area, treatment in place. Resident #45's Weekly Skin Checks dated 3/27/26 and 3/20/26 are exactly the same as 4/6/25. There were no current wound assessments. In an interview on 04/15/2026 at 1:40 PM, LPN KK reported that the wound on Resident #45's chin/neck was a skin cancer that he elected not to get treatment for several years ago. LPN KK reported that there are no orders for wound care and/or a dressing. Review of Resident #45's Dermatology (skin specialist) Visit Note dated 7/19/23 revealed, .Basal Cell Carcinoma (skin cancer), nodular type on the left inferior medial buccal cheek (lower cheek/chin). Review of Resident #45's Provider Visit Note dated 4/7/26 revealed, .Noted to have a basal cell carcinoma on his jaw line. However, this skin cancer has progressed from a small lesion which would have been usually excised under local anesthetic to the deep ulcerative lesion that swell into the subcutaneous tissue. There was no mention of wound treatments and/or a wound on Resident #45's buttocks. In an interview on 04/15/2026 at 3:38 PM, UM D reported that Resident #45 had a skin cancer on his left chin/neck a few years ago and declined surgical interventions. UM D reported that they do not currently have orders in place to clean the wound, no wound dressing orders, and there are no orders in place for monitoring the wound. UM D reported that Resident #45's left chin/neck and/or buttocks wounds were not being documented in the weekly skin checks; the assessment details were copied from the week before. During an observation on 04/15/2026 at 4:09 PM Resident #45 was lying in his bed. UM D and LPN KK entered the room to complete a wound assessment. Observed a large deep open wound on his right chin/neck area that was beefy red and crusted along the edges. UM D measured the chin/neck wound; 5.5 cm x 5.5 cm. In an interview on 04/16/2026 at 7:44 AM, UM D reported that she had just completed a thorough skin check and wound assessments for Resident #45. UM D reported that she did observe a stage 1 pressure wound on Resident #45's buttocks and she would be entering orders for barrier cream and repositioning. UM D reported that she would also be adding EBP (enhanced barrier precautions, an infection intervention for residents with open wounds) for Resident #45 due to the chronic open wound on his chin/neck. Resident #53 Review of an admission Record revealed Resident #53 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Pressure ulcers of sacral region and heel, both unspecified. Review of Resident #53's Wound Management Care Plan revealed, Bilateral heels, Coccyx. Date initiated: 11/6/25. In an interview on 04/16/2026 at 9:25 AM, UM D reported that Resident #53 had wounds on her heels and buttocks, and at one time a couple months ago had concerns for osteomyelitis (infection in the bone caused by infected tissue) because the wounds on her feet were not healing. UM D did not know the status of Resident #53's wounds. Reviewing Resident #53's records with UM D and there was no documentation of wound assessments that measured size, no pressure wound interventions listed, and all weekly skin checks were noted as normal. UM D reported that the facility did not have a dedicated wound nurse or provider, and that the floor nurse was expected to complete all wound assessments during the weekly skin check and notify UM D or a provider if there was a concern. UM D reported that the facility also uses a Wound Log to document when a concern is identified. Review of the facility Wound Communication Log revealed, (Resident #53) 4/2/26 Sacral wound purulent (a thick substance indicative of infection) drainage 3x2cm, new bruise right upper thigh/hip, new wound to right of current wound .5x.2cm. There was no documentation in the blanks for dressing orders or risk management completed. In an interview on 04/17/2026 at 10:04 AM, UM D reported that she was not aware of the wound communication log note from 4/2/26 related to Resident#53's wounds. UM D reported that Resident #53's orders had not changed since then and there were no progress notes or physician notes to correlate that the wound concern was assessed and being monitored. During an observation on 04/17/2026 at 10:26 AM Resident #53 was lying in bed with the HOB (head of bed) raised. At 10:46 AM UM D, CNA CC, and Nurse Practitioner (NP) N were in the room at the bedside to complete incontinence care and wound care. Upon observation, NP N reported Resident #53's coccyx wound was 8 cm x 9.5 cm and called it a Stage 3 pressure ulcer and said that it was deteriorating since there was tissue exposed. Observed a large purple discolored wound on Resident #53's right upper thigh that followed the line of an incontinence brief. UM D reported that she was not aware of the wound on the right upper thigh. Observed Resident #53's toes on her left foot discolored; the toes were not examined. In an interview and observation on 04/17/2026 at 12:04 PM, Registered Nurse (RN) I reported that they were applying betadine (antiseptic for infection prevention) to Resident #53 toes. Observed Resident #53 lying in her bed; her left great toe had a thick scab covering the tip, and the 2nd and 3rd toes were discolored black at the tips. RN I reported that Resident #53's left great toe was an unstageable pressure injury. It was noted that these wounds were not noted in the list of skin issues in the Weekly Skin Checks. Review of Resident #53's Physician Note dated 2/9/26 revealed, .Staff concerned with skin issues on her bilateral feet. Bilateral heel wounds were being treated with Dakins (helps reduce infection and promote healing) solution on bilateral heels while floating and has an air mattress to offload pressure. Now concern with discoloration of toes.Physical exam: .Bilateral heels have stage 3 pressure injury with beefy red wound base and macerated edges surrounding both wounds are individually the size of a nickel, right great toe has deep purple scab to the tip of the toe, right 2nd digit has small area on the pad of the toe which is dark purple, left great toe appears to have gangrene at the tip, left 2nd digit has gangrene nearly to the DIP (distal interphalangeal: closest to tip of toe) joint, bilateral legs have venous insufficiency with skin color changes.Assessment and Plan: 1. Impaired skin integrity. New orders placed for wounds on bilateral heels and toes. X-ray of bilateral feet. Vascular referral ASAP. Concern with gangrene. In an interview on 04/17/2026 at 12:44 PM, UM D reported that nursing staff notified her today of Resident #53's wounds on her toes. UM D reported that the orders were entered into the computer on 2/10/26 for her right toes instead of the left toes. UM D reported she could not explain why there was not follow up by a provider and/or wound assessments of her toes. Review of Resident #53's Health Status Note documented by UM D dated 2/13/26 revealed, wound treatment completed as ordered. Toes painted with betadine as order. Tolerated dressing change well. Wound on buttocks appears deteriorated. Wound on heels improved. Toes are stable. Wound log updated. Son and NP made aware. Review of Resident #53's Weekly Skin Check dated 3/20/26 indicated there were no new skin issues identified and listed the following wounds as not evaluated: Right inguinal region, left heel, left gluteal fold, coccyx, general bruising, left inguinal region, right gluteal fold and right heel. There was no documentation related to Resident #53's toes. Review of Resident #53's Weekly Skin Check dated 3/30/26 revealed, Skin: Skin warm & dry, skin color WNL and turgor is normal. Foot evaluation completed. No new skin issues identified. Skin issues: #1 Skin issue HAS been evaluated. Location: left inguinal region. Moisture associated skin damage (MASD). Progress: improving. #2 Skin issue has NOT been evaluated. Location: Coccyx. #3 Skin issue HAS been evaluated. Location: right inguinal region.MASD. #4 Skin issue has NOT been evaluated. Location: right heel.Unstageable pressure injuries. #5 Skin issue has NOT been evaluated. Location: left heel.Unstageable pressure injuries. There was no documentation the Resident #53's coccyx, heels and toe wounds were assessed. Review of Resident #53's Weekly Skin Check dated 4/6/26 revealed, Skin: Skin warm & dry, skin color WNL and turgor is normal. Foot evaluation completed. No new skin issues identified. Skin Issues: #1: Skin issue has NOT been evaluated. Location: Coccyx. #2: Skin issue has NOT been evaluated.#2 Skin issue has NOT been evaluated. Location: Right heel. Issue type: Pressure ulcer / injury. Progress: Stalled: previously improving wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury . #3: Skin issue has NOT been evaluated. Location: Left inguinal (groin) region . Moisture associated skin damage (MASD). #4: Skin issue has NOT been evaluated. Location: Right inguinal region. Issue type: Moisture associated skin damage (MASD). #5: Skin issue has NOT been evaluated. Location: Left heel. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstageable pressure injuries. It was noted that none of Resident #53's wounds were assessed and there were no wounds noted on her toes. Review of Resident #53's most recent Weekly Skin Check dated 4/13/2026 revealed, Skin: Skin warm & dry, skin color WNL and turgor is normal. Foot evaluation completed. No new skin issues identified. Skin Issues: #1: Skin issue has NOT been evaluated. Location: Coccyx. #2: Skin issue HAS been evaluated. Location: Right heel. Issue type: Pressure ulcer / injury. Progress: Stalled: previously improving wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury . Length (cm): 7.4 Width (cm): 7.8.Exudate amount: Light. Exudate type: Serous: clear watery fluid, which is separated from solid elements. #3: Skin issue HAS been evaluated. Location: Left inguinal (groin) region . Moisture associated skin damage (MASD). Progress: Stable: previously deteriorating wound characteristics plateaued . Measurements not documented as part of this assessment. #4: Skin issue HAS been evaluated. Location: Right inguinal region. Issue type: Moisture associated skin damage (MASD). Progress: Stable: previously deteriorating wound characteristics plateaued . Measurements not documented as part of this assessment. #5: Skin issue HAS been evaluated. Location: Left heel. Issue type: Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury.Measurements not documented as part of this assessment.Clean dressing applied. There was no documentation of the wounds on Resident #53's toes and it was noted that the coccyx wound was not assessed. Resident #61 Review of an admission Record revealed Resident #61 was originally admitted to the facility on [DATE]. During an observation on 04/15/2026 at 1:58 PM CNA W entered Resident #61's room to perform incontinence care. CNA W positioned Resident #61 on her right side and 2 raised crusted areas of skin were observed near the resident's gluteal crease (butt crack) with the entire surrounding skin on the buttocks and upper thighs bright red. Resident #61 winced in pain when CNA W touched the area. Review of Resident #61's Weekly Skin Check dated 4/15/26 at 12:49 PM documented by LPN FF revealed, Skin warm & dry, skin color WNL and turgor is normal.Foot evaluation completed. No new skin issues identified. Skin issues: #1 Skin issue has NOT been evaluated. Location: rear right thigh.Issue type: medical device related pressure ulcer.Wound acquired in house. #2 Skin issue has NOT been evaluated. Location: right lateral thigh. Issue Type: scratch. #3 Skin issue has NOT been evaluated. Location: Coccyx (upper buttock/tailbone). Issue type: redness. The wound assessments were not documented. See interview below. In a subsequent interview on 04/15/2026 at 4:06 PM, LPN FF reported that she had not completed Resident #61's skin check yet today and was not aware that it had been documented already. In an interview on 04/16/2026 at 8:48 AM, After review of Resident #61's record UM D reported that the resident had a pressure ulcer on her buttocks and UM D could not report when the last time Resident #61's pressure wound on her buttocks had been assessed. Resident #7 Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE]. Review of Resident #7's Physician Communication Note dated 4/15/26 at 7:17 AM revealed, Resident has a small slit in between intergluteal cleft (butt crack), barrier cream applied. Review of Resident #7's Physician Orders revealed, cleanse the pressure injury area in the intergluteal cleft with skin wipes and apply barrier cream BID (twice a day). Start date 4/15/26. In an interview on 04/15/26 at 11:50 AM, CNA W reported that Resident #7 complained of a sore spot on her buttocks that day and a new thin open wound in the crease of her buttocks was observed during incontinence care. Review of Resident #7's Weekly Skin Check dated 4/15/26 at 3:46 PM revealed, Skin warm & dry, skin color WNL and turgor is normal. Skin Issue: #1 Skin issue has NOT been evaluated. Location: left heel. Issue type: blanchable redness. There was no mention of the wound on Resident #7's buttocks. In an interview on 04/16/2026 at 7:57 AM, Director of Nursing (DON) C reported that she understood the concern for non-compliance with wound management and that the facility would be implementing a new program going forward to ensure that wound assessments were completed accurately and that there was a qualified provider driving the treatment of wounds. In an interview on 04/16/2026 at 11:30 AM, Interim CEO (Chief Executive Officer) B was asked to provide documentation that may support the facilities compliance with wound management. I-CEO B reported that he had been present in the facility for the past few months and was aware that the facility needed to work on their wound management program. I-CEO B reported that there was no additional documentation to support compliance for Resident #7, #41, #45, #53, and/or #61. Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, High-quality documentation and reporting are necessary to enhance efficient, individualized patient care. Quality documentation and reporting have five important characteristics: they are factual, accurate, complete, current, and organized .Criteria for thorough communication exist for certain health problems or nursing activities. Your written entries in a patient's medical record describe the nursing care you administer and the patient's response .Timely entries are essential in a patient's ongoing care. Delays in documentation lead to unsafe patient care .It is more effective when notes are concise, clear, and to the point .Use the nursing process to give logic and organization to your documentation. [NAME], P. A., [NAME], A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 350-353 According to Legal and Ethical Issues in Nursing, 4th Edition, ([NAME], G, 2006), A major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete. Review of the facility policy Documentation in Medical Record dated 3/13/24 revealed, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3. Documentation may be performed manually or as per the facility's specific electronic medical record software program. 4. Principles of documentation include but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented. ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. iii. Subjective information shall be recorded only as relevant, such as the resident's verbalizations, in quotation marks. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. c. Documentation shall be timely and in chronological order. d. Write legibly in black ink or follow the facility's specific electronic medical record software for inputting information. e. Record date and time of entry. f. Sign each entry with name and credentials of the person making the entry. g. Only standardized terminology, acronyms, and symbols may be used. h. Avoid generalizations and vague phrases or expressions. i. Only document conclusions that can be supported by data and avoid bias, labels, and value judgments . Resident #81 Review of an admission Record revealed Resident #81 was originally admitted to the facility on [DATE] with pertinent diagnoses which included essential hypertension (high blood pressure) and type 2 diabetes mellitus (chronic metabolic disorder characterized by insulin resistance and relative insulin deficiency, leading to high blood sugar.) Review of Resident #81's Progress Note dated 2/13/26 and documented by Registered Nurse (RN) DD revealed, Resident sent to hospital for stroke-like symptoms. This nurse contacted the daughter to inform of sending resident out . (Nurse Practitioner (NP) DDD) assessed resident and wanted resident sent out for evaluation. Noted that NP DDD's assessment of Resident #81 on 2/13/26 was not in his record. On 4/17/2026 at 10:26 AM, This writer requested NP DDD's visit note for Resident #81 on 2/13/26 to Nursing Home Administrator (NHA) A and Interim CEO B. This writer attempted to contact RN DD via telephone on 4/17/2026 at 10:28 AM. RN DD did not return this writer's call prior to survey exit. During an interview on 4/17/2026 at 12:20 PM, Interim CEO B reported that he was not able to obtain the record of Resident #81's visit with NP DD at the facility on 2/13/26. Interim CEO B confirmed that the facility was unable to provide any further information related to Resident #81's assessment which indicated a need for urgent transfer because the facility was missing documentation of Resident #81's visit with NP DD on 2/13/26. Resident #18 Review of an admission Record revealed Resident #18 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (an umbrella term for a decline in mental ability, such as memory, language, problem solving skills) and heart failure (chronic condition in which the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs). Review of a Minimum Data Set (MDS) assessment for Resident #18 with a reference [TRUNCATED]

Based on observation, interview and record review, the facility failed to revise care plan interventions for pressure ulcer prevention for 1 (Resident #18) of 18 residents reviewed for care planning, resulting in staff being unaware of current pressure ulcer prevention interventions for the resident, and a potential for the resident to experience worsening of pressure ulcers. Findings include: Resident #18Review of an admission Record revealed Resident #18 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (an umbrella term for a decline in mental ability, such as memory, language, problem solving skills) and heart failure (chronic condition in which the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs).Review of a Minimum Data Set (MDS) assessment for Resident #18 with a reference date of 2/20/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 1/15, which indicated the resident was severely cognitively impaired. Section M of the MDS revealed Resident #18 was at risk of developing pressure ulcers.Review of a Care Plan for Resident #18 with a reference date of 10/9/25 revealed the following focus/goal/interventions: Focus: I am at risk for skin breakdown r/t (related to) dependence on staff for assist with bed mobility.Goal: To minimize or prevent skin breakdown during residents stay.Interventions: Float heels on pillow as tolerated and skin prep to R (right) heel for prevention of breakdown. There was no intervention for the use of heel protector boots.Review of Physician Orders for Resident #18 with a reference date of 4/2/26, revealed Heel protectors at all times, every day and night shift for prevention of skin impairment. Further review revealed Resident #18's roommate did not have orders for use of heel protectors.In an interview on 4/15/26 at 2:20pm, Certified Nursing Assistant (CNA) H reported she worked on units throughout the building and referred to each resident's Kardex to know their care needs. CNA H reported the information for the Kardex came from the resident's care plan. When queried regarding pressure ulcer prevention strategies that were in place for Resident #18, CNA H reported he used a specialty mattress. When further queried, CNA H stated they were using boots for his feet at one point, then confirmed it was her understanding the resident no longer needed the heel protector boots.Review of a Kardex (summary of care needs) for Resident #18 revealed Resident Care: Float heels on pillow as tolerated and skin prep to R heel for prevention of breakdown. The Kardex did not include information about the physician's order for heel protectors.During serial observations on 4/16/26 at 8:16am, 8:42am, 8:55am, 9:15am, 9:36am and 9:50am, Resident #18 was lying supine in bed with both heels resting directly on the mattress. Resident #18's heel protector boots were in a chair by his roommate's bed.

This citation pertains to intake 2642352. Based on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL) care was provided for 4 (Resident #1, #57, #16, #26) of 7 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's dependent on staff for assistance. Findings include: Resident #1: Review of Care Plan for Resident #1, revised on 3/3/26, revealed the focus, .I have an ADL (activities of daily living) deficit and need assistance with daily care r/t (related to) weakness/debility. with the intervention .ADL care to meet my needs. During an observation and interview on 04/14/2026 at 10:55 AM, Resident #1 reported she was scheduled to get her showers on Thursdays and Saturdays. Resident #1 was observed to have greasy appearing hair, her face appeared as if it needed to be washed, hair needed to be combed, and when this writer questioned if staff had offered to get a basin or washcloth for her to wash her face she indicated they had not on this day. Review of Shower Sheets revealed Resident #1 received bed baths on 4/4/26, 4/2/26, 2/28/26, and 2/22/26. Resident #1 received a shower on 3/28/26. It was noted on a shower sheet dated 3/14/26. Resident #1 was admitted on [DATE] which indicated she had 16 opportunities for staff to provide her with a shower/bed bath. Resident #1 was provided with a total of 5 shower/bed baths during this time. During an observation and interview on 04/16/2026 at 3:02 PM, Resident #1 reported she had received a bed bath earlier, but her hair appeared dirty and greasy still. When this writer queried when the last time was, she had her hair washed, Resident #1 reported it had been a couple weeks at least. Resident #57: Review of an admission Record revealed Resident #57 was a male with pertinent diagnoses which included dementia and physical debility. During an observation on 04/14/2026 at 9:52 AM, Resident #57 was observed seated in his reclining broda chair (specialized adjustable wheelchair or positioning chair designed for residents with mobility challenges) in the TV room area. Resident #57 was observed to have fingernails which extended far beyond the fingertips, the nails were jagged and misshapen, with dark dried material under the nails gathered at the hyponychium (seal of skin located just beneath the free edge of the nail plate, acts as a barrier to bacteria, fungi, and debris from entering the nail bed). During an observation on 04/15/26 at 4:01 PM, Resident #57 was observed seated in the tv room area and he had dark dried material under his fingernails, his fingernails extended far beyond the fingertips and were broken and jagged. During an observation on 04/17/2026 at 11:50 AM, Resident #57 was observed seated in the tv room area and he had dark dried material under his fingernails, his fingernails extended far beyond the fingertips and were broken and jagged. In an interview on 04/17/2026 at 12:53 PM, UM D reported the nurses were able to cut the fingernails for a resident when asked. UM D reported the nail clippers were not kept in the nurse's cart, and the nurse would have to go to downstairs to supply to obtain them. UM D reported the CNAs were able to use the wooden nail cleaning tool to clean under a resident's fingernails during a resident's scheduled shower. Resident #16 Review of an admission Record revealed Resident #16 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: schizoid personality disorder (chronic mental health condition characterized by limited emotional expression, strong preference for isolation and lack of motivation), depression (a serious, common mental illness causing persistent sadness) and body max index (BMI) 40-44.9 (morbid obesity). Review of a Minimum Data Set (MDS) assessment for Resident #16 with a reference date of 2/6/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section D of the MDS revealed Resident #16 felt down, depressed, or hopeless during 12-14 days of the 14-day assessment period. Section GG of the MDS revealed Resident #16 was dependent (helper does all of the effort) for bathing. Review of a Care Plan for Resident #16 with a reference date of 1/27/26 revealed the following focus/goal/interventions: Focus: I have an ADL (activities of daily living) deficit and need assistance with daily care.I prefer a bed bath.Goal: I will have my needs met on a daily basis as evidenced by my neat, clean, well groomed appearance.Interventions: ADL care to meet my needs. During an observation and interview on 4/14/26 at 4:15pm, Resident #16's hair appeared tangled and disheveled, and facial hairs were noted on her chin. Resident #16 reported she preferred to have a bed bath rather than a shower but was only being assisted with getting cleaned up (bed bath or shower) about once a week and she felt that was not enough. Review of Shower Sheets for Resident #16 revealed the resident was a shower or bed bath on 4 occasions between 2/15-4/15/26. Review of a Kardex (brief overview of a resident's care needs) revealed Bathing: Bed bath 2 person assist with care at all times, on Saturday afternoon to late evening. Review of an electronic communication received on 4/15/26 at 1:02pm revealed Chief Executive Officer (CEO) B reported the facility did not have any additional shower sheets for Resident #16 for the period of 2/15-4/15/26. Resident #26 Review of an admission Record revealed Resident #26 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: congestive heart failure (progressive condition where the heart muscle is too weak to pump blood efficiently) and major depressive disorder (serious mental health condition characterized by at least 2 weeks of persistent, severe sadness, loss of interests, fatigue). Review of a Minimum Data Set (MDS) assessment for Resident #26 with a reference date of 3/7/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 11/15, which indicated the resident was moderately cognitively impaired. Section GG of the MDS revealed Resident #26 required maximal assistance (helper does more than half) for bathing. Review of a Care Plan for Resident #26 with a reference date of 12/5/25 revealed the following focus/goal/interventions: Focus: I have an ADL deficit and need assistance with daily care.I often refuse bed baths, showers.Goal: I will maintain my current level of function through the review date. Interventions.no male caregivers, staff to assist me with ADLs.PRN (as needed) . Review of a Summary of Complaint with a reference date of 10/14/25 at 9:42am revealed Complainant stated the staff are not taking care of (Resident #26) .Complainant states that (Resident #26) has an odor. (Resident #26's) hair has been observed filthy. (Resident #26) smells of body odor. Efforts to contact the complainant were unsuccessful prior to the conclusion of the survey. Review of a Task Description for Resident #26 revealed ADL-Bathing Mondays and Thursday AM; I often refuse to take a shower/bath in the shower room; I would rather have a bed bath most of the time on my shower days. During an observation and interview on 4/14/26 at 4:22pm, Resident #26 was in bed, was wearing a hospital gown and appeared disheveled. Resident #26 reported she does not get cleaned up as often as she would like and isn't offered the opportunity twice a week. Review of Shower Sheets provided by the facility for Resident #26 revealed the resident was offered or received bathing during 10 of 17 opportunities between 2/15-4/25/26. Review of an electronic communication received on 4/15/26 at 1:02pm revealed Chief Executive Officer (CEO) B reported the facility did not have any additional shower sheets for Resident #26 for the period of 2/15-4/15/26. In an interview on 4/16/26 at 8:49am, Certified Nursing Assistant (CNA) MM reported when staffing numbers fall below what was scheduled, staff were not able to offer residents shower/bathing assistance at times. In an interview on 4/16/26 at 2:49pm Unit Manager (UM) D reported CNAs were expected to complete a shower sheet each time they offered residents assistance with bathing. UM D reported after the CNA completed a shower sheet; the nurse was expected to sign it and then turn it in for the UM to review it. UM D reported each resident was scheduled to receive at least 2 opportunities for bathing each week and could request additional opportunities per their preference.

This citation pertains to intake #2616992Based on observation, interview and record review, the facility failed to ensure residents achieved their highest practicable physical well-being and follow professional standards of practice by: 1. ensure staff assess and monitor non-pressure wounds, 2.) recognize and assess symptoms of infection, 3.) follow physician's orders for use of medication, and 4.) recognize episodes of hypoglycemia(low blood sugar level)/hyperglycemia(elevated blood sugar level) requiring physician's notification in 5 (Resident #29, #45, #3, #18 and #10) of 18 residents reviewed for quality of care, resulting in Resident #29 not being assessed or treated for potential eye infection, the potential for infection of a wound for Resident #45, Resident #3's elevated blood sugar levels going unreported to the physician, Resident #18's low blood sugar level not being reported to the physician, and Resident #10 receiving medications outside ordered parameters. Findings include:Resident #29: Review of an admission Record revealed Resident #29 was a male with pertinent diagnoses which included diabetes, mild cognitive impairment (noticeable memory or thinking changes), acquired absence of left eye, strep group B (bacteria can cause sepsis) in left knee, and arthritis due to bacteria in left knee. Review of current Care Plan for Resident #29, revised on 3/11/26, revealed the focus, .I am at risk for skin breakdown. with the intervention .Notify resident/representative of any new areas of skin alteration. During an observation and interview on 04/14/2026 at 1:13 PM, Resident #29 was dressed and observed seated in his wheelchair. This writer observed Resident #29's left eye which had thick dried green eye discharge matted on his top and bottom eyelashes. Resident #29 had moist, stringy green material which stretched from the top to bottom lashes. His bottom and top left eye lids appeared irritated and swollen. Resident #29 reported he believed the issue with his eye was a blocked tear duct and reported he does not have an ointment placed in his eye, and the nurse sometimes put drops in his eye. Review of Medication Administration Record (MAR) for Resident #29 revealed, he was prescribed on 3/11/26, Refresh Tears Ophthalmic Solution.Instill 3 drops in both eyes three times a day for dry eyes. Review of the MAR for March 2026 and April 2026, revealed it was documented Resident #29 had received drops in his eyes three times per day at 0900, 1400 (2:00 PM), 2100 (9:00 PM). In an interview on 04/17/2026 at 11:14 AM, Director of Nursing (DON) C reported the nurse should clean the resident's face and eyes, complete an assessment and notify the provider to do a follow up. Review of Resident #29's medical record revealed there was no physician communication note for the physician to follow up with the resident on his left eye discharge. In an interview on 04/16/2026 at 9:42 AM, Infection Preventionist (IFP) E reviewed the infection tracking report and reported she did not have Resident #29 on the tracking. IFP E reported due to the lack of documentation by the floor nurses quite frequently a resident would be started on an antibiotic or require precautions and they would not complete the necessary documentation, and she would not be notified and therefore she would not be tracking the resident. IFP E reviewed Resident #29's medical record and reported there was nothing there which indicated a concern for infection with his left eye. This writer explained the observation had of Resident #29's eye and IFP E reported the resident should have been assessed and the provider contacted to assess further. IFP E reported she had provided education to the nurses on 2/12/26 using the assessment and documenting findings in progress notes. Review of Resident #29's provider progress notes revealed no assessment or documentation of a concern for potential infection in Resident #29's left eye. In an interview on 04/17/2026 at 12:12 PM, Interim Chief Executive Officer (CEO) B reported Nurse Practitioner (NP) N stated she was not aware Resident #29 had unusual drainage from the removal of his left eye. In an interview and review of Resident #29's medical record on 04/17/2026 at 11:15 AM, Director of Nursing (DON) C reported she was unable to locate a progress note, and/or an assessment for possible infection in the medical record. DON C reported there was not a physician communication note for the concern with Resident #29's eye. Resident #45 Review of an admission Record revealed Resident #45 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 3/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated Resident #45 was cognitively impaired. Review of the Functional Abilities revealed that Resident #45 required partial to moderate assistance for hygiene. Review of Resident #45's Skin Care Plan revealed, I am at risk for skin breakdown.Date initiated: 4/19/21. Interventions: .Report any changes in skin to physician. Date initiated: 5/10/23. There was no mention of a wound on Resident #45's chin. During an observation on 04/14/2026 at 11:27 AM Resident #45 was lying in his bed, his gown was soiled with flakes of dried blood and there was a large deep open wound on his left chin/neck. There was no signage indicating that Resident #45 had Enhanced Barrier Precautions (EBP) in place for the open wound that was not covered. Review of Resident #45's Weekly Skin Check dated 4/6/26 revealed, Skin warm & dry, skin color WNL and turgor is normal. No new skin issues identified . # 3 Skin issue has NOT been evaluated. Location: chin, left.open wound that resident picks at non-stop.Wound is greater than 3 months . Resident #45's Weekly Skin Checks dated 3/27/26 and 3/20/26 are exactly the same as 4/6/25. In an interview on 04/15/2026 at 1:40 PM, LPN KK reported that the wound on Resident #45's chin/neck was a skin cancer that he elected not to get treatment for years ago. LPN KK reported that there were no orders for wound care and/or a dressing. Review of Resident #45's Dermatology (skin specialist) Visit Note dated 7/19/23 revealed, .Basal Cell Carcinoma (skin cancer), nodular type on the left inferior medial buccal cheek (lower cheek/chin). We recommend the following: Schedule [NAME] (a type of surgery to remove skin cancer and preserve tissue). Due to size of lesion we were not able to operate today, this is being referred to plastics for treatment. Review of Resident #45's Provider Visit Note dated 4/7/26 revealed, .Noted to have a basal cell carcinoma on his jaw line. However, this skin cancer has progressed from a small lesion, which would have been usually excised under local anesthetic to the deep ulcerative lesion that swell (sic) into the subcutaneous tissue. In an interview on 04/15/2026 at 3:38 PM, UM D reported that Resident #45 had a skin cancer on his left chin/neck a few years ago and declined surgical interventions. UM D reported that they do not currently have orders in place to clean the wound, no wound dressing orders, and there are no orders in place for monitoring the wound. UM D reported that Resident #45's left chin/neck wound was not being documented in the weekly skin checks; the assessment details were copied from the week before. During an observation on 04/15/2026 at 4:09 PM Resident #45 was lying in his bed. UM D and LPN KK entered the room to complete a wound assessment. Observed a large deep open wound on his left chin/neck area that was beefy red and crusted along the edges. There were flakes of crusted blood covering the front of Resident #45's gown and his fingernails had blood underneath them. UM D measured the chin/neck wound; 5.5 cm x 5.5 cm. In an interview on 04/16/2026 at 7:32 AM, CNA GGG reported that direct care staff did not perform any type of wound care or cleansing of the open wound on Resident #45's chin. In an interview on 04/16/2026 at 7:44 AM, UM D reported that she had just completed a thorough skin check and wound assessments for Resident #45. UM D reported that she would also be adding EBP for Resident #45 due to the chronic open wound on his chin/neck. In an interview on 04/16/2026 at 7:57 AM, Director of Nursing (DON) C reported that she understood the concern for non-compliance with wound management and that the facility would be implementing a new program going forward to ensure that wound assessments were completed accurately and that there was a qualified provider driving the treatment of wounds. Resident #3 Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: type 2 diabetes (chronic condition in which the body cannot use insulin (hormone produced by the pancreas that regulates blood sugar levels in the blood properly) resulting in high or low blood sugar levels), and hyperglycemia. Review of a Minimum Data Set (MDS) assessment for Resident #3 with a reference date of 3/20/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 12/15, which indicated the resident was moderately cognitively impaired. Section N revealed Resident #3 received daily insulin injections. Review of a Care Plan for Resident #3 with a reference date of 3/23/26 revealed the following focus/goal/interventions: Focus: I have Diabetes Mellitus.refuse my insulin at times.Goal: I will be free from any s/sx (signs and symptoms) of hyperglycemia through the review date. Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.report to MD (Doctor of Medicine) s/sx of hypoglycemia.repot to MD PRN (as needed) s/sx of hyperglycemia. Review of a complaint filed on 9/15/25 at 10:02am revealed Complainant states the nurse broke the rules by not calling the doctor due to a reading (blood sugar over 500) . Review of a Blood Sugar Graph for Resident #3 with a date range of 9/1/25-4/17/26 revealed the resident's blood sugar level registered at over 500mg/dL (milligrams per deciliter of blood) 3 times during that time period. Review of a Blood Sugar Summary for Resident #3 revealed the resident's blood sugar registered at 523mg/dL on 12/11/25, 547mg/dL on 12/29/25 and 541mg/dL on 3/12/26. Review of Progress Notes revealed no documentation of physician notification related to Resident #3's episodes of critical blood sugar levels on 12/11/25, 12/29/25 and 3/12/26. In an interview on 4/16/26 at 2:46pm, Unit Manager (UM) D reported it was the expectation that the responsible nurse would contact the physician if a resident's blood sugar registered less than 70mg/dL or greater than 350 mg/dL. UM D reviewed the documentation for Resident #3, confirmed his blood sugar registered greater than 500mg/dL on 3 occasions and there was no documentation that the physician was notified or that further action was taken. Resident #18 Review of an admission Record revealed Resident #18 was originally admitted to the facility on [DATE] with pertinent diagnosis which included: type 2 diabetes. Review of a Minimum Data Set (MDS) assessment for Resident #18 with a reference date of 2/20/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 1/15, which indicated the resident was severely cognitively impaired. Section N of the MDS revealed Resident #3 received daily injections of insulin. Review of a Care Plan for Resident #18 with a reference date of 10/9/25 revealed the following focus/goal/interventions: Focus: I have a nutritional problem r/t (related to) .DM (diabetes) with insulin.Goal: I will be free from hunger.Interventions: Administer medications as ordered. Monitor/Document for side effects and effectiveness. Review of a Blood Sugar Summary for Resident #18 with a reference date of 4/1-4/17/26 revealed the resident experienced hypoglycemia (blood sugar below 70mg/dL) on 4/1, 4/6, 4/9, and 4/14/26. Review of Progress Notes for Resident #18 on 4/1, 4/6, 4/9 and 4/14/26 revealed no documentation of physician notification of the resident's low blood sugar. In an interview on 4/16/26 at 9:44am, Licensed Practical Nurse (LPN) FF reported the nurse should contact the physician if a resident's blood sugar level was less than 70mg/dL or greater than 250mg/dL. LPN FF reported blood sugar levels outside these parameters required physician guidance. LPN FF reported the nurse should also document in a progress note that the physician was contacted and any new orders given/guidance given. In an interview on 4/16/26 at 9:47am, Registered Nurse (RN) I reported the nurse should contact the physician immediately if a resident's blood sugar level registered below 70mg/dL or above 350mg/dL unless there was already further guidance for the nurse to follow in the physician's orders for the resident. RN I reported the nurse should also document contacting the physician and the guidance they provided in a progress note. In an interview on 4/17/26 at 10:43am, Nurse Practitioner (NP) N confirmed it was an expectation that a provider would be contacted by the nurse if a resident's blood sugar was higher than 350 mg/dL or lower than 70 mg/dL because it may be necessary to further medical direction in order to maintain the well-being of the resident. Resident #10 Review of an admission Record revealed Resident #10 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks) and hypotension (low blood pressure). Review of Resident #10's Orders revealed, Midodrine (medication used to treat low blood pressure) 10 mg (milligrams). Give 1 tablet by mouth before meals for hypotension. Hold if systolic (the top (first) number in a blood pressure reading, measuring the maximum pressure in your arteries when the heart muscle contracts and pumps blood) blood pressure above 130. Review of Resident #10's Medication Administration Record (MAR) revealed that Resident #10 had received the midodrine medication when her blood pressure was out of order parameters on the following dates: 2/7/26, 2/12/26, 3/1/26, 3/7/26, 3/20/26, two administrations on 3/21/26, 3/23/26, 3/24/26, 3/25/26, 4/4/26 and 4/8/26. It was also noted that on 3/27/26 the midodrine order was documented as given without vital signs documented to indicate if Resident #10's vital signs were in parameters to administer the medication.

Based on observation, interview, and record review, the facility failed to maintain the cleanliness of resident shared equipment, resulting in the potential for cross contamination, infections, and bacterial harborage. Findings include: During an observation on 04/14/2026 at 9:57 AM, outside of room [ROOM NUMBER] there was a hoyer (mechanical device used to transfer limited mobility residents) in the hallway along the wall. The hoyer dried white material on the footrest base area, there as dried brownish/tannish material spots splattered on the base. During an observation on 04/14/2026 10:31 AM sit to stand outside of room [ROOM NUMBER] had dirt and debris on the based and foot board area. The knee pads had white dried smeared material on the curve of the knee pad on the inside of the pad, a gait belt on it as well as slung over the top, plastic bag with no wipes in it. There was a hoyer next to it, which had white dried material on the base of the machine on both sides, like someone had white powder on their feet and had stepped on it. There was a plastic bag with no wipes in it.During an observation on 04/15/2026 at 2:22 PM, the sit to stand outside of room [ROOM NUMBER] and room [ROOM NUMBER] was soiled as it was yesterday. There were purple wipes in the plastic bag. There was white dried material on the knee pads, and the footrests had dirt and debris on them. During an observation on 04/15/2026 at 2:24 PM, the hoyer (mechanical lift) between room [ROOM NUMBER] and room [ROOM NUMBER] had dried white material on the footrest base area, there was dried brownish/tannish material spots splattered on the base. In an interview on 04/16/2026 at 09:18 AM, Infection Preventionist (IFP) E reported the staff had recently had Customer service training on 12/23/25 and 3/27/26 which also included re-education and reminders to perform sanitization of resident shared equipment after each use to prevent the spread of potential infection.

Based on observation, interview and record review the facility failed to develop and implement resident focused care plans based on a comprehensive assessment for 5 (Resident #41, #45, #53, #61, and #10) of 18 residents reviewed for comprehensive care plans, resulting in unidentified care needs and the potential for worsening of medical conditions. Findings include: Resident #41 Review of an admission Record revealed Resident #41 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of sacral (tailbone) region stage unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #41, with a reference date of 3/11/26 revealed a Brief Interview for Mental Status (BIMS) score of severe cognitive impairment. Review of Behaviors revealed no rejections of care. Review of the Functional Abilities revealed that Resident #41 was completely dependent on staff for toileting and transfers. Review of Resident #41's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 3/20/26 revealed, Sensory perception: slightly limited. Moisture: very moist.Bedfast (does not get out of bed). Resident is very limited. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: Excellent. Friction and shear: problem. Braden Score: 13. This evaluation indicated the resident is at moderate risk to develop a pressure ulcer. Review of Resident #41's Skin Care Plan revealed, I am at risk for skin breakdown. Date initiated: 11/26/25. Interventions: Educate resident/representative about primary risk factors and prevention, Monitor for pain and medicate as necessary per physician order. Notify resident/representative of any new areas of skin alteration. Report any changes in skin status to physician. Date initiated 11/26/25. Additional interventions, Roho (air filled to reduce pressure) cushion to wheelchair, Turn and reposition every 2 hours as requested and tolerated. Date initiated 1/27/26. There was no indication of why Resident #41 was at risk for skin breakdown. There was no care plan related to Resident #41 incontinence and/or urinary catheter use. Review of Resident #41's Wound Care Plan revealed, .I have wound on my sacral buttock area, left BKA (below the knee amputation) surgical incision, left gluteus, right gluteus. Date initiated: 12/19/25. Interventions: .Monitor ulcer for signs of infection, Monitor ulcer for signs of progression or declination, notify provider if no signs of improvement on current wound regimen, Provide wound care per treatment order. Date initiated: 12/10/25. Additional interventions: .Air mattress DX (diagnosis) sacral decubitus (pressure ulcer). Offload wounds while laying in bed and in chair as tolerated, cushion in wheelchair. Provide wound care per treatment order. Date initiated: 1/6/26. There was no information related to Resident #41's pressure ulcer on the right foot and/or the use of a blue protective boot and did not include the use of an indwelling urinary catheter to promote wound healing. Review of Resident #41's Infection Control Care Plan revealed, Enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO). The resident must be placed in isolation (enhanced) due to risk of spreading MDRO's via an indwelling device, chronic/non-healing wound. Date initiated: 1/6/26. Interventions: .Staff are to wear PPE (personal protective equipment) before entering room if they are providing high contact care. Date initiated: 1/6/26. There was no indication of what type of indwelling device was being used. Review of Resident #41's Kardex (care guide for direct care staff) and the record did not include that Resident #41 should have a blue boot on her right foot for pressure ulcers and did not include that she had an indwelling urinary catheter. During an observation and interview on 04/14/2026 at 11:03 AM Resident #41 was lying in her bed and Hospice Nurse (HN) M was performing wound care and a wound dressing change for Resident #41's sacral wound. Resident #41 verbalized that the wound was painful. Observed a foley catheter bag hanging from the bed frame. HN M was not wearing a gown. Review of Resident #41's Hospice Progress Note dated 4/14/26 revealed, .Communicates verbally very effectively.Rates sacral wound pain 8/10.Wound care provided: Sacrum – stage 4 pressure wound – 6 x 6 x1 cm (centimeters), right heel – stage 1 pressure wound 2 x 2 cm, right lateral foot – stage 1pressure wound 0.3 x 0.3 cm. In an interview on 04/15/2026 at 12:12 PM, Certified Nursing Assistant (CNA) W reported that Resident #41 does not get out of her bed and was not able to make her needs known related to being incontinent. CNA W reported that she had checked on Resident #41 a couple of hours ago, approximately 10:15 AM and she was dry, so she did not reposition her, she just let the resident rest. CNA W reported that Resident #41 had big sores on her buttocks and would be repositioned after lunch around 2:00 PM. During subsequent observations on 04/15/2026 from 11:39 AM-1:23 PM when Resident #41 received lunch, she remained in the same position. At 1:23 PM Resident #41's HOB (head of bed) was raised so that she could eat lunch. Resident #41 remained in this position until approximately 2:42 PM (4 1/2 hours) when this surveyor requested to observe Resident #41's wound dressings along with LPN KK. In an interview and observation on 04/15/2026 at 2:42 PM, LPN KK reported that she had changed Resident #41's wound dressing on her sacrum early that morning and flushed her foley catheter. LPN KK reported that the wound did not look good, there was a lot of slough (white dead tissue) and green drainage. LPN KK reported that Resident #41 was on an oral antibiotic for the wound. Observed Resident #41 still lying in bed, positioned on her left side, with the HOB at 45-90 degrees. Observed a large adhesive bandage covering Resident #41's sacrum, and bandages covering her right foot and heel. Observed Resident #41's catheter tubing pulled tight and laying across her right leg; there was no catheter securement device observed to anchor the tubing in place. In an interview on 04/16/2026 at 8:14 AM, Unit Manager (UM) D reported that Resident #41's last wound clinic visit was on 4/6/26 and an antibiotic was ordered due to Resident #41's sacral (coccyx, tailbone) wound infection at that time. UM D reported that Resident #41 was hospitalized [DATE]-[DATE] for UTI (urinary tract infection) and returned to the facility with a foley catheter (an indwelling device to drain urine from the bladder) in place to help with sacral wound healing. Review of Resident #41's Wound Clinic Visit dated 3/9/26 at 11:00 AM revealed, .Her wound has declined today. Please encourage increased repositioning from side to side . Review of Resident #41's Hospital After Visit Summary dated 3/19/26 (admitted on [DATE]) revealed, .Transfer Instructions: .Wound Site: Sacrum .Right heel, Right lateral foot, left medial thigh and left upper lateral thigh.Foley in place for maintenance of sacral wound. Review of Resident #41's Hospital Wound Consult Dated 3/12/26 revealed, .consulted for a coccyx, right heel and buttock wounds.Several more wounds that were found. Right buttock, right heel, right lateral foot, left medial thigh and left lateral thigh are all deep tissue wounds. Left buttock is a stage 2, sacral wound is a stage 3.Wound Assessment: 1. Sacral.length 5.5 cm x width 5 cm x depth 0.6 cm. 2. Left medial thigh DTPI (deep tissue pressure injury). length 5.5 cm x width 5 cm. 3. Left upper later thigh DTPI. length 5 cm x width 3 cm. 4. Left Buttock Stage 2 Pressure injury. length 1 cm x width 1 cm. 5. Right heel DTPI (deep tissue pressure injury). length 2 cm x width 1.5 cm. 6. Right lateral foot DTPI. length 2.2 cm x 1.5 cm. 7. Right buttock DTPI. length 5 cm x width 3 cm. Assessment: .General surgery was consulted for chronic sacral decubitus ulcer.There does appear to be superficial necrotic (dead) slough at the superior and right lateral aspects of the sacral decubitus ulcer. Review of Resident #41's Wound Clinic Visit dated 4/6/26 revealed, .Based on culture results of the sacrum we would like to begin Ciprofloxin (antibiotic) 500 mg twice a day for 10 days to treat the pseudomonas (bacteria).Her wound on her sacrum has declined today. Please encourage increased repositioning from side to side. If dressings are soiled they need to be changed or risk for infection will increase. Do not wipe them off. New dressings are needed. In an interview on 04/17/2026 at 9:16 AM, CNA G reported that she had not been in with Resident #41 since the start of her shift at 7:00 AM (2 hours ago). CNA G reported that she would have to look at Resident #41's kardex/care plan to know what care needed to be done. Resident #45 Review of an admission Record revealed Resident #45 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 3/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated Resident #45 was cognitively impaired. Review of the Functional Abilities revealed that Resident #45 required partial to moderate assistance with toileting and hygiene. Review of Resident #45's Skin Care Plan revealed, I am at risk for skin breakdown.Date initiated: 4/19/21. Interventions: .Report any changes in skin to physician. Date initiated: 5/10/23. There was no mention of skin breakdown on buttocks, wound on chin, and/or pressure ulcer prevention. There was no personalized skin care plan related to Resident #45. During an observation on 04/14/2026 at 11:27 AM Resident #45 was lying in his bed, his gown was soiled with flakes of dried blood and there was a large open wound on his left chin/neck. In an interview on 04/15/2026 at 1:40 PM, LPN KK reported that the wound on Resident #45's chin/neck was a skin cancer that he elected not to get treatment for several years ago. LPN KK reported that there are no orders for wound care and/or a dressing. LPN KK reported that Resident #45 stayed in bed most of the time. During an observation on 04/15/2026 at 4:09 PM Resident #45 was lying in his bed. UM D and LPN KK entered the room to complete a wound assessment. Observed a large deep open wound on his right chin/neck area that was beefy red and crusted along the edges. UM D measured the chin/neck wound; 5.5 cm x 5.5 cm. In an interview on 04/15/2026 at 4:25 PM, CNA W reported that Resident #45 needed encouragement for ADL's (activities of daily living), usually was incontinent of urine and occasionally used the toilet for bowel movements. In an interview on 04/16/2026 at 7:32 AM, CNA GGG reported that Resident #45 rarely gets out of bed or moves around in bed. CNA GGG reported that Resident #45 is always incontinent of urine but at times will use the toilet for a bowel movement. CNA GGG reported that Resident #45 has open areas on his bottom on and off. CNA GGG reported that direct care staff did not perform any type of wound care or cleansing of the open wound on Resident #45's chin. In an interview on 04/17/2026 at 9:12 AM, CNA G reported that Resident #45 is incontinent in his brief but will also use the toilet. CNA G reported that she had not provided care to Resident #45 yet that day and was not familiar with the resident's wounds and to her knowledge he is not on any type of infection control precautions. In an interview on 04/16/2026 at 7:44 AM, UM D reported that she had just completed a thorough skin check and wound assessments for Resident #45. UM D reported that she did observe a stage 1 pressure wound on Resident #45's buttocks and she would be entering orders for barrier cream and repositioning. UM D reported that she would also be adding EBP for Resident #45 due to the chronic open wound on his chin/neck. Resident #53 Review of an admission Record revealed Resident #53 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Pressure ulcers of sacral region and heel, both unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #53, with a reference date of 2/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #53 was cognitively intact. Review of the Functional Abilities revealed that Resident #53 required substantial/maximal assistance (>50%) for rolling in bed and was completely dependent on staff for toileting needs. Review of Resident #53's Braden Scale for predicting Pressure Ulcer Risk Evaluation dated 2/5/26 revealed, 12 indicating at high risk to develop pressure ulcers. Review of Resident #53's Skin Care Plan revealed, I am at risk for skin breakdown. Date initiated: 10/31/25. Interventions: Monitor for pain and medicate as needed per physician's order. Date initiated: 10/31/25. There was no documentation related to Resident #53's risk for pressure ulcers and/or interventions in place to reduce the risk. There was no personalized care plan related to Resident #53's need for assistance with bed mobility, toileting and or status of bowel and bladder continence. There was no care plan related to Enhanced Barrier Precautions (EBP). Review of Resident #53's Wound Management Care Plan revealed, Bilateral heels, Coccyx. Date initiated: 11/6/25. Interventions: Measure ulcer on regular intervals. Monitor ulcer for signs of infection. Monitor ulcer for signs of progression or declination. Notify provider if no signs of improvement on current regimen. Provide wound care per treatment orders. Date initiated 11/6/25. There were no updates made to this care plan and no personalized interventions. In an interview on 04/15/2026 at 8:36 AM, LPN LL reported that Resident #53 does not get out of bed anymore and the wound on her buttocks was not doing good at all. LPN LL reported that Resident #53 was incontinent of bowel and bladder, very compliant with cares and repositioning, but the blue protective boots do not stay on her feet well. LPN LL reported that Resident #53 also had pressure point wounds on the tips of her toes, therefore staff had to constantly watch so that her feet don't press up against the end of the bed. It was noted that this information was not included in Resident #53's care plan. In an interview on 04/16/2026 at 9:25 AM, UM D reported that Resident #53 had wounds on her heels and buttocks, and at one time a couple months ago had concerns for osteomyelitis (infection in the bone caused by infected tissue) because the wounds on her feet were not healing. UM D did not know the status of Resident #53's wounds. Reviewing Resident #53's records with UM D and there was no documentation of wound assessments that measured size, no pressure wound interventions listed, and all weekly skin checks were noted as normal. Review of Resident #53's Physician Note dated 2/9/26 revealed, .Staff concerned with skin issues on her bilateral feet. Bilateral heel wounds were being treated with Dakins (helps reduce infection and promote healing) solution on bilateral heels while floating and has an air mattress to offload pressure. Now concern with discoloration of toes.Physical exam: .Bilateral heels have stage 3 pressure injury with beefy red wound base and macerated edges surrounding both wounds are individually the size of a nickel, right great toe has deep purple scab to the tip of the toe, right 2nd digit has small area on the pad of the toe which is dark purple, left great toe appears to have gangrene at the tip, left 2nd digit has gangrene nearly to the DIP (distal interphalangeal: closest to tip of toe) joint, bilateral legs have venous insufficiency with skin color changes.Assessment and Plan: 1. Impaired skin integrity. New orders placed for wounds on bilateral heels and toes. X-ray of bilateral feet. Vascular referral ASAP. Concern with gangrene. The wounds on Resident #53's toes were not included in the care plan. During an observation and interview on 04/17/2026 at 9:49 AM Resident #53 was sitting up in bed and reported that her butt was sore. Resident #53 was not wearing the blue protective boots on her feet. During an observation on 04/17/2026 at 10:26 AM Resident #53 was still sitting up in her bed and her blue protective boots were not in place on her feet. UM D was present in the room, preparing to complete wound care. In an interview on 04/17/26 at 11:11 AM, CNA CC reported that Resident #53 was very compliant with care and would stay in whatever position we place her in; she does not refuse repositioning or the blue protective boots. CNA CC reported that Resident #53 was always incontinent and that the last time she had completed incontinence care for Resident #53 was the day before. CNA CC was not aware that Resident #53 should have EBP in place. In an interview on 04/17/2026 at 11:40 AM, Infection Preventionist (IP) E reported that she had just been informed that Resident #53's wounds were deteriorating therefore the resident would be placed on EBP. In an interview and observation on 04/17/2026 at 12:04 PM, Registered Nurse (RN) I reported that they were applying betadine (antiseptic for infection prevention) to Resident #53 toes. Observed Resident #53 lying in her bed; her left great toe had a thick scab covering the tip, and the 2nd and 3rd toes were discolored black at the tips. RN I reported that Resident #53's left great toe was an unstageable pressure injury. Resident #61 Review of an admission Record revealed Resident #61 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #61, with a reference date of 1/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #61 was cognitively intact. Review of the Functional Abilities revealed that Resident #61 required substantial/maximal assistance to roll in bed and was dependent on staff for toileting. Review of Resident #61's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 4/9/26 revealed .Occasionally moist. Activity: bedfast. Resident is slightly limited, makes frequent though slight changes in body or extremity position independently.Score 14. This indicated Resident #61 was low-moderate risk. Review of Resident #61's Skin Care Plan revealed, At risk for skin breakdown related to dependence on staff for assistance with bed mobility, morbid obesity, incontinence.Date initiated: 1/5/22. Revision on: 9/7/23. Interventions: Apply barrier cream to left hip q (every) shift and PRN (as needed). Date initiated: 12/21/23. Apply Calmoseptine (moisture barrier cream) to left gluteal fold every shift and PRN with incontinence episode for friction shearing. Dated initiated: 4/24/24.Standards of care for pressure relief and skin breakdown prevention. Date initiated: 1/5/22. Revision on: 6/17/24. There were no personalized care plans related to toileting needs and/or prevention of pressure wounds. The most recent revisions were approximately 2 years ago and did not include current physician orders. During an observation on 04/15/2026 at 1:58 PM CNA W was at the bedside performing incontinence care for Resident #61. CNA W positioned Resident #61 on her right side and 2 raised crusted areas of skin were observed near the resident's gluteal crease (butt crack) with the entire surrounding skin on the buttocks and upper thighs bright red. Resident #61 winced in pain when CNA W touched the area. CNA W applied a thick coating of antifungal powder to the buttocks area and reported that Resident #61 did not have any topical treatments ordered. CNA W reported that staff applied the powder after each incontinent episode. In an interview on 04/16/2026 at 8:48 AM, UM D reported that Resident #61 should have A&D barrier cream at the bedside to be used after incontinence care and as needed. After further review of Resident #61's record, UM D reported that the resident had a pressure ulcer on her buttocks and the antifungal powder should not be applied to that area. UM D could not report when the last time Resident #61's pressure wound on her buttocks had been assessed. Review of Resident #61's Physician Orders revealed, Cleanse excoriation on buttocks with wound cleanser. Apply A&D (skin protectant) ointment to area with each incontinence episode and PRN. Every day and night shift for excoriation healing. Start date: 2/16/26. Apply anti-fungal powder to peri-area and inner thighs leave brief open until resolve two times a day. Start date: 2/28/25. According to Fundamentals of Nursing ([NAME] and [NAME]) 9th edition, The care plan (see Chapter 18) is a map for nursing care and demonstrates your accountability for patient care. By making accurate nursing diagnoses, your subsequent care plan communicates a patient's health care problems to other professionals and ensures that you select relevant and appropriate nursing interventions .A well-planned, comprehensive nursing care plan reduces the risk for incomplete, incorrect, or inaccurate care. As a patient's problems and status change, so does the plan. A nursing care plan is a guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used later in evaluation (see Chapter 20). The plan of care communicates nursing care priorities to nurses and other health care providers. The care plan (see Chapter 18) is a map for nursing care and demonstrates your accountability for patient care. By making accurate nursing diagnoses, your subsequent care plan communicates a patient's health care problems to other professionals and ensures that you select relevant and appropriate nursing interventions. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 16159-16161). Elsevier Health Sciences. Kindle Edition. A well-planned, comprehensive nursing care plan reduces the risk for incomplete, incorrect, or inaccurate care. As a patient's problems and status change, so does the plan. A nursing care plan is a guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used later in evaluation (see Chapter 20). The plan of care communicates nursing care priorities to nurses and other health care providers. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 16878-16882). Elsevier Health Sciences. Kindle Edition. Resident #10 Review of an admission Record revealed Resident #10 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks) and anxiety disorder. Review of Resident #10's Care Plan revealed, Focus: I (Resident #10) have impaired cognitive function/dementia, Alzheimer's disease, or impaired thought processes Date Initiated: 03/30/2021. Goal: I will maintain current level of cognitive function through the review date. Date Initiated: 03/30/2021. interventions: Administer meds (medications) as ordered, Monitor/document /report to MD (Medical Doctor) any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Date Initiated: 03/30/2021. During an interview on 4/17/2026 at 12:56 PM, Manager of Case Management (MCM) BB reported that she was responsible for creating resident care plans. MCM BB reported that Resident #10's dementia care plan was the facility standard dementia care plan, and that Resident #10's care plan interventions did not include comprehensive and individualized goals because Resident #10 had a behavior care plan that addressed Resident #10's dementia diagnosis. Review of Resident #10's Behavior Care Plan revealed, Focus: I (Resident #10) have a mood/behavior problem r/t (related to) my distressing delusions/hallucinations . Date initiated: 3/30/21. Goal: I will be without s/s of adverse side effects of my psychotropic medications as evidenced by observation and documentation. Date Initiated: 07/22/2021. Interventions: Assure me that I am safe and I do not have to leave the SNF (skilled nursing facility) Date Initiated: 07/22/2021, Call my niece. Date Initiated: 10/04/2022, encourage care, food and weights. Date Initiated: 10/18/2022, Introduce self and reason for visit. Date Initiated: 04/17/2026, and Review in Behavior WellnessDate Initiated: 03/30/2021. Noted that Resident #10's Dementia and Behavior care plan was not individualized and did not address Resident #10's medical, nursing, or mental and psychosocial needs identified in her most recent comprehensive assessment. During an interview on 4/17/2026 at 1:01 PM, Nursing Home Administrator (NHA) A reported that he had recently discovered that resident care plans at the facility needed improvement, as many were not individualized and person-centered based on resident needs. NHA A reported that the facility had not initiated any changes to resident care plans at the time of the interview.

Based on interview and record review, the facility failed to ensure timely physician follow up with pharmacy recommendations for 3 residents (Resident #3, Resident #10, and Resident #57) of 5 reviewed for medications resulting in the potential for residents to experience avoidable medication side effects and/or receive unnecessary medications.Findings include: Resident #3 Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: insomnia (common sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up to early, leading to unrefreshed sleep and daytime impairment). Review of a Minimum Data Set (MDS) assessment for Resident #3 with a reference date of 3/20/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 12/15, which indicated the resident was moderately cognitively impaired. Section N of the MDS revealed Resident #3 received a hypnotic medication. Review of a Care Plan for Resident #3 with a reference date of 12/29/25 revealed the following focus/goal/interventions: Focus: I have behavior problem r/t (related to) my .Dx (diagnosis) of Insomnia.I'm upset when staff enter my room before 8am.Goal: I will not experience difficulties with behavior or mood through the review date. Review of a Pharmacy Consultation Report for Resident #3 with a reference date of 2/9/26 revealed Comment: (Resident #3) has an order for Zolpidem Tartrate (sedative-hypnotic) 10mg (milligrams) QHS (every night) for insomnia that is above the maximum recommended dose for older adults. Recommendation: Please decrease the dose to Zolpidem Tartrate to 5mg QHS. No physician response to the recommendation was documented. Review of an Order Summary for Resident #3 with a reference date of 4/17/26 revealed an active order Zolpidem Tartrate Oral Tablet 10 MG. Give 1 tablet by mouth one time a day for insomnia. In an interview on 4/17/26 at 12:40pm, Chief Executive Officer (CEO) B reported the facility was not in compliance with ensuring the physician promptly responded to pharmacy recommendations; CEO B reported he was unsure how many residents may have been impacted by this deficient practice but described the situation as significant trend. CEO B confirmed the noncompliance left Residents #3, #10 and #57 at risk for receiving unnecessary medications. Review of a Medication Regimen Review policy with a reference date of 4/24/24 revealed .The Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication.The pharmacist shall communicate any recommendations and identified irregularities via written communication.Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Resident #10 Review of an admission Record revealed Resident #10 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks) and anxiety disorder. Review of Resident #10's Pharmacy Consultation Report dated 2/9/26 revealed, Comment: (Resident #10) receives Quetiapine Fumarate (antipsychotic medication) ER (extended release), Clonazepam (benzodiazepine used to treat seizures and panic disorder) and Trintellix (antidepressant), and has a diagnosis of dementia. Recommendation: If the current regimen is to continue, it is recommended that a) the prescriber document an assessment of risks verses benefit, and indicating that it continues to be a valid therapeutic intervention for this individual; b) the record contains documentation of the dose reduction history, specific target behavior (s), desired outcome (s), and the effectiveness of individualized nonpharmacological interventions . and c) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences . Physicians Response: Empty Noted the provider did not respond to the pharmacy consultation report. This writer attempted to contact Medical Director (MD) CCC via telephone on 4/17/2026 at 12:36 PM. MD CCC did not return this writer's phone call by survey exit. During an interview on 4/17/2026 at 1:01 PM, Interim CEO B confirmed that the facility was not able to provide documentation to verify that MD CCC had reviewed Resident #10's consultation report. Interim CEO B was unable to report how the facility had missed completing Resident #10's February 2026 medication review. Resident #57: Review of an admission Record revealed Resident #57 was a male with pertinent diagnoses which included dementia, age related debility, and mild cognitive impairment (problems with memory and thinking). Review of Order dated 11/5/2025 for Resident #57, revealed, .Clotrimazole Athletes Foot External Cream 1 % (Clotrimazole (Topical)) Apply to bilateral feet topically two times a day for boot feet. Review of Resident #57's medical record revealed the consulting pharmacist had a recommendation when the monthly medication review for February 2026 was conducted. Review of Resident #57's medical record revealed no pharmacy consultation report for recommendations dated 2/9/26. In an interview on 04/15/26 at 4:15 PM, Interim (Chief Executive Officer) CEO B reported he was unable to locate the MMR report for Resident #57 for 2/9/26. Interim CEO B' reported the facility would check all scanned documents during that time frame to see if the facility can find it. CEO B reported the Director of Nursing (DON) C would receive the pharmacy consultation reports via email notification and she was to print them out and provide them to the provider to review and sign. Review of Pharmacy Consultation Report dated 2/9/2026, revealed, .Comment: (Resident #57) has received a topical anti-infective, clotrimazole, for greater than 4 weeks without a documented stop date .Recommendation: lease discontinue clotrimazole. If therapy cannot be immediately discontinued, please document a stop date .Rationale for Recommendation: Prolonged use may increase the risk of adverse consequences, including the development of drug-resistant organisms .References: 1) Centers for Disease Control and Prevention: The core elements of antibiotic stewardship for nursing homes. 2024. 2) [NAME] DA et al. Current and emerging topical antibacterial and antiseptics: Agents, action and resistance patterns. Clin Microbiol Rev. 2017; 30(3):827-860 . In an interview on 04/16/26 at 8:50 AM, Interim (Chief Executive Officer) CEO B reported the facility did not have documentation supporting the review of the Pharmacy monthly medication review consultation report. Interim CEO B reported the facility had receive the note but no proof it was given to the provider and reviewed. Review of policy, Medication Regimen Review approved 4/24/24, revealed, .4. The pharmacist shall document, either manually or electronically, that each medication regimen review has been completed. (See Medication Regimen Review form.) .a. The pharmacist shall document either that no irregularity was identified or the nature of any identified irregularities.b. The pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendation. c. Each MRR shall be signed by the pharmacist 5. The pharmacist shall communicate any irregularities to the facility in the following ways:a. Verbal communication to the attending physician. Director of Nursing, and/or staff of any urgent needs .b. Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing 6. Written communications from the pharmacist shall become a permanent part of the resident's medical record .

Based on interview, and record review, the facility failed to provide and document evidence of prompt resolution of grievances in 2 of 2 residents (Resident #2 & #1) reviewed for resolution of grievances, resulting in the potential to experience frustration, apprehension, helplessness, and a negative psychosocial outcome for the residents impacting their quality of life.Findings include:Resident #2 Review of an admission Record revealed Resident # 2 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: legal blindness (severe visual impairment with some usable vision, often able to see light, shapes or large print) as defined in the USA (United States of America), diabetic retinopathy(damage to the retina caused by high blood sugar levels, resulting in blurry vision, dark floaters in the visual field, poor night vision and color changes), and surgical amputation of right leg. Review of a Minimum Data Set (MDS) assessment for Resident #2 with a reference date of 2/2/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section B revealed Resident #2's visual was highly impaired- object identification in question, but eyes appear to follow objects. Section E revealed Resident #2 had no behaviors. Review of a Care Plan for Resident #2 with a reference date of 11/18/24 revealed the following focus/goal/interventions: Focus: I have impaired visual function. Goal: I will have no indications of acute eye problems through next review. Interventions: Arrange consultation with eye care practitioner as required. No other interventions were present. During an observation and interview on 4/14/26 at 11:26am, it was noted that there was a narrow space of approximately two feet between the end of Resident #2's bed and his chest of drawers. Resident #2's stereo sat atop the chest of drawers. Resident #2 had access to 1 electrical outlet, with 2 sockets, on his half of the room. Resident #2's laptop and a phone charger were plugged into the outlet. A talking book machine sat nearby but was not plugged in. Resident #2 reported he was frustrated by the setup of his room and reported he had to thread himself backwards between his bed and his chest of drawers, while in his powerchair, then lean his torso forward in order to see the dials on his stereo. Resident #2 reported he was also frustrated by the lack of electrical outlets within his reach in his room, because he could not charge his devices and use his talking book player at the same time. Resident #2 reported he had voiced his concerns regarding the lack of accessibility in his room to several staff members, but nothing had been done. Resident #2 stated this room feels like a cage. Resident #2 reported he wanted to do more than lay in bed like a lazy bum and felt he could do the things he wanted to do in his room if some modifications were made. Resident #2 stated I don't like to ask the staff to do things for me that I could do for myself if the room was set up better. Resident #2 reported he had asked for a power strip several times but was always told they were illegal. Resident #2 reported he had also asked if he could have a LED (light-emitting diode) bulb in his overhead light because it would reduce glare and allow him to adjust the light level, but no one had followed up. Resident #2 reported he felt the facility was not willing to meet the needs of residents who were visually impaired. In an interview on 4/15/26 at 3:53pm, Interim Chief Executive Officer (CEO) B reported he reviewed the Caring Partners weekly check in sheets for Resident #2 and found the resident had voiced a concern about the accessibility of his room in February, 2026 but a grievance was never filed as it should have been, and there had been no follow-up. CEO B reported the facility had no grievances related to any of Resident #2's concerns. CEO B stated We did not follow our policy. Review of a Caring Partners form with a reference date of 2/24/26 revealed (Resident #2) wants.items in room moved around; Space is limited. In an interview on 04/16/2026 at 9:41 AM Certified Nursing Assistant (CNA) MM reported Resident #2 had complained to her about not being to see well in his room due the lighting and reported he said he wished the facility was more thoughtful about the individual needs of those with vision impairments. CNA MM confirmed she had not filled out a grievance form about Resident #2's concern regarding the lighting in his room. In an interview on 4/16/26 at 12:04pm, UM D confirmed she provided weekly Caring Partners visits to Resident #2. UM D confirmed she did not complete a grievance form for the concerns Resident #2 voiced about the layout of his room on 2/24/26. UM D reported Resident #2 also voiced a need for a larger room due to his limited ability to access his belongings in his current room, but she did not complete a grievance form for that request as she felt it was something the facility could not accommodate. UM D confirmed it was important for the facility to address individual resident needs, including accessibility and low vision needs, to promote independence. In an interview, Occupational Therapist (OT) XX reported she placed glow in the dark tape on the end of Resident #2's overhead light cord so he would be able to see it at night. When queried, OT XX reported she was not aware of any concerns Resident #2 had related to accessibility/low vision modifications needed in his room. OT XX reported she could assist Resident #2 if the facility provided a referral for assessment and treatment. Resident #1: Review of an admission Record revealed Resident #1 was a female with pertinent diagnoses which included high blood pressure, back pain, muscle weakness, depression, and pneumonia. In an interview on 04/14/2026 at 11:39 AM, Resident #1 reported her pajama tops were missing, and no one had come to speak to her about replacing them. Resident #1 reported the facility looked for them in the laundry and other resident's closets but were unable to locate them. Requested concern forms for Resident #1's missing pajama tops and was informed there were no concern forms completed for her missing pajama tops. In an interview on 4/15/26 at 12:39 pm, Life Enrichment Manager ([NAME]) U reported if a concern was brought up during resident council, if it was something easy, if she could take care of it, she would take care of it. [NAME] U reported if it was really important, she would complete a concern form for the resident who had the concern. In an interview on 4/15/26 at 1:13 PM, Director of Facility Operations (DFO) R reported a form was completed for missing items that gets filled out. DFO R reported if a resident had an item missing, laundry would search for it and usually the staff were able to find it rather quickly. DFO R reported once it was determined the item could not be found the form was completed and submitted to the Nursing Home Administrator. In an interview on 4/15/26 at 2:29 PM, Nursing Home Administrator (NHA) A reported when a resident would report an item missing, if the staff were unable to locate it, the item information was placed on a sticky note and the grievance process was circumvented. NHA A reported if the floor staff were informed of the missing items the staff were to fill out a concern form, then during morning meeting the concern was given to the lead to follow up on. NHA A reported the Laundry staff should have followed the same process. Review of policy, Resident Grievance Process revised 3/12/26, revealed, .Blank Help Us Serve You Better forms will be maintained at the nurses stations with 24-hour access.3. Residents, families and visitors may fill out the form and give it to a staff member to return to the management team.4. Staff may assist in completing the form, if at the request of the resident, family or visitor.5. The Administrator or designee will bring the concern form to the morning meeting for IDT (Interdisciplinary Team) review After reviewing the form, it will be assigned to the appropriate staff member for action to be taken.6. The assigned staff member will investigate the concern, resolve the issue, document the findings, and return the form to the Administrator within 7 days during the IDT meeting (based on the scope of the complaint, immediate action may need to be taken to prevent further potential violations of any resident right while the alleged violation is being investigated). The assigned staff member will also contact the complainant as requested or required. Residents have the right to obtain a written decision regarding his/her grievance.

Based on observation, interview, and record review, the facility failed to arrange room furniture in a functional manner, provide adequate power outlets for adaptive equipment and implement low-vision modifications to promote independence for one (Resident #2) of three residents reviewed for accommodation of needs, resulting in feelings of frustration, loss of independence and lack of an individualized environment.Findings include:Resident #2Review of an admission Record revealed Resident #2 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: legal blindness (severe visual impairment with some usable vision, often able to see light, shapes or large print) as defined in the USA (United States of America), diabetic retinopathy (damage to the retina caused by high blood sugar levels, resulting in blurry vision, dark floaters in the visual field, poor night vision and color changes), and surgical amputation of right leg.Review of a Minimum Data Set (MDS) assessment for Resident #2 with a reference date of 2/2/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section B revealed Resident #2's vision was highly impaired- object identification in question, but eyes appear to follow objects. Section E revealed Resident #2 had no behaviors.Review of a Care Plan for Resident #2 with a reference date of 11/18/24 revealed the following focus/goal/interventions: Focus: I have impaired visual function. Goal: I will have no indications of acute eye problems through next review. Interventions: Arrange consultation with eye care practitioner as required. No other interventions were present.During an observation and interview on 4/14/26 at 11:26am, it was noted that there was a narrow space of approximately 2 feet between the end of Resident #2's bed and his chest of drawers. Resident #2's stereo sat atop the chest of drawers. Resident #2 had access to 1 electrical outlet, with 2 sockets, on his half of the room. Resident #2's laptop and a phone charger were plugged into the outlet. A talking book machine sat nearby but was not plugged in. Resident #2 reported he was frustrated by the set up of his room and reported he had to thread himself backwards between his bed and his chest of drawers, while in his powerchair, then lean his torso forward in order to see the dials on his stereo. Resident #2 reported he was also frustrated by the lack of electrical outlets within his reach in his room, because he could not charge his devices and use his talking book player at the same time. Resident #2 reported he had voiced his concerns regarding the lack of accessibility in his room to several staff members, but nothing had been done. Resident #2 stated this room feels like a cage. Resident #2 reported he wanted to do more than lay in bed like a lazy bum and felt he could do the things he wanted to do in his room if some modifications were made. Resident #2 stated I don't like to ask the staff to do things for me that I could do for myself if the room was set up better. Resident #2 reported he owned a braille writer (mechanical typewriter-like device that allows the user to emboss braille directly onto paper), enjoyed writing greeting cards with it in the past, but had not been able to use it at the facility due to the lack of outlets and workspace. Resident #2 reported he had asked for a power strip several times but was always told they were illegal. Resident #2 reported he had also asked if he could have a LED (light-emitting diode) bulb in his overhead light because it would reduce glare and allow him to adjust the light level, but no one had followed up. Resident #2 reported he felt the facility was not willing to meet the needs of residents who were visually impaired.In an interview on 4/15/26 at 3:39pm, Nursing Home Administrator (NHA) A reported the facility provided power strips to residents in need of them, but he was not aware Resident #2 needed extra outlets. NHA A confirmed Unit Manager (UM) D provided weekly Caring Partners visits to Resident #2.In an interview on 4/15/26 at 3:53pm, Interim Chief Executive Officer (CEO) B reported he reviewed the Caring Partners weekly check in sheets for Resident #2 and found the resident had voiced a concern about the accessibility of his room in February 2026 but there had been no follow-up.Review of a Caring Partners form with a reference date of 2/24/26 revealed (Resident #2) wants.items in room moved around; Space is limited.In an interview on 4/16/26 at 12:04pm, UM D confirmed she provided weekly Caring Partners visits to Resident #2. UM D confirmed Resident #2 voiced concerns about the layout of his room on 2/24/26. UM D reported Resident #2 also voiced a need for a larger room due to his limited ability to access his belongings in his current room. UM D confirmed it was important for the facility to address individual resident needs, including accessibility and low vision needs, to promote independence.In an interview on 04/16/2026 at 9:41 AM Certified Nursing Assistant (CNA) MM reported Resident #2 had complained to her about not being to see well in his room due the lighting and reported he said he wished the facility was more thoughtful about the individual needs of those with vision impairments. During an observation and interview on 4/17/26 at 10:07am, the cord for Resident #2's overhead light hung against the wall, between his nightstand and the table he used for his laptop. Both the cord and the wall were white. A piece of glow in the dark tape (approximately one inch square in size) was affixed near the end of the cord that hung toward the floor. Resident #2 reported he could not see the light cord because there was no contrast between it and the wall. Resident #2 stated I need contrast in order to be able to see things like that. Resident #2 reported until recently he had a nice bright yellow privacy curtain that he could see well, but the facility changed it without asking him and hung a dull curtain, that looked like a dingy grey color to him. The privacy curtain Resident #2 referenced was a pale light green with a faint blue floral pattern. When queried, Resident #2 reported he could not see any pattern in the curtain, and the color looked depressing.In an interview on 4/17/26 at 12:07pm, Occupational Therapist (OT) XX reported she placed glow in the dark tape on the end of Resident #2's overhead light cord so he would be able to see it at night. When queried, OT XX reported she was not aware of any concerns Resident #2 had related to accessibility/low vision modifications needed in his room.Review of an Accommodation of Needs policy with a reference date of 3/5/24 revealed .The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom.facility staff shall make efforts to reasonably accommodate the needs.of the resident as they make use of their physical environment.based on individual needs.the facility will assist the resident in maintaining and/or achieving independent functioning, dignity and well-being.Review of A Systematic Review of Home Modifications for Aging in Place in Older Adults, https://pmc.ncbi.nlm.nih.gov/articles/PMC11988477/, revealed .The interaction between an individual's physical and cognitive abilities and the built environment significantly influences functional independence and quality of life. According to the environmental press theory, balance is maintained when the environment supports an individual's capabilities. When housing environments impose excessive demands beyond an individual's diminished functional capacity, disability and dependence increase.

Based on observation, interview, and record review, the facility failed to provide an environment that promoted resident dignity in 1 (Resident #29) of 4 residents reviewed for dignity, resulting in the potential of feelings of humiliation, embarrassment, and loss of self-worth.Findings include:Resident #29:Review of an admission Record revealed Resident #29 was a male with pertinent diagnoses which included diabetes, mild cognitive impairment (noticeable memory or thinking changes), acquired absence of left eye, strep group B (bacteria can cause sepsis) in left knee, and arthritis due to bacteria in left knee. Review of current Care Plan for Resident #29, revised on 3/24/26, revealed the focus, .I am at risk for falls d/t (due to) impaired safety awareness. with the intervention .Anticipate my needs, round to my room frequently and ask if there is anything I need.Remind resident to push call light and wait for assistance.In an interview on 04/14/2026 at 9:58 AM, Resident #29 reported when he pressed his call light it would take the staff too long to respond even though he would press the call light well before he was going to need them, but he would end up going doo doo in his pants because it would take too long for the staff to get there. Resident #29 reported he did not like going doo doo in his pants as it was embarrassing and he felt bad for the staff to have to clean him up but he couldn't help going in his pants as the staff took too long. Resident #29 reported he was a one person assist with his wheelchair because of his leg.In an interview on 04/16/2026 at 8:49 AM, CNA MM reported recent staffing levels had made it challenging to meet resident needs.Review of policy, Accommodation of Needs approved on 3/5/2024, revealed, .The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident .

Based on observation, interview, and record review, the facility failed to assess and ensure the right to safe self-administration of medication in 1 of 18 residents (Resident #16) reviewed for medication administration, resulting in the potential for unsafe self-administration of medication, medication errors, and medications not being stored in a secure manner.Findings include:Resident #16Review of an admission Record revealed Resident #16 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: schizoid personality disorder (chronic mental health condition characterized by limited emotional expression, strong preference for isolation and lack of motivation) and depression (a serious, common mental illness causing persistent sadness).Review of a Minimum Data Set (MDS) assessment for Resident #16 with a reference date of 2/6/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section D of the MDS revealed Resident #16 felt down, depressed, or hopeless during 12-14 days of the 14-day assessment period.Review of a Care Plan for Resident #16 with a reference date of 1/27/26 revealed the following focus/goal/interventions: Focus: I have acetaminophen (brand name omitted) at the bedside that I have been approved to self-administer. Goal: I will have relief from any pain on a daily basis.Interventions: evaluate continued appropriateness for self-administration of meds per facility policy.Review of Physician Orders for Resident #16 revealed a medication order with a reference date of 5/16/24: Acetaminophen Oral Tablet, give 650 tablets by mouth every 8 hours as needed for pain unsupervised self-administration Not to exceed 3000mg daily.During an observation and interview on 4/14/26 at 10:32am, Resident #16 was supine in bed (on her back), the bedside table was across her bed at chest level. A clear plastic medication cup was on the table, filled with what appeared to be chocolate pudding with flecks of a white substance throughout the brown pudding. Resident #16 reported unknown medications had been left for her in the pudding mixture in the medication cup. No staff were present in the room.In an interview on 04/15/26 at 2:29 PM, Nursing Home Administrator (NHA) A reported a resident would need to have a self-administration assessment completed annually and with a change of condition, to self-administer medications.Review of the most recent Medication Self-Administration Assessment for Resident #16, revealed the resident was last assessed for self-administration of medications on 6/20/24.Review of a Self-Administration of Medications by Residents policy with a reference date of 6/10/2008, revealed Each resident has the right to self-administer medications unless the interdisciplinary team (IDT) has determined, for that resident, that this practice is unsafe.The IDT determines the resident's ability to self-administer medications by means of a skill assessment conducted on admission, annually or significant change.

Based on interview and record review, the facility failed to 1.) provide adequate supervision and implement appropriate care planned interventions to prevent a fall in 1 resident (Resident #57) reviewed for falls, 2.) ensure safe transfer for 1 resident (Resident #5) and 3.) ensure safe wheelchair transport in 1 resident (Resident #37) of 3 residents reviewed for safety resulting in the potential for residents to sustain a fall and/or injury.Findings include: Resident #57: Review of an admission Record revealed Resident #57 was a male with pertinent diagnoses which included dementia, physical debility, anxiety, seizures, stroke, and hearing loss. Review of Care Plan for Resident #57 revealed the focus, .I am at risk for falls d/t (due to) generalized weakness, impaired mobility, physical limitations. with the interventions .Routine visual checks.Anticipate my needs, round to my room frequently and ask if there is anything I need.Bed in lowest position.Bolster(s) (long thick pillow that is placed to provide a barrier/for support) on bed.Dycem (non-slip material used to prevent slipping and sliding) to be placed on top of broda chair (specialized wheelchair that provides comfort, support, and mobility for limited mobility patients) cushion to decrease potential for forward slide.Mat on floor at bedside when I am in bed, as long it isn't a trip hazard to me. Note: Care Plan was not updated following the falls on 3/15/26 and 3/16/26. During an observation on 04/14/2026 at 3:58 PM, Resident #57 was observed in his room lying in his bed supine position (lying flat with face up) with his blanket tucked in around him, with him appearing like a burrito. Resident #57's bed was not in a low position, and he did not have any bolsters or other items to act as a barrier to prevent him from falling out of bed. Review of Health Status Note dated 1/31/2026 at 4:37 PM, revealed, .Resident found on the floor by CNA (certified nurse aide) lying on his left side with his head partially resting on the room chair. Resident stated he needed to use the bathroom. resident was assessed and vitals taken no visible injuries was noted. resident checked for incontinent, brief was dry. suspected resident rolled out of bed as he was last observed in bed. resident unable to report pain clearly due to baseline behavior. Provider (Nurse Practitioner) NP and brother (Name) was notified. resident later reported headache pain medication was given. neuro checked was initiated. staff ensured bed was in lowest position and that call light and personal items were within reach. continue to monitor resident. Review of Post Fall Evaluation dated 1/31/2026 at 7:20 PM, revealed, .Fall Details: Date / Time of Fall: 01/31/2026 4:00 PM Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: wanted to use the toilet The reason for the fall was not evident. Did an injury occur as a result of the fall: No. Did fall result in an ER visit/hospitalization: No. Provider: (Nurse Practitioner) Time notified: 01/31/2026 Notified of: fall and actioned taken Resident's responsible party notified: Yes. Person contacted: Brother Details of notification: notified of the fall and action. Date of Resident's responsible party notification: 01/31/2026 4:25 PM Fall Details Note: resident found on the laying on left side with head partially resting on a chair. resident mentioned that he wanted to use the bathroom. resident was assessed and no visible injury was observed. resident unable to clearly report pain due to baseline behavior. provider and brother was notified. Tylenol was given for pain and neuro check initiated.Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: No. Wheelchair was not involved in fall. Wearing glasses at the time of the fall: No. Footwear at time of fall: Non-skid shoes/socks. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall. Resident was using incontinence supplies at the time of the fall. Incontinent at time of fall: No. Bedside call light on when Resident was found: No. Bathroom call light on when Resident was found: No. Personal alarm sounding when Resident found: No. Other Residents were not involved in fall. Contributing factors note: unknown per the resident he wanted to use the toilet. resident was checked brief was dry.Medication Changes: Recent change to Resident's medications: No.Pain: Indicators of pain: Vocal complaints of pain. Pain Issue: #001: New. Location: Head. Pain score: 4. Unable to describe pain. Resident position changed. PRN (as needed) medication provided. Note: no indication range of motion (ROM)was performed on Resident #57. Review of Incident Report dated 1/31/26 at 4:00 PM, revealed, .Immediate Action Taken: Provider (NP) and resident brother was notified. Neuro check (assessed movement, sensation, hearing/speech, vision) initiated and resident monitored. Note: No immediate intervention to ensure Resident #57's safety. Review of Fall Risk Evaluation dated 2/8/2026 3:11 PM, revealed, .Fall Risk: History of falls (past 3 months): 1-2 falls in past 3 months. Level of consciousness / mental status: Disoriented x 3 at all times. Resident is chairbound / incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: None present. Resident did not have a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. Gait / balance: N/A - not able to perform function. Medication: Takes 3-4 these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 11.0. Note: Score of 7-11 would be considered low risk. Review of Health Status Note dated 3/15/2026 at 10:39 AM, revealed, .This nurse walked past (Resident #57's room) resident was in bed on side at 6:45am, was informed of the resident fell onto his knees between the bed and register(heater)at 7:50 am. This nurse did assessment on the resident to look for bleeding, have been doing neuro checks on the resident 15min, 30min, 1hour.This nurse called Brother-(Name), on call provider, and DON (Director of Nursing) to make aware of the incident. Review of Post Fall Evaluation dated 3/15/2026 at 10:46 AM, revealed, .Fall Details: Date / Time of Fall: 03/15/2026 7:50 AM Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: Resident was lying on the bed, resident was sitting up on knees on the floor keeping himself up right The reason for the fall was not evident. Did an injury occur as a result of the fall: No. Did fall result in an ER visit/hospitalization: No. Provider: on call provider, (Nurse Practitioner) Time notified: 03/15/2026 Resident's responsible party notified: Yes. Person contacted (Name) Details of notification: This informed (Brother) that the resident was lying in bed and he was sitting on his knees ,keeping himself up right in between the bed and a heater. This nurse stated there was no injuries and have been taking vitals and neuro checks ,vitals are within normal limits. (Brother) Thanked me for calling him Date of Resident's responsible party notification: 03/15/2026 9:30 AM.Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: No. Wheelchair was not involved in fall. Wearing glasses at the time of the fall: No. Footwear at time of fall: Non-skid shoes/socks. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall. Bedside call light on when Resident was found: Yes. Bathroom call light on when Resident was found: No. Personal alarm sounding when Resident found: No. Other Residents were not involved in fall.Medication Changes: Recent change to Resident's medications: No Vitals: T (temperature) 97.4 - 3/15/2026 10:57 Route: Forehead (non-contact)BP (blood pressure) 142/90 - 3/15/2026 09:27 Position: Sitting l/arm P (Pulse) 75 - 3/15/2026 09:27 Pulse Type: UTD - Unable to Determine.R (respirations) 18 - 3/15/2026 10:57.O2 (Oxygen level) 96 % - 3/15/2026 10:57 Method: Room Air.W (Weight) 192.0 lb. (pounds) - 3/13/2026 09:21 Scale: Hoyer Lift (mechanical device used to transfer a resident with limited mobility).Pain: Indicators of pain: None.Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor (skin's elasticity) is normal.Physical Findings: Change in diagnosis status: No. Recent diagnosis of stroke, TIA (Transient ischemic attack – short period of symptoms similar to a stroke) or arrhythmia (problem with rate and rhythm of heartbeat): No. Decrease in fluid intake: No. Change in blood glucose levels: No. Change in mental status: No. Change in behaviors: No. Change in mobility status: No. Recent weight loss: No. Sensory impairment: No. Resident does not have orthostatic BP changes. Note: no indication range of motion was performed on Resident #57. Review of Incident Report dated 3/15/26 at 07:50 AM, revealed, .Immediate Action Taken: Two CNA's put the resident back in bed, and then in his chair. This nurse did an assessment on the resident and also taking neuro checks every 15 min, 30 min, 1 hour. This nurse called DON, Brother, and On Call Provider to inform of the incidence. Note: No immediate intervention to ensure Resident #57's safety noted in the incident report. Review of Health Status Note dated 3/16/2026 at 02:32 AM revealed, .Vital signs monitored every 4 hours and have been stable throughout the night. No apparent pain or discomfort observed. Wedge placed on bed to help prevent patient rolling out of bed . Review of Health Status Note dated 3/16/2026 at 05:17 AM, revealed, .Heard resident yelling, upon entering his room, observed resident laying on floor next to his bed. Had pushed wedges off his bed when he rolled out of bed. VS (vital signs): 98.2-76-18-117/70.Resident was assessed for injury, none noted. Vital signs stable. ROM (range of motion) adequate to all extremities. Resident was transferred back to his bed by Hoyer lift and 3 staff assist. Resident is alert, orient to self and situation at times. Was aware he was laying on the floor. Review of Post Fall Evaluation 3/16/2026 at 05:20 AM, revealed, .Fall Details: Date / Time of Fall: 03/16/2026 4:30 AM Fall was not witnessed. Fall occurred bedside. Activity at the time of fall: Rolled self out of bed The reason for the fall was not evident. Did an injury occur as a result of the fall: No. Did fall result in an ER visit/hospitalization: No. Provider: (Health Facility) on-call provider Time notified: 03/16/2026 Notified of: fall without injury Resident's responsible party notified: Yes. Person contacted: (Brother) Details of notification: Resident rolled out of bed without injury Date of Resident's responsible party notification: 03/16/2026 4:50 AM Fall Details Note: Resident was heard yelling, observed laying on the floor next to his bed. No injury noted. VSS (vital signs stable).Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: Yes. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: No. Wheelchair was not involved in fall. Wearing glasses at the time of the fall: No. Footwear at time of fall: Bare feet. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall. Resident was using incontinence supplies at the time of the fall. Incontinent at time of fall: Yes. Bedside call light on when Resident was found: No. Bathroom call light on when Resident was found: No. Personal alarm sounding when Resident found: No. Other Residents were not involved in fall. Medication Changes: Recent change to Resident's medications: No.Vitals: T 98.2 - 3/16/2026 05:34 Route: Forehead (non-contact)BP 117/70 - 3/16/2026 05:34 Position: Lying l/arm P (pulse) 76 - 3/16/2026 05:34 Pulse Type: Regular R 18 - 3/16/2026 05:34.W (weight) 192.0 lb. - 3/13/2026 09:21 Scale: Hoyer Lift.Pain: Indicators of pain: Facial expressions. Pain Issue: #001: New. Location: Generalized. Pain score: 3. Aching.Skin: Skin warm & dry, skin color WNL and turgor (skin's elasticity) is normal.Physical Findings: Change in diagnosis status: No. Recent diagnosis of stroke, TIA or arrhythmia: No. Decrease in fluid intake: No. Change in blood glucose levels: No. Change in blood pressure: No. Change in mental status: No. Change in behaviors: No. Change in mobility status: No. Recent weight loss: No. Sensory impairment: No. Resident does not have orthostatic BP changes. Review of Incident Report dated 3/16/26 at 04:30 AM, revealed, .Immediate Action Taken: Resident was assessed for injury, none noted. Vital signs stable. ROM adequate to all extremities. Resident was transferred back to his bed by Hoyer lift and 3 staff assist. Note: No immediate intervention to ensure Resident #57's safety noted in the incident report. Review of Health Status Note dated 3/17/2026 at 12:11 PM, revealed, .Nurse on unit summoned writer to assist with resident sliding out of chair. Therapy was on unit and informed staff the chair was a trial for the resident. This writer, unit nurse, CNA and therapy team member assisted resident back into chair. Chair has dycem (non-slip material used to prevent slipping and sliding), foot buddy (padded box around the footrests) in place. Resident transferred safely to previous chair with Hoyer assist x 3. No other known acute changes at this time. During an observation on 04/15/2026 at 11:51 AM, Resident #57 was observed his bed, which was not in a low position, higher than transfer position for Resident #57. During an observation on 04/16/2026 at 8:19 AM, Resident #57 was observed in bed, his rectangle bolster was sideways under his bed, it was squished by the bed, he was at an angle in bed with his head near the edge on the left side and his feet more towards the right side, fall mat was in place, his body had slid down in the bed and his head was lower than the enabler bar so Resident #57 could've easily could fallen off the bed. During an observation on 04/16/26 at 11:42 AM, Resident #57 was observed lying in his bed, the rectangle bolster was on the recliner in the corner, the blue wedge was on the floor on the right side of the foot of the bed. No bolsters, pillows were placed on his bed. He was lying in a supine position at an angle. During an observation on 04/16/2026 at 12:20 PM, Resident #57 was observed lying in his bed, the rectangle bolster was on the recliner in the corner, the blue wedge was on the floor on the right side of the foot of the bed. No bolsters, pillows were placed on his bed. He was lying in a supine position at an angle. In an interview on 04/17/2026 at 11:54 AM, Registered Nurse (RN) HH reported staff would ensure the fall interventions were in place because the facility did not want the resident to fall again and the resident could get hurt or get hurt further. In an interview on 04/17/2026 at 11:55 AM, Certified Nursing Assistant (CNA) T reported if the resident was a fall risk, he would make sure the resident received constant supervision as he would look in on them every time he would pass by the room. In an interview on 04/17/2026 at 12:56 PM, Unit Manager (UM) D reported when a fall happened this was discussed during the Interdisciplinary team (IDT) meetings. UM D reported when a fall happened the nurse in charge was responsible for implementing an immediate intervention for the resident's safety. UM D reported range of motion should be completed on all residents following a fall as the resident may have an injury and moving them would cause undue pain or cause further injury. Review of policy, Fall Prevention Program implemented on 3/13/24, revealed, .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.7. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program.8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.Interventions will be monitored for effectiveness.The plan of care will be revised as needed.8. When any resident experiences a fall, the facility will: Assess the resident.Complete a post-fall assessment.Complete an incident report.Notify physician and family.Review the resident's care plan and update as indicated.Document all assessments and actions.Obtain witness statements in the case of injury. Resident #5: Review of an admission Record revealed Resident #5 was a female with pertinent diagnoses which included diabetes, peripheral vascular disease (circulation disorder involving narrowed or blocked vessels), dementia, and muscle weakness. Review of Resident #5's Kardex (Care Guide) revealed, .Transferring: 2 assist using hoyer (mechanical device sued to safely lift and transfer patients with limited mobility) . During an observation and interview 04/15/2026 at 11:58 AM, Resident #5 was seated in her recliner, and this writer observed a large deep purple bruise, approximately 4 inches in diameter, with light green/yellow on the outer edges located midway down on her right top shin. Home Care Aide WW reported when she returned to the facility on Monday, 4/14/26 she observed the bruise and reported it to the nurse on duty. Home Care Aide WW reported the bruise was not present when she finished her shift on Friday, 4/10/26. Home Care Aide WW reported she thought the bruise occurred from when the staff transferred Resident #5 with the hoyer as the staff do not tuck her feet in, her feet were stuck straight out, and Resident #5 would hit her leg on the base of the hoyer when staff were trying to reposition her for lowering into her bed or chair. Review of Skin Check assessment dated [DATE] at 03:45 AM, revealed there was no noted bruise on Resident #5's right lower leg. Review of Resident #5's medical record revealed no skin assessment, progress note, or other documentation for the observed bruise located on Resident #5's top of her shin. Review of Incident Report dated 4/15/2026 at 6:00 PM, revealed, .4/15/2026: The resident was assessed by this nurse and the LTC (long term care) unit manager. Presents with ecchymosis (large bruise >1 CM (centimeters) characterized by skin discoloration caused by blood leaking from broke vessels.It appears as blue/purple, fading to green/yellow over 1-3 weeks) on the lateral (outside of) and anterior aspect (front side) of the right lower extremity. Bilateral lower extremities are cool in temperature and color is appropriate for ethnicity. During an observation on 04/15/26 at 2:39 PM, Resident #5 was being transferred by CNA Y and CNA TT from her recliner to the bed. CNA Y lowered the hoyer to the recliner to attach the straps on to the hoyer. CNA Y attached the bottom straps to the hoyer while CNA TT was raising Resident #5's bed to transfer height. CNA Y requested Resident #5 hold on to her catheter bag, both CNAs attached the top straps to the hoyer, Resident #5 held her legs straight out in front of her with her feet resting on the foot rests of the hoyer on each side of the base, Resident #5 held her legs straight out in front of her while CNA Y was slowly raising her via the hoyer. Resident #5 was facing the base of the hoyer, as she was being raised CNA Y began to slowly move Resident #5 to the right so she was parallel with the bed, while he was doing this Resident #5's lower leg and feet were caught on the hoyer base and she yelled out in pain. Neither CNA had a hold of her legs or feet to guide her around the base. CNA Y apologized and maneuvered her legs and feet around the hoyer. CNA Y moved the hoyer closer to the bed and slowly lowered her to the bed while CNA TT gently guided her legs/feet while lowering her to the bed. In an interview on 04/17/2026 at 11:54 AM, Registered Nurse (RN) HH reported when staff were transferring a resident the staff were to ensure they observed where the resident's extremities were at as to prevent injuries to the resident. In an interview on 04/17/2026 11:55 AM, CNA T reported when transferring a resident, staff were to be mindful of where the legs of the resident were located so as to not cause an injury for the resident. In an interview on 04/17/2026 at 12:59 PM, UM D reported when the staff were transferring a resident they were supposed to have two people at all times. UM D reported the staff were to ensure the resident had their arms tucked in or were holding on to the bars which hold the straps, ensure not to bump the legs, and if need to support and guide the legs so they were not bumped and as the resident was being lowered to the bed or to the chair for proper positioning. Resident #37 Review of an admission Record revealed Resident #37 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia (disease that causes impaired thinking skills due to reduced blood flow to the brain) and legal blindness (severe visual impairment in which individuals may still have some usable vision). Review of a Minimum Data Set (MDS) assessment for Resident #37 with a reference date of 3/14/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 5/15, which indicated the resident was severely cognitively impaired. Section B revealed Resident #37's vision was severely impaired-no vision or sees only light, colors or shapes; eyes do not appear to follow objects. Section GG revealed Resident #37 was dependent (helper does all of the effort) for mobility while using a wheelchair. Review of a Care Plan for Resident #37 with a reference date of 3/17/26 revealed the following focus/goal/interventions: Focus: I am at risk for falls.Goal: To minimize risk for falls and prevent injury.Interventions.Keep in line of sight, non-skid material in seat of chair. During an observation on 4/14/26 at 12:10pm, Resident #37 was transported to the dining room via wheelchair by Certified Nursing Assistant (CNA) CC; Resident #37's feet hung unsupported, a few inches above the floor, during the transport. No footrests were present on the wheelchair. During an observation on 4/17/26 at 9:40am, CNA RR approached Resident #37 as she sat in her wheelchair at the desk area of the nurse's station. Resident #37's feet rested on the floor. The footrests on the wheelchair were folded up. Without telling Resident #37 what she was going to do, CNA RR approached Resident #37, grabbed the handles on the back of Resident #37's wheelchair and moved her away from the nurse's station by turning the wheelchair, then pushed the resident down the hall to her room. Resident #37's feet were unsupported throughout the entire time CNA RR pushed her wheelchair. In an interview on 4/17/26 at 10:18am, CNA RR reported it was important to ensure residents' feet were on footrests when transporting them via wheelchair because if they were not, their feet could get caught in the wheels or bumped against obstacles. CNA RR confirmed she did not put Resident #37's feet on the foot pedals when she took her to her room earlier. In an interview on 4/17/26 at 12:04pm, Occupational Therapist (OT) BBB reported transporting residents in a wheelchair without the use of footrests put the resident at significant risk for injury, including falls with major injury.

Based on observation, interview and record review, the facility failed to ensure that the necessary care and services were in place for a Foley catheter (tube inserted into bladder to drain urine) for 1 resident (Resident # 41) and failed to provide timely incontinence care for 1 resident (Resident #7), from a sample of 3 residents reviewed for incontinence care, resulting in the potential for trauma due to an unsecure Foley catheter, and skin breakdown and recurrent UTI's (urinary tract infections) due to inadequate incontinence care. Findings include:Resident #41Review of an admission Record revealed Resident #41 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of sacral (tailbone) region stage unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #41, with a reference date of 3/11/26 revealed a Brief Interview for Mental Status (BIMS) score of severe cognitive impairment. Review of the Functional Abilities revealed that Resident #41 was completely dependent on staff for toileting.Review of Resident #41's Skin Care Plan revealed there was no care plan related to Resident #41 incontinence and/or urinary catheter use.Review of Resident #41's Infection Control Care Plan revealed, Enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO). The resident must be placed in isolation (enhanced) due to risk of spreading MDRO's via an indwelling device, chronic/non-healing wound. Date initiated: 1/6/26. Interventions: .Staff are to wear PPE before entering room if they are providing high contact care. Date initiated: 1/6/26. The care plan did not indicate that Resident #41's indwelling device was a urinary catheter.During an observation and interview on 04/14/2026 at 11:03 AM Resident #41 was lying in her bed and Hospice Nurse (HN) M was performing wound care and a wound dressing change for Resident #41's sacral wound. Resident #41 verbalized that the wound was painful. Observed a foley catheter bag hanging from the bed frame. HN M was not wearing a gown.In an interview and observation on 04/15/2026 at 2:42 PM, Licensed Practical Nurse (LPN) KK reported that she had changed Resident #41's wound dressing on her sacrum early that morning and flushed the foley catheter. Observed Resident #41 still lying in bed and Resident #41's urinary catheter tubing was pulled tight and laying across her right leg; there was no catheter securement device observed to anchor the tubing in place. LPN KK reported that she did not notice that earlier. In an interview on 04/16/2026 at 8:14 AM, Unit Manager (UM) D reported that Resident #41 was hospitalized [DATE]-[DATE] for UTI (urinary tract infection) and returned to the facility with a foley catheter in place to help with sacral wound healing. Review of Resident #41's Hospital After Visit Summary dated 3/19/26 (admitted on [DATE]) revealed, .Foley in place for maintenance of sacral wound.Review of Resident #41's re-admission Assessment dated 3/19/26 revealed, Arrived by ambulance. Urinary Catheter intact. In an interview on 04/17/2026 at 9:16 AM, CNA G reported that she had not been in with Resident #41 since the start of her shift at 7:00 AM (2 hours ago). CNA G reported that she would have to look at Resident #41's care plan to know what care needed to be done.Review of Resident #41's Bowel and Bladder task record completed by the direct care staff indicated that in the past 30 days, Resident #41 was incontinent and/or not rated due to indwelling catheter every day.Review of Resident #41's Physician Orders for April 2026 revealed, Monitor foley catheter (size/balloon information needed) r/t (related to) wound healing. Change PRN (as needed) for obstruction every shift for infection control hygiene. Start date 3/19/26. Change foley catheter leg securement device every night shift on Sunday for trauma prevention, at bedtime every Sunday for wound. Start date: 3/22/26. The order did not include the size of catheter and size of balloon. Resident #7Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral infarction (stroke) that caused paralysis to right side. Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 4/2/26 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #7 was cognitively impaired. Review of the Functional Abilities revealed that Resident #7 was completely dependent on staff for toileting.Review of Resident #7's Incontinence Care Plan revealed, I have bladder incontinence r/t dementia, history of UTI, impaired mobility. Date initiated: 4/14/26. Interventions: Incontinent: Check and assist me to change as needed for incontinence. Wash, rinse and dry perineum (private area). Change clothing PRN after incontinence episodes. Monitor/document for s/sx (signs and symptoms) of UTI (urinary tract infection) . Date initiated: 4/14/26. During an observation and interview on 04/15/2026 at 9:40 AM Resident #7 was lying in her bed. Resident #7 reported that staff do not come timely when she puts her call light on, she had multiple UTI's in the past and she was sitting in a wet brief at that time. Resident #7 reported that she had a sore spot on her butt and stated, it's real sore!Review of Resident #7's Physician Communication Note dated 4/15/26 at 7:17 AM revealed, Resident has a small slit in between intergluteal cleft (butt crack), barrier cream applied.During an observation on 04/15/2026 at 11:49 AM Resident #7 was lying in her bed and CNA W and CNA RR were preparing to get her out of bed and into her wheelchair. Resident #7 asked the CNA's why couldn't you get me up earlier? CNA W replied to Resident #7, we were just working our way down the hall.In an interview on 04/15/26 at 11:50 AM, CNA W reported that Resident #7 was always incontinent of urine and bowels and did not always know when she was soiled. CNA W reported that the last time Resident #7 had incontinence care that day was at approximately 6:00 AM (greater than 5 hours earlier) that morning. CNA W reported that Resident #7 complained of a sore spot on her buttocks that day and a new thin open wound in the crease of her buttocks was observed during incontinence care. CNA W reported that she applied zinc (skin protectant) cream to the open area but was not sure if the nurse knew about it yet. CNA W reported that there were 2 call ins that morning and they were working shorthanded until 9:30 AM.

Based on interview and record review, the facility failed to ensure a physician (provider) supervised the medical care of residents and participated in the resident's wound assessments and treatment plans for 1 resident (Resident #53) of 18 residents reviewed for physician supervised care, resulting in the potential for a decline in overall health due to worsening of wounds. Findings include: Resident #53Review of an admission Record revealed Resident #53 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Pressure ulcers of sacral (coccyx, tailbone) region and heel, both unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #53, with a reference date of 2/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #53 was cognitively intact. Review of Resident #53's Braden Scale for predicting Pressure Ulcer Risk Evaluation dated 2/5/26 revealed, 12 indicating at high risk to develop pressure ulcers.Review of Resident #53's Skin Care Plan revealed, I am at risk for skin breakdown. Date initiated: 10/31/25. Interventions: Monitor for pain and medicate as needed per physician's order. Date initiated: 10/31/25. There was no documentation related to Resident #53's risk for pressure ulcers and/or interventions in place to reduce the risk. Review of Resident #53's Wound Management Care Plan revealed, Bilateral heels, Coccyx. Date initiated: 11/6/25. Interventions: Measure ulcer on regular intervals. Monitor ulcer for signs of infection. Monitor ulcer for signs of progression or declination. Notify provider if no signs of improvement on current regimen. Provide wound care per treatment orders. Date initiated 11/6/25. There were no updates made to this care plan.In an interview on 04/15/2026 at 8:36 AM, Licensed Practical Nurse (LPN) LL reported that Resident #53 does not get out of bed anymore, her heel sores have completely resolved, but the wound on her buttocks was not doing good at all. LPN LL reported that Resident #53 also had pressure point wounds on the tips of her toes, therefore staff had to constantly watch so that her feet don't press up against the end of the bed.In an interview on 04/16/2026 at 9:25 AM, Unit Manager (UM) D reported that Resident #53 had wounds on her heels and buttocks, and at one time a couple months ago had concerns for osteomyelitis (infection in the bone caused by infected tissue) because the wounds on her feet were not healing. UM D did not know the status of Resident #53's wounds. Reviewing Resident #53's records with UM D and there was no documentation of wound assessments that measured size, no pressure wound interventions listed, and all weekly skin checks were noted as normal. UM D reported that the facility did not have a dedicated wound nurse or provider, and that the floor nurse was expected to complete all wound assessments during the weekly skin check and notify UM D or a provider if there was a concern. UM D reported that the facility also uses a Wound Log to document when a concern was identified.Review of the facility Wound Communication Log revealed, (Resident #53) 4/2/26 Sacral wound purulent (liquid substance indicative of infection) drainage 3x2cm, new bruise right upper thigh/hip, new wound to right of current wound .5x.2cm. There was no documentation in the blanks for dressing orders or risk management completed.In an interview on 04/17/2026 at 10:04 AM, UM D reported that she was not aware of the wound communication log note from 4/2/26 related to Resident#53's wounds. UM D reported that Resident #53's orders had not changed since then and there were no progress notes or physician notes to correlate that the wound concern was assessed and being monitored. This surveyor requested to observe Resident #53's wounds and UM D agreed to collect supplies to complete assessments and wound care for all of Resident #53's wounds.During an observation on 04/17/2026 at 10:26 AM Resident #53 was lying in her bed in a sitting position. UM D was gathering supplies for wound care. At 10:46 AM UM D, Certified Nursing Assistant (CNA) CC, and Nurse Practitioner (NP) N were in the room at the bedside, donned (put on) gloves and began explaining to Resident #53 that they would be doing incontinence care and looking at her wounds. UM D removed the wound dressings from Resident #53's right and left heels, and NP N assessed the wounds. This surveyor observed nickel size brown scabs on both heels. NP N reported that the right heel wound measured 1 cm x 1 cm and the left heel wound measured 2 cm x 1 cm and called the wounds deep tissue injuries. This surveyor observed Resident #53's toes on her left foot, they were discolored and scabbed, the staff did not assess that area. CNA CC and UM D rolled Resident #53 to her left side to provide incontinence care and assess her buttocks wound. There was an extra-large bandage covering Resident #53's coccyx area dated 4/17/26 that was visibly soaked with drainage from the wound. UM CC removed the bandage which revealed a large open wound with slough (moist white dead tissue) and eschar (black hard dead tissue) in the center of the wound. NP N reported Resident #53's coccyx wound was 8 cm x 9.5 cm and called it a Stage 3 pressure ulcer and said that it was deteriorating since there was tissue exposed now. There was a large purple discolored wound on Resident #53's right upper thigh that followed the line of an incontinence brief. UM D reported that she was not aware of the wound on the right upper thigh. NP N reported that Resident #53's wound on the right upper thigh appeared to be from shearing (a wound affecting deep tissue layers due to lateral shifts in movement). In an interview on 04/17/26 at 11:10 AM, NP N reported that she did not know how long Resident #53 had the wounds that were observed that day. NP N reported that at this time they would continue the same wound treatment as previously ordered.In an interview on 04/17/2026 at 11:17 AM, Infection Preventionist (IP) E reported that she would expect staff to notify her when there was a concern for wound infection and stated, a lot of the time I don't know until I find out on my own. IP E reported that residents with pressure wounds are not automatically placed in EBP. IP E reported that if a wound is diagnosed as a certain stage or was found to be infectious, then EBP were implemented at that time. IP E reported that Resident #53 wounds were not open and she does not require EBP. In a subsequent interview on 04/17/26 at 11:40 AM, IP E reported that she was informed Resident #53's wounds were deteriorating therefore she would be placed on EBP.In an interview on 04/17/2026 at 12:01 PM, NP N reported that she had not seen Resident #53's toes in the earlier observation and was not aware that she had any wounds on her toes. In an interview and observation on 04/17/2026 at 12:04 PM, Registered Nurse (RN) I reported that they were applying betadine (antiseptic for infection prevention) to Resident #53 toes. Observed Resident #53 lying in her bed; her left great toe had a thick scab covering the tip, and the 2nd and 3rd toes were discolored black at the tips. RN I reported that Resident #53's left great toe was an unstageable pressure injury.Review of Resident #53's Physician Note dated 2/9/26 revealed, .Staff concerned with skin issues on her bilateral feet. Bilateral heel wounds were being treated with Dakins (helps reduce infection and promote healing) solution on bilateral heels while floating and has an air mattress to offload pressure. Now concern with discoloration of toes.Physical exam: .Bilateral heels have stage 3 pressure injury with beefy red wound base and macerated (softening and breaking down of skin due to prolonged exposure to moisture) edges surrounding both wounds are individually the size of a nickel, right great toe has deep purple scab to the tip of the toe, right 2nd digit has small area on the pad of the toe which is dark purple, left great toe appears to have gangrene (tissue death) at the tip, left 2nd digit has gangrene nearly to the DIP (distal interphalangeal: closest to tip of toe) joint, bilateral legs have venous insufficiency with skin color changes.Assessment and Plan: 1. Impaired skin integrity. New orders placed for wounds on bilateral heels and toes. X-ray of bilateral feet. Vascular referral ASAP. Concern with gangrene.Review of Resident #53's X-ray of bilateral feet dated 2/10/26 revealed, .No osteomyelitis is seen.Medicine (sic) bone scan are more sensitive for detecting osteomyelitis.Review of Resident #53 Progress Notes for documentation related to her toes revealed, no provider visits and/or nurse's notes related to assessment and monitoring.In an interview on 04/17/2026 at 12:44 PM, UM D reported that nursing staff notified her today of Resident #53's wounds on her toes. UM D reported that the orders were entered into the computer on 2/10/26 for her right toes instead of the left toes. UM D reported she could not explain why there was not follow up by a provider and/or wound assessments of her toes.Review of Resident #53's Weekly Skin Check dated 3/20/26 indicated there were no new skin issues identified and listed the following wounds as NOT evaluated: Right inguinal (groin) region, left heel, left gluteal (buttocks) fold, coccyx, general bruising, left inguinal region, right gluteal fold and right heel. There was no documentation related to Resident #53's toes.Review of Resident #53's Weekly Skin Check dated 3/30/26 revealed, Skin: Skin warm & dry, skin color WNL and turgor is normal. Foot evaluation completed. No new skin issues identified. Skin issues: #1 Skin issue HAS been evaluated. Location: left inguinal region. Moisture associated skin damage (MASD). Progress: improving. #2 Skin issue has NOT been evaluated. Location: Coccyx. #3 Skin issue has been evaluated. Location: right inguinal region.MASD. #4 Skin issue has NOT been evaluated. Location: right heel.Unstageable pressure injuries. #5 Skin issue has NOT been evaluated. Location: left heel.Unstageable pressure injuries. Resident #53's wounds on her coccyx and heels were not evaluated.Review of Resident #53's Weekly Skin Check dated 4/6/26 revealed, Skin: Skin warm & dry, skin color WNL and turgor is normal. Foot evaluation completed. No new skin issues identified. Skin Issues: #1: Skin issue has been evaluated. Location: Coccyx. #2: Skin issue has Not been evaluated.#2 Skin issue has NOT been evaluated. Location: Right heel. Issue type: Pressure ulcer / injury. Progress: Stalled: previously improving wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury . #3: Skin issue has NOT been evaluated. Location: Left inguinal (groin) region . Moisture associated skin damage (MASD). #4: Skin issue has NOT been evaluated. Location: Right inguinal region. Issue type: Moisture associated skin damage (MASD). #5: Skin issue has NOT been evaluated. Location: Left heel. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstageable pressure injuries. It was noted that none of Resident #53's wounds were assessed and there were no wounds noted on her toes.Review of Resident #53's most recent Weekly Skin Check dated 4/13/2026 revealed, Skin: Skin warm & dry, skin color WNL and turgor is normal. Foot evaluation completed. No new skin issues identified. Skin Issues: #1: Skin issue has NOT been evaluated. Location: Coccyx. #2: Skin issue HAS been evaluated. Location: Right heel. Issue type: Pressure ulcer / injury. Progress: Stalled: previously improving wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury . Length (cm): 7.4 Width (cm): 7.8.Exudate amount: Light. Exudate type: Serous: clear watery fluid, which is separated from solid elements. #3: Skin issue HAS been evaluated. Location: Left inguinal (groin) region . Moisture associated skin damage (MASD). Progress: Stable: previously deteriorating wound characteristics plateaued . Measurements not documented as part of this assessment. #4: Skin issue HAS been evaluated. Location: Right inguinal region. Issue type: Moisture associated skin damage (MASD). Progress: Stable: previously deteriorating wound characteristics plateaued . Measurements not documented as part of this assessment. #5: Skin issue HAS been evaluated. Location: Left heel. Issue type: Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury.Measurements not documented as part of this assessment.Clean dressing applied. There was no documentation of the wounds on Resident #53's toes and it was noted that the coccyx wound was not assessed.Review of Resident #53's Physician Visit Notes from 2/20/26, 3/4/26, 4/6/26 for information related to the resident's pressure wounds on coccyx, heels and toes. There were no additional physical exams or assessment/plans following the 2/9/26 visit note.

Based on interview and record review, the facility failed to allow resident choice regarding personal care in 1 of 1 resident (Resident #1) reviewed for self-determination, resulting in Resident #1 not receiving care (showers/baths) at her preferred time of day. Findings include:Resident #1:Review of Care Plan for Resident #1, revised on 3/3/26, revealed the focus, .I have an ADL (activities of daily living) deficit and need assistance with daily care r/t (related to) weakness/debility. with the intervention .ADL care to meet my needs.Review of Kardex (care guide) for Resident #1 revealed, .ADL-Bathing 1 assist extensive Thursday and Saturday.Personal hygiene: independent following set-up. During an observation and interview on 04/14/2026 at 10:55 AM, Resident #1 reported she didn't get her shower on Saturday as the staff member came at 10:00 PM and the shower was not offered for the next day. Resident #1 reported she had declined the shower due to it being late, she was tired and not up to taking a shower that late. Resident #1 reported she was scheduled to get her showers on Thursdays and Saturdays. In an interview on 4/15/26 at 12:42 PM, Certified Nursing Assistant (CNA) AAA reported when a resident refused a shower it was documented on the shower sheet after the staff attempted multiple times to encourage the resident to obtain a shower. CNA AAA reported once completed the shower sheet was submitted to the nurse for review and signature. Review of Shower Sheets for Resident #1 revealed on 2/19/26, CNA EEE had written on the shower sheet Resident #1 wanted to take showers on day shift and the nurse on duty signed and indicated the change was requested as well. Review of Shower Sheets revealed on 2/29/26, Resident #1 had reported to CNA EEE she wanted showers to be switched to day shift showers. Review of Shower Sheets for Resident #1 revealed on 4/9/26, CNA EEE had written the request again for Resident #1's showers to be changed to the day shift. In an interview on 04/16/2026 at 2:41 PM, CNA EEE reported Resident #1 had requested she received her showers during the day shift, and she had written her preference on the shower sheet for the nurse to review, and the Unit Manager was aware Resident #1 wanted her showers during the day shift. In an interview on 04/16/2026 at 2:51 PM Unit Manager (UM) D reported the nurse would enter an alert in the resident's medical record which would notify her of the requested change of shower days for a resident. UM D reported she had educated the nurses on entering the request in that manner so she would be alerted to the change as she received several shower sheets and was not always able to review all timely.

This citation pertains to Intake # MI00143491. Based on observation, interview, and record review, the facility failed to immediately treat a hot liquid burn per professional standards of practice in 1 of 5 residents (Resident #103) reviewed for quality of care, resulting in an Immediate Jeopardy when on 2/22/24 Resident #103 spilled a cup of hot liquid on her lap. Facility staff did not immediately apply cool liquid to the site to stop the burn, resulting in additional skin breakdown, prolonged healing, infection requiring IV (intravenous) antibiotics, and ongoing pain. Findings include: Review of an Admission Record revealed Resident #103 was a female, with pertinent diagnoses which included second-degree burn of thigh, skin infection, stroke with left sided weakness, peripheral vascular disease, dementia, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 2/8/24, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated severe cognitive impairment. In an observation and interview on 4/10/24 at 9:57 AM, Resident #103 was in bed in her room, eating independently from her breakfast tray. No hot liquids observed on breakfast tray. Resident #103 reported she used to drink hot tea, but had a spill in the dining room which resulted in burns. Resident #103 reported her burns are still healing, and she goes out to the wound clinic for treatment. Review of an Incident/Accident report for Resident #103, dated 2/22/24 at 10:30 AM, revealed .Nurse was informed that resident spilled hot liquid on her lap while eating breakfast .Immediate Action Taken .Nurse had resident taken to the room where she resides and did a full skin assessment on her and the finding was red skin . Review of a Skin Assessment for Resident #103, dated 2/22/24 at 11:30 AM, revealed .Inner thighs have a red area to the skin due to a hot beverage getting spilled on her legs. Will continue to monitor the area until no longer red . No additional interventions noted. In an interview on 4/10/24 at 10:29 AM, Family Member LL reported Resident #103 had a hot liquid spill in the dining room on 2/22/24. Family Member LL reported Resident #103 spilled a cup of hot tea on her lap, which resulted in burns to both her legs and her buttocks. Family Member LL reported Resident #103 had to go to the wound clinic for care, and has treatments completed twice a day. Family Member LL reported Resident #103's wounds are painful, and stated .She still cries because it is so painful . Family Member LL reported staff did not know how to respond to the hot liquid spill, and stated .She sat in the (hot) water. They didn't know how to treat it . Review of a Health Status Note for Resident #103, dated 2/22/24 at 12:41 PM, revealed .Resident went to kitchen and asked for a cup of coffee. Kitchen manager gave resident a cup of coffee with a lid on the cup. Resident then took the lid off the cup of coffee and was trying to drink from the cup. Resident spilled the cup of coffee on her lap. Resident was immediately taken to her room to do a skin assessment of the area. Inner thighs had a red area to it. Cream was applied to the red area and clothes were changed. Resident was re-educated on the importance of keeping the lid on hot beverages. Staff will continue to monitor the area until it is healed . Note, no cool water was applied to stop the burning process prior to placing cream on the burns. Review of a Health Status Note for Resident #103, dated 2/22/24 at 4:46 PM, revealed .Resident was drinking hot liquids in the dining room for breakfast and spilled the hot beverage on her legs. A full skin assessment was performed after the incident. The finding was red area on the inner thigh. Resident c/o (complained of) pain at the area. Another skin assessment was performed at (4:00 PM) and the finding was blisters noted on the inner thighs all the way back to the buttocks. (Nurse Practitioner J) assessed the areas and gave orders to the nurse to start for wound care. Will continue to monitor the area until healed . Review of a Health Status Note for Resident #103, dated 2/22/24 at 5:40 PM, revealed .Measurement for blisters on inner thighs. Left thigh and buttocks blister 36cm (this runs all the way across left buttocks.) 36cm x 8cm. Right inner thigh 10.5cm x 5.5cm blister. skin tear below right thigh blister 5.5cm x 2.5cm . Review of a Physician's Progress Note for Resident #103, dated 2/23/24 at 11:39 AM, revealed .Apparently yesterday she was drinking hot tea and spilled her tea in her lap - subsequently skin was burned and nursing requesting evaluation .Second degree burns with two large blisters of left thigh - one intact and the second one has opened with pink wound bed .Second degree burns on right thigh with long nearly circumferential blister that is fluid filled and three additional circular burns with fluid filled blisters .Plan: Second degree burns on thighs after tea spilled in her lap. Cover open blister with TAO (triple antibiotic ointment) and sterile dressing, changing dressing daily and monitoring for drainage. Monitor fluid filled blisters and try to keep blisters intact - avoid friction or rubbing . In an observation on 4/10/24 at 12:24 PM, Assistant Director of Nursing (ADON) W and Licensed Practical Nurse (LPN) Q completed wound care for Resident #103. Observed extensive burns to Resident #103's right and left thighs, with reddened wound bases and a small amount of blood-tinged drainage. Observed Resident #103 flinch as the old dressings were removed from the wounds, and state .ow, ow, ow . while holding her hand over her mouth. In an interview on 4/10/24 at 2:53 PM, Registered Nurse (RN) AA reported she was Resident #103's assigned nurse on 2/22/24 when the hot liquid spill occurred. RN AA reported staff brought Resident #103 to the unit from the dining room immediately after the hot liquid spill. RN AA stated Resident #103 .had removed the top from her coffee cup and it had spilled on her lap . RN AA reported she brought Resident #103 to her room and removed her pants to assess the affected area. RN AA stated .There was slightly red skin . when the area was initially assessed. RN AA reported no other treatment or intervention was done at that time, and stated .just the assessment of the skin . RN AA reported later on that day, Resident #103 was complaining of pain. RN AA reported she completed another assessment of Resident #103's skin, and noted blisters had formed on her thighs. In an interview on 4/10/24 at 3:20 PM, Server DD reported she served Resident #103 a cup of hot tea with a lid on 2/22/24. Server DD stated .Next thing you know I hear her screaming .She had spilt it all over herself . Server DD reported she and Server EE immediately brought Resident #103 to her assigned nurse. Server DD reported that since the incident, she was educated that cool liquid should be immediately applied to the burned area. Server EE stated .I didn't know that was what we were supposed to do . In an interview on 4/10/24 at 4:01 PM, ADON W reported she was working the day Resident #103's burns occurred. ADON W reported after staff notified her of the incident, she went in to assess Resident #103's skin to determine the severity of the burn. ADON W stated when she assessed Resident #103's skin .It wasn't blistered at the time .It looked like a dark area on her skin . ADON W reported Resident #103 reported pain from the affected area. In an interview on 4/11/24 at 9:05 AM, Nurse Practitioner (NP) J reported she was notified after Resident #103's hot liquid spill on 2/22/24. NP J reported when she assessed the wounds, she noted second-degree burns on Resident #103's thighs. NP J reported after the incident, Resident #103 complained of increased pain and was sent out to the hospital on 2/25/24. NP J reported Resident #103 returned to the facility with orders to be seen at the wound clinic. NP J reported Resident #103's wounds began draining, her wound was cultured, and she was started on IV antibiotics. NP J reported topical lidocaine was initiated during dressing changes .because she is so painful . and a Foley catheter was placed for wound management. NP J reported Resident #103's wounds were .more than just superficial break down . Review of a Hospital After Visit Summary for Resident #103, dated 2/25/24, revealed .has second-degree burns on the inner thighs .A referral was placed to the burn clinic for follow-up . Review of a Burn and Wound Center note for Resident #103, dated 2/27/24, revealed .Chief Complaint .evaluation and management of second degree burn on thighs .Location: bilateral thighs .Burn occurred due to staff handing pt (patient) a cup of hot tea and she spilled it on her lap .Wound #1 status is Open. Original cause of wound was Thermal Burn. The date acquired was: 2/22/2024. The wound is currently classified as a Partial Thickness wound with etiology of 2nd degree Burn and is located on the Right, Circumferential Upper Leg. The wound measures 26cm length x 23 cm width x 0.1cm depth .There is Fat Layer (Subcutaneous Tissue) exposed .There is a large amount of serous drainage noted. There is medium (34-66%) red granulation within the wound bed. There is a medium (34-66%) amount of necrotic tissue within the wound bed including Eschar .Wound #2 status is Open. Original cause of wound was Thermal Burn. The date acquired was: 2/22/2024. The wound is currently classified as a Full Thickness Without Exposed Support Structures wound with etiology of 2nd degree Burn and is located on the Left, Circumferential Upper Leg. The wound measures 8.5cm length x 18.5cm width x 0.1cm depth .There is Fat Layer (Subcutaneous Tissue) exposed .There is a large amount of serous drainage noted. There is medium (34-66%) red, pale granulation within the wound bed. There is a medium (34-66%) amount of necrotic tissue within the wound bed including Eschar . Review of a Burn and Wound Center note for Resident #103, dated 3/5/25, revealed Chief Complaint .evaluation and management of second degree burns on thighs .Pt has bilateral thigh burns due to a cup of hot water spilling on her thighs. The kitchen staff took pt back to her room which may have contributed to the burns depth . Review of a Health Status Note for Resident #103, dated 3/11/24 at 5:42 PM, revealed .Observed green drainage from burns on left and right thigh and buttocks. NP notified. Order to culture wound completed . Review of a Physician's Progress Note for Resident #103, dated 3/14/24 at 11:14 AM, revealed .Recent burns on upper thighs after spilling hot liquid - blistered - treated with antibiotic therapy Keflex and appeared to be improving .additionally going to the wound clinic .2 days ago nursing reported malodorous green discharge from wounds - wound cultures and grew Pseudomonas aeruginosa, E. coli, providencia stuartii, and Pseudomonas aeruginosa #2 .Wound dressings are changed twice daily according to wound clinic treatment .Increased pain noted with wound dressing changes .Plan: Burns on bilateral inner thigh now infected with multiple organisms. Ordered Midline placement by access RN .Cefepime IV twice daily for 10 days .Topical lidocaine prior to dressing changes and Tramadol . Review of a Burn and Wound Center note for Resident #103, dated 3/19/24, revealed .Chief Complaint .evaluation and management of second degree burns on thighs .Wound #1 status is Open. Original cause of wound was Thermal Burn .The wound is currently classified as a Full Thickness Without Exposed Support Structures wound with etiology of 2nd degree Burn and is located on the Right, Circumferential Upper Leg. The wound measures 32cm length x 14cm width x 0.1cm depth .There is Fat Layer (Subcutaneous Tissue) exposed. There is a large amount of serous drainage noted. There is small (1-33%) red granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including Eschar and Adherent Slough .(note, this necrotic tissue had increased in size) .Wound #2 status is Open. Original cause of wound was Thermal Burn .The wound is currently classified as a Full Thickness Without Exposed Support Structures wound with etiology of 2nd degree Burn and is located on the Left, Circumferential Upper Leg. The wound measures 14cm length x 15cm width x 0.1cm depth .There is Fat Layer (Subcutaneous Tissue) exposed .There is a large amount of serous drainage noted. There is small (1-33%) red, pale granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including Eschar and Adherent Slough (note, this necrotic tissue had increased in size) .Per caregiver, Patient now on IV (intravenous) Cefepime . In an interview on 4/11/24 at 10:45 AM, Server EE reported he was present at the time of Resident #103's hot liquid spill on 2/22/24. Server EE stated .I heard her yell and then turned and rushed her to the nurses' station . Server EE reported cool water was not applied to Resident #103's burned area. In an interview on 4/11/24 at 3:36 PM, RN AA reported in regard to treatment immediately after a hot liquid spill, cool liquid should be applied to the affected area. RN AA reported in regard to Resident #103's burns that occurred on 2/22/24 cool liquid was not applied to the affected area immediately after the hot liquid spill occurred. RN AA stated this intervention .Wasn't anything I was thinking of at the time . Review of a WebMD article titled Thermal Burns Treatment, dated 2024, revealed .For All Burns .Stop Burning Immediately .Put out the fire or stop the person's contact with hot liquid, steam, or other material .Remove hot or burned clothing. If clothing sticks to the skin, cut or tear around it .Remove Constrictive Clothing Immediately .Take off jewelry, belts, and tight clothing. Burns can swell quickly. Then take the following steps: For First-Degree Burns (Affecting Top Layer of Skin) 1. Cool Burn .Hold burned skin under cool (not cold) running water or immerse in cool water until the pain subsides. Use compresses if running water isn't available .For Second-Degree Burns (Affecting Top 2 Layers of Skin) 1. Cool Burn .Immerse in cool water for 10 or 15 minutes. Use compresses if running water isn't available. Don't apply ice. It can lower body temperature and cause further pain and damage . Obtained from https://www.webmd.com/first-aid/thermal-heat-or-fire-burns-treatment Review of a Cleveland Clinic article titled Second-Degree Burn, dated 2022, revealed .Care and Treatment .Use cool water to gently wash your burn. Try to keep your burn area under water for at least five minutes, up to 30 minutes. Gently pat the burn dry with a clean towel . Obtained from https://my.clevelandclinic.org/health/symptoms/24527-second-degree-burn Review of an American Family Physician article titled Outpatient Burn Care: Prevention and Treatment, dated 2020, revealed .Most patients with burn injuries are treated as outpatients. Two key determinants of the need for referral to a burn center are burn depth and percentage of total body surface area involved. All burn injuries are considered trauma, prompting immediate evaluation for concomitant injuries. Initial treatment is directed at stopping the burn process. Superficial (first-degree) burns involve only the epidermal layer and require simple first-aid techniques with over-the-counter pain relievers. Partial-thickness (second-degree) burns are subdivided into two categories: superficial and deep. Superficial partial-thickness burns extend into the dermis, may take up to three weeks to heal, and require advanced dressings to protect the wound and promote a moist environment. Deep partial-thickness burns require immediate referral to a burn surgeon for possible early tangential excision .Pruritus, hypertrophic scarring, and permanent hyperpigmentation are long-term complications of partial-thickness burns. Burn injuries are more likely to occur in children and older people .Burn injuries are dynamic in nature, and even minor-appearing injuries can worsen with time (burn wound conversion) and need to be reassessed in 24 to 72 hours. Superficial partial-thickness burns can deepen spontaneously to deep partial-thickness or full-thickness involvement within 48 hours. Depth can also increase because of inadequate treatment or superinfection .For all types of minor burn injuries, the goals of initial treatment are to minimize the extent of the burn, clean the wound, and address pain. For scalds, immediate clothing removal lessens burn injury .Active cooling of the burn surface with running tap water (at 46.4 F [8 C] to 77 F [25 C]) for at least 20 minutes has been shown to reduce burn depth, improve healing time, and decrease grafting requirements. Cooling should commence within 30 minutes of the initial burn, but emerging evidence suggests this benefit may be achieved up to three hours after the burn. Wet dressings are not effective at cooling wounds. Ice should not be used because of its vasoconstrictive effects and risk of further tissue injury . Obtained from https://www.aafp.org/pubs/afp/issues/2020/0415/p463.html On 4/11/24, Administrator A was notified of an Immediate Jeopardy that began on 2/22/24 when the facility failed to immediately treat Resident #103's hot liquid burn per professional standards of practice. On 4/12/24, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. Resident #103 was assessed by the Licensed Nurse and Nurse Practitioner on 2/22/2024 with new orders for continued assessment of the reddened area. On 2/23/24 new orders were obtained for wound treatment. Based upon continued nursing assessment, Resident #103 was sent to the ER (emergency room ) for evaluation on 2/25/24 and was referred to the Wound Clinic to obtain further treatment orders. Facility staff are trained, based upon the policy, to apply cool liquid immediately after a hot liquid spill and take the resident to a licensed nurse for further assessment and treatment. Per protocol, nurses report to the provider and obtain orders for treatment. 2. Residents residing in the community were reassessed for safety with hot liquids by the Director of Nursing or designee by 3/01/2024. Care plans were updated to reflect appropriate interventions. Hot liquid evaluations were added to the admissions checklist to ensure residents are assessed upon admission. 3. The policy/procedure for Hot Liquid Safety was reviewed by Administrator A on 2/23/2024 with updates as necessary. 4. On 2/23/2024 education was initiated for all active staff on the policy/procedure for Hot Liquid Safety through the Relias platform (a computer-based training system). This education includes directions to pour cool liquid on the spill immediately and escort the resident to their nurse. The policy also ensures nursing staff assess the area for 24 hours after the incident. Nursing staff should take direction from the provider for further treatment of the area. Education has been completed by 142 out of 157 employees. Employees who have not yet completed their education have not worked the floor since 3/01/2024. 5. The Director of Nursing or designee will conduct a daily audit of residents, Monday through Friday, during meal service to ensure appropriate interventions for hot liquid spills are in place per resident care plan. During the weekend, licensed professionals on shift should continue to follow the policy by offering clothing protectors to all residents and providing a lid for all hot liquids. This audit will continue for 12 weeks. 6. The Dining Services Manager will conduct a daily audit of the coffee machine for 12 weeks to ensure temperatures of hot liquids are not greater than 140 degrees based upon the policy. This policy was adopted via The Compliance Store, and has references observed: Centers for Medicare and Medicaid Services. State Operations Manual, Appendix PP: Guidance to Surveyors, F-689 Free of Accidents Hazards / Supervision / Devices. Should a resident request their hot liquids be hotter than what is indicated in the policy, the community would utilize the Resident Assessment process where the Interdisciplinary Team would review the request, assess the resident, assess the staff ability to accommodate the request, and if the accommodation can be made, discuss how to provide that service in a safe manner. All documentation would then go into the resident care plan. 7. Results of the audits will be brought to the Quality Assurance Performance Improvement Committee meetings for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible for attaining and maintaining compliance. Compliance was attained by 3/01/2024. The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, the Hot Liquid Safety policy was developed and implemented, and the facility had achieved sustained compliance. Therefore, no plan of correction will be required.

This citation pertains to Intake # MI00137543. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopement and ensure a functional alarm system was in place in 1 of 5 residents (Resident #103) reviewed for wandering/elopement, resulting in an Immediate Jeopardy when on [DATE] at approximately 5:50 PM, Resident #103, who was cognitively impaired, exited the facility unbeknownst to facility staff and traveled on foot along a busy four lane road with a speed limit of 30 miles per hour to a store to purchase a beverage. Resident #103 was found by a staff member who was driving in to work between 6:00 PM-6:15 PM. The resident had an alarm bracelet in place, however, it was not functional. The facility had initiated 15-minute checks prior to the elopement. The last observation of Resident #103 was at 5:48 PM. This deficient practice placed 5 additional residents identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of a Health Status Note for Resident #103, dated [DATE] at 5:53 PM, revealed .Resident was found walking around outside. Activity personnel saw resident walk outside and immediately started going out to talk to him. this nurse witnessed the resident walking by the front door. This nurse immediately went outside to bring the resident back inside and noticed the activity personnel was heading towards him as well. No injuries occurred. Skin assessment was completed. This nurse asked the resident where he was going, and he stated for a walk. this nurse informed the resident that he needs to notify someone if he wants to go for a walk. Wander guard was placed on the left ankle. Family was notified. Administrator was notified . Review of an Elopement Assessment for Resident #103, dated [DATE], revealed a score of 14, which indicated Resident #103 was At Risk for elopement. Per the assessment, a Wander Guard (alarm bracelet used to alert staff when a resident attempts to exit the building) was in place. Review of a Behavior Note for Resident #103, dated [DATE] at 5:51 PM, revealed .Wanderguard alarm went off for main entrance. Resident was found sitting in chair in area between the doors. He said, I am cold. This RN (Registered Nurse) asked the resident to please come back in the building. Resident went to his room . Review of a Health Status Note for Resident #103, dated [DATE] at 6:29 PM, revealed .Resident took a shower at (5:45 PM), got dressed and went down to dining room for dinner at (5:48 PM). This nurse laid eyes on resident in dining room eating. At (5:48 PM) resident was in the facility. Resident at some point walked out of the facility. Resident (may) have walked to the store and walked back to the facility. Resident is safe in bed room at this time. Resident has no new skin concerns or pain noted. Will (continue) to monitor for changes . In an interview on [DATE] at 9:49 AM, LPN Q reported she was assigned to Resident #103 on [DATE]. LPN Q reported they were doing 15-minute checks on Resident #103 because the Wander Guard bracelet he had on was not working. That's why he was on around the clock checks, because we were waiting for a new shipment (of Wander Guard bracelets) to come in . LPN Q reported Resident #103 had a shower, and then went to the dining room for dinner. LPN Q reported she last saw Resident #103 in the dining room on [DATE]. LPN Q reported at some point after that he left the building, purchased a beverage at the store, and returned. LPN Q reported another staff member found him outside and brought him back in through the front door. LPN Q reported at the time he exited the facility on [DATE], he was wearing two alarm bracelets. LPN Q stated in regard to Resident #103 .He gets mistaken for a visitor . LPN Q reported when Resident #103 returned to the facility on [DATE] a new alarm bracelet was applied. LPN Q reported she completed an incident report in regard to Resident #103's elopement on [DATE]. In an observation on [DATE] at 11:56 AM, noted the road in front of the facility had four lanes of traffic, with a speed limit of 30 miles per hour. Noted the nearest gas station was 0.5 miles away and a ten minute walk in one direction. In an interview on [DATE] at 2:37 PM, RN F reported in regard to Resident #103's elopement on [DATE] she was driving into work and observed Resident #103 on the sidewalk outside of the facility, along the four lane road. RN F reported Resident #103 told her he went to the store to get a pop. RN F reported she was unsure what time this occurred, and estimated it was around 6:00 PM. RN F reported she was not asked to provide a statement after the incident. RN F reported she notified Resident #103's assigned nurse, the manager, and Administrator A. In an interview on [DATE] at 3:09 PM, LPN Q reported Resident #103 returned to the facility on [DATE] between approximately 6:00 PM and 6:15 PM. In an observation and interview on [DATE] at 10:18 AM, noted the front entrance door to the facility was locked and required a code for entry. Administrative Assistant C reported the code to unlock the doors has not been changed for .years . Noted the front entrance door utilized a Wander Guard alarm system. Review of a Health Status Note for Resident #103, dated [DATE] at 6:57 PM, revealed .Resident has new (Wander Guard) on left ankle. (Wander Guard) is functioning, resident in bed room with call light at reach . In an observation and interview on [DATE] at 3:40 PM, Licensed Practical Nurse (LPN) G reported the front entrance door utilizes a Wander Guard system, and it is the only exit door at the facility that has this system in place. LPN G reported if the door is opened when a resident wearing a Wander Guard alarm bracelet is near, an alarm will sound. Observed LPN G demonstrate the functioning of the front entrance door Wander Guard system. LPN G reported there is a separate alarm system for the back door near the rehabilitation room, which requires a second bracelet be worn for residents at risk for elopement. LPN G reported this second bracelet does not sound an alarm, but instead sends a notification to the call light system that the resident is in the back section of the facility. LPN G stated in regard to Resident #103 .He might know the code . to unlock the doors. LPN G reported all the exit doors at the facility utilize the same code. In an interview on [DATE] at 9:47 AM, Registered Nurse (RN) GG reported residents at risk for elopement generally wear only one alarm bracelet. RN GG reported all of the exit doors at the facility utilize a Wander Guard system, which alarms at the doors and sends a notification to the call light system. Note this information is different than what was reported by LPN G. In an interview on [DATE] at 12:21 PM, RN E reported a resident with a Wander Guard bracelet will have a Physician Order to check function and placement of the bracelet daily. RN E reported the batteries in the newer bracelets last longer, and require a magnet to check function, while the older bracelets utilize a special device to check function. RN E reported she was unsure if residents at risk for elopement were required to wear two alarm bracelets and stated .I don't know if they have to have both of them on or not . In an observation on [DATE] at 12:50 PM, RN E checked Resident #103 for function/placement of alarm bracelets. Noted two bracelets on Resident #103's left ankle, a Wander Guard bracelet (for the front entrance) and a [NAME] bracelet (for the back door by the rehabilitation room). In an interview on [DATE] at 2:52 PM, with Administrator A and Director of Nursing (DON) B, DON B reported residents at risk for elopement should have two alarm bracelets in place, the Wander Guard bracelet and the [NAME] bracelet. DON B reported the front entrance door utilizes the Wander Guard alarm system, and the back door by the rehabilitation room utilizes the [NAME] system. DON B reported those two doors are the only ones with alarms linked to resident bracelets. The remaining exit doors have a 15-second egress system or key code entry. Administrator A reported Resident #103 had an incident where he exited the facility without supervision on [DATE] to go for a walk. Administrator A reported Resident #103 was re-assessed for elopement risk at that time, and a Wander Guard bracelet was added as a new intervention. Review of an Admission Record revealed Resident #103 was a male, with pertinent diagnoses which included kidney disease, high blood pressure, obstructive lung disease, and Alzheimer's disease. Review of a Social Services Note for Resident #103, dated [DATE] at 7:54 AM, revealed .CC (Care Conference) held on [DATE] with (Family Member V) via phone .Had concerns regarding (Resident #103's) elopement risk and wandering behaviors . Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a current Care Plan for Resident #103 revealed the focus .I have impaired cognitive function/dementia or impaired thought processes r/t (related to) Dementia . initiated [DATE]. Review of a current Care Plan for Resident #103 revealed the focus .I am a wanderer and like to go outside for fresh air and to walk. I sometimes go outside to the courtyard, I sometimes walk with someone from activities or nursing department and sometimes I walk outside by myself in a straight line to the gas station and back for fresh air and a soda. POA (Power of Attorney) aware and in agreement with plan. POA has later requested a Wanderguard for his dad which has been reapplied . initiated [DATE] and revised [DATE], with interventions which included .WANDER GUARD to the left ankle . initiated [DATE]. Review of an Administration Note for Resident #103, dated [DATE] at 11:18 AM, revealed .Wanderguard is not functional. There is not currently a replacement in the facility. Med rooms on both halls and the purchasing room were searched .Notified on call, awaiting instructions on how to proceed . Review of an Administration Note for Resident #103, dated [DATE] at 12:00 PM, revealed .On call provided orders for every 15 minute whereabout checks . Review of an Order Summary Report for Resident #103 revealed an order to .check residents whereabouts every 15 minutes due to non functioning (Wander Guard) . with a start date of [DATE]. Noted this order was discontinued on [DATE]. Review of an Administration Note for Resident #103, dated [DATE] at 10:18 AM, revealed .(Wander Guard) not functional .Fifteen minute check implemented . In an interview on [DATE] at 12:09 PM, Agency LPN T reported he identified Resident #103's Wander Guard bracelet was not working in August during a routine check for placement/function. Agency LPN T reported he attempted to locate a replacement Wander Guard bracelet, but there were none available. Agency LPN T stated .I checked everywhere in the building . Agency LPN T reported since there were no functional Wander Guard bracelets available .we implemented 15-minute checks . Agency LPN T stated .The system is kind of weird. Some bracelets work for the other doors and some work for the front doors . Agency LPN T reported he did not remove the non-functional Wander Guard bracelet from Resident #103, and stated he .thought it would be to our advantage if he (Resident #103) thinks it (the Wander Guard bracelet) works . In an interview on [DATE] at 12:55 PM, DON B reported she was not aware that Resident #103's Wander Guard bracelet was non-functional. DON B reported there was an order placed for more Wander Guard bracelets at one point, however they were on backorder. DON B reported she had a conversation with Family Member V in early October where they discussed Resident #103 going outside. DON B reported she and Family Member V agreed that it was OK for Resident #103 to be outside of the facility without supervision for ten minutes. DON B stated .He (Family Member V) was fine with that and agreed . DON B clarified that this conversation occurred after Resident #103 exited the facility without supervision on [DATE]. DON B reported she was unsure where Resident #103 had went on [DATE] to purchase a beverage, and stated .He may have gone to the dollar store .I heard gas station . DON B reported an incident/accident report was not completed in regard to Resident #103's elopement on [DATE]. In regard to the Health Status Note for Resident #103, dated [DATE] at 6:57 PM, DON B stated .The staff sometimes call the pendant (Beacon alarm) the Wander Guard . In an interview on [DATE] at 8:41 AM, Family Member V reported he was not notified that Resident #103 had exited the facility without supervision on [DATE]. Family Member V stated .The next day I was there and someone came to talk to me about it . When asked if he was OK with Resident #103 walking outside of the facility without supervision, Family Member V stated .No, not really . Family Member V reported Resident #103 admitted to the facility due to Alzheimer's dementia and stated .I had concerns that he would get lost if he were alone. That's the reason why he was there . Family Member V reported when Resident #103 first admitted to the facility, he had a Wander Guard in place which was later removed. Family Member V reported a Wander Guard bracelet was reapplied in [DATE] after a staff member saw him (Resident #103) attempt to leave the facility. Family Member V stated .Then it seems like the Wander Guard died or ran out of battery. For a while, when I went to go pick him (Resident #103) up and take him out (on a leave of absence) the alarm would not go off. I kept telling them it was not working . Family Member V reported the incident where Resident #103 eloped from the facility on [DATE] was during the period of time where the Wander Guard bracelet was not working. Family Member V stated DON B .was asking me that day ([DATE]) if I was OK with him going outside by himself. She told me that he seems to be aware enough where he would be able to go out for a walk by himself. I was hesitant because again I'm not sure (what) the risk would be. What if he takes a wrong turn? I think we kind of left it as I am a little skeptical about that (going out of the facility without supervision). Only in a very controlled way. She was saying like we could let him out and have him back in ten minutes. I was just not sure. I said I would be OK but I would need more details . Review of a Health Status Note for Resident #103, dated [DATE] at 4:45 PM, revealed .Writer spoke with resident's son regarding resident's desire to walk outside and get fresh air at times when the weather is nice. Resident has a slight language barrier and son is POA (Power of Attorney); son was able to translate conversation to resident and resident was able to understand and converse back. Son mentioned that he likes when someone from activities walks with him as he worries about resident getting lost but is ok with resident going outside on his own, with staff knowing when he leaves and when he returns (if someone from activities is not available). Son agrees that a 10 minute walk is ok as resident states that he likes to get fresh air and per resident, he only goes in a straight line and likes to get soda. Resident showed son that he does have a couple dollars in his wallet for the soda but son said it's not about the soda, it's about the walk. Writer and son also spoke about encouraging resident to walk when family visits and also within facility and utilize the courtyard for fresh air; son thought that was a great idea. IDT (Interdisciplinary Team), NP (Nurse Practitioner) made aware of communication with son/resident. Staff aware . In an interview on [DATE] at 2:00 PM, Life Enrichment Staff X reported she would often take walks with Resident #103 outside of the facility. Life Enrichment Staff X described the route taken with Resident #103, and stated .It was a long walk. We could have went even further. He is a good walker . Life Enrichment Staff X reported in regard to whether or not Resident #103 was safe to walk outside without supervision .I don't know .I did not determine that but someone else did. I was still trying to walk with him as much as possible . In an interview on [DATE] at 3:59 PM, CNA N reported in regard to Resident #103's elopement on [DATE] .it happened so quick .We did his shower .Must have been right after dinner . CNA N reported a third shift nurse came and asked if Resident #103 was still a resident at the facility. CNA N reported this nurse saw him walking on the sidewalk along the street and brought him back to the facility. CNA N stated .(Resident #103) went to the store and got a pop and came back . CNA N reported Resident #103 was on 15-minute checks at the time of the elopement on [DATE]. CNA N reported a nurse applied a Wander Guard bracelet after the elopement on [DATE]. CNA N reported was unsure why Resident #103 was on 15-minute checks, and stated it was .probably the attempts to escape . In an interview on [DATE] at 4:10 PM, CNA R reported she was assigned to Resident #103 at the time of his elopement on [DATE]. CNA R reported Resident #103 had just taken a shower, and gone down to the dining room for dinner. CNA R stated .One of our nurses came running in asking if he was still a resident . CNA R reported Resident #103 walked through the front door with a pop. CNA R reported they asked Resident #103 why he went outside and he stated for some .fresh air . CNA R reported Resident #103 told her he went to the gas station which was a .significant walk . CNA R reported Resident #103 was on 15-minute checks at the time of his elopement on [DATE], and that he was gone from the building for approximately 15 minutes. CNA R stated after Resident #103's elopement on [DATE] .They took his 15-minute checks more seriously . and a new alarm bracelet was applied, a [NAME] alarm. CNA R reported a couple days after the elopement, it was determined that Resident #103 could go outside for a walk as long as a staff member was present. Review of the policy/procedure Elopement Prevention/Procedure/Reporting, dated [DATE], revealed .(Company Name) will strive to provide a safe and secure environment for its residents at all times. It is the policy of (Company Name) to assess all residents upon admission, as well as after a significant change in condition and quarterly for possible elopement risks. Residents found to be at risk will remain in a safe environment at all times .The safety and well-being of residents who live in our communities is a priority .Definition of Elopement: When a cognitively impaired resident leaves the premises or a safe area without authorization and/or necessary supervision to do so .ELOPEMENT PREVENTION .Residents will be assessed upon admission, upon exhibiting exit seeking behaviors and/or with a change in condition and reviewed quarterly for elopement risk utilizing the elopement assessment form .Residents found to be at risk shall be identified to the staff .A Plan of Care will be developed for those residents assessed as being at risk for elopement including interventions to prevent elopement .Residents determined to be at risk for elopement will have a wander guard signaling device as appropriate. The wander guard may be worn around a wrist or ankle and in unique situations on an assistive device. The wander guard is an electronic monitoring system with an audible warning signal for entrance/exit doors that is activated by a signaling device worn by a resident .Residents identified as being at risk for elopement will have placement of wander guard verified each shift and initialed in the Residents MAR (Medication Administration Record). Proper functioning of the residents signaling device will be checked daily (every 24 hours) and initialed in the residents MAR .The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision .After an elopement .the Resident Incident/Unusual Occurrence report will be completed and reviewed by the inter-disciplinary and behavior symptom management teams .for appropriateness of the care plan, corrective measures and current interventions . On [DATE], Administrator A was notified of an Immediate Jeopardy that began on [DATE] when Resident #103, who was identified as an elopement risk, exited the facility, unbeknownst to facility staff. On [DATE], this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1) Resident #103 no longer resides in the community. 2) On [DATE] Elopement Education was initiated in the Relias platform to include the difference between wander guards and beacon bracelets. As of [DATE] at 4:00 PM, 54 staff of 176 have completed this education. Education must be completed prior to working on [DATE]. 3) On [DATE] the Elopement Policy and Procedure was reviewed by the Administrator, and education was initiated in the Relias platform. As of 4:00 PM on [DATE], 39 staff of 176 have completed this education. Education must be completed prior to working on [DATE]. 4) On [DATE] the community modified the front door system to be locked at all times with key-pad entry. 5) On [DATE] Like residents were assessed by the LMSW to ensure elopement assessment, physician orders, and care plans for each resident were accurate and up to date for appropriate supervision. 6) On [DATE] Like residents had both wander guard and beacon bracelets tested by the DON to ensure proper function with no concerns noted. 7) On [DATE] All egress doors were assessed by the Administrator to ensure proper function with no concerns observed. 8) Beginning [DATE], The Director of Nursing and/or designee will audit the MAR to ensure all wander guard and beacon alarm systems are in place and functional according to Physician order. This audit will be completed daily X12 weeks. Results of the audits will be brought to the QAPI Committee Meeting monthly for review. Any changes to the auditing process will be made by the QAPI Committee. 9) The Administrator is responsible for attaining and maintaining compliance. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for minimal harm that is not Immediate Jeopardy due to the fact that all education had not yet been completed and sustained compliance had not yet been verified by the State Agency.

Based on observation, interview and record review the facility failed to ensure quality of care for 2 of 7 residents (Resident #101 and #104) reviewed for quality of care when, 1.) staff failed to adequately treat a [CONDITION(S)] (urinary tract infection), and identify an acute change in condition following a fall for Resident #101, and 2.) staff failed to coordinate care and monitor Resident #104 for symptoms of [CONDITION(S)] and identify the root cause of multiple falls. This deficient practice resulted in Resident #101 receiving inadequate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] #104 being hospitalized for [CONDITION(S)] due to [CONDITION(S)]. Findings include: Review of an Admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #101's written and faxed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M.) revealed, [MEDICATION(S)] (antibiotic) 250mg po (by mouth) QID (four times a day) x 7 days, Indication: [CONDITION(S)] . Review of Resident #101's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M.) The record indicated that Resident #101 received a total of 7 doses of [MEDICATION(S)] 250mg, instead of the 28 doses that were prescribed. During an interview on 8/09/22 at 4:10 P.M., Licensed Practical Nurse (LPN) F reported that Resident #101's prescription was transcribed incorrectly and that Resident #101 only received 25 % of the prescribed dose of [MEDICATION(S)] for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN F reported that she reviews the facility infections and ensures that the correct antibiotic is prescribed and stated, .it was the correct antibiotic .but I didn't see that the order was entered wrong . Review of Resident #101's Physician's Progress Note dated 6/7/2022 at 13:45 (1:45 P.M.) revealed, .Today she is complaining of lower abdominal pain with dysuria (painful urination) and urinary urgency though it is unknown how long this has been going on for - straight cath (catheter-tube inserted to drain urine) procedure performed with >1000ml return of dark malodorous urine .Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Plan: Check UA (urinalysis-urine test) with culture and sensitivity . Review of Resident #101's lab results for Culture Urine collected on 6/7/22 at 17:56 (5:56 P.M.) revealed, Greater than 100,000 cfu/ml Escherichia coli (bacteria found in feces) . Review of Resident #101's Nurses Note dated 6/8/2022 at 21:46 (9:46 P.M.) revealed, New orders for [MEDICATION(S)] 250 once daily for seven days for [CONDITION(S)]. Review of Resident #101's Physician Note dated 6/9/22 at 13:03 (1:03 P.M.) revealed, .UA with culture and sensitivity was collected and culture grew E. coli which she was started on [MEDICATION(S)] .Plan: UA with culture and sensitivity showed growth of E. coli and started on [MEDICATION(S)] x7 days She has been having bladder scans done routinely in which she is retaining urine anywhere between 300-600 mL and having to be straight cathed. Place Foley catheter and follow-up with urology Additionally encouraged her to drink fluids Review of Resident #101's Nurses Note dated 6/13/22 at 12:43 P.M. revealed, .She continues on ABT (antibiotic) for tx (treatment) [CONDITION(S)], Foley (catheter) is patent draining amber-colored urine. Resident asked how long she has to have the catheter in for and she still has burning pain down there . Review of Resident #101's Nurses Note dated 6/15/22 at 12:38 P.M. revealed, .Recently diagnosed with catheter associated [CONDITION(S)] and continues on antibiotic treatment. Continues to have some confusion noted per staff Review of Resident #101's Nurses Note dated 7/8/22 at 4:16 A.M. revealed, Resident was observed on the floor parallel to bed on her left side. Fall was unwitnessed .Earlier in the shift, resident had small fluid emesis (vomit), yellow in color. Throughout the shift resident had been yelling out i want to go home and be with my husband. At first was easily redirected but became more agitated throughout the evening .When she began yelling more, this writer went into her room and she kept saying get this out and was grabbing for her belly .She continued to yell out random comments that were not making sense, which is also baseline for resident. No injuries were noted as a result of unwitnessed fall. Doctor was contacted, new orders for labs and u/a with CNS (culture and sensistvity), encourage fluids . Review of Resident #101's Nurses Note dated 7/8/2022 at 16:39 (4:39 P.M.) revealed, Abdominal flat plate (x-ray) completed, UA obtained, cbc/cmp (blood work) drawn awaiting pickup. Resident continues to speak incoherently, is clammy and lethargic. She has not eaten or drank nearly anything this day . Review of Resident #101's Nurses Note dated 7/8/2022 at 18:25 (6:25 P.M.) revealed, Covid antigen test given d/t (due to) displaying s/s (signs symptoms) covid i.e. (for example) perspiration, change in LOC (level of consciousness), reduced appetite and output. Results are negative although resident has had positive test within last 90 days. Review of Resident #101's Nurses Note dated 7/9/2022 at 8:44 A.M. revealed, Resident was sent out to (hospital) because of condition change. was lethargic, slurred speech but vital (sic) were within the normal range . Review of Resident #101's Hospital Records admitted [DATE] at 11:25 A.M. - discharge date [DATE] revealed, .Chief complaint: possible stroke .brought in by EMS (emergency medical services) from SNF (skilled nursing facility) after a fall a few days ago, and suspected stroke with last known normal three days ago .Per husband She has been complaining of feeling cold and burning with urination .ED (emergency department) course: with stroke code called on arrival . UA with pyuria (pus in urine from infection), positive bacteria and leukocyte esterase (test that indicates white blood cells in the urine). CT head and neck with and without contrast was done found to have P2 occlusion (where the blockage is located in the brain) .with associated moderate size right occipital lobe and posterior - inferior temporal lobe infarct (blockage) .Neurosurgery (brain surgeon) was consulted from ED and recommended no surgical intervention as it likely already completely infarct . Neurological: both eyes deviated to right, with left hemi neglect, left upper extremity and left lower extremity paralyzed .Impression and plan: acute [CONDITION(S)] with devastating right occipital and temporal infarct .Metabolic [CONDITION(S)] (brain damage) due to multiple infectious sources . [CONDITION(S)] - recent urinary retention .[CONDITION(S)] (life threatening condition due to infection) .likely due to combination of above .ED course: .She has right eye deviation and some weakness on the right .no intervention is planned at this time as this does not appear amendable as she already completely infarcted . Review of Resident #101's lab results for Culture Urine collected on 7/8/22 at 19:46 (7:46 P.M.) revealed, Greater than 100,000 cfu/ml Escherichia coli, Greater than 100,000 cfu/ml Enterococcus group D (bacteria that is difficult to treat) . This result was final on 7/11/22, after Resident #101 was already in the hospital. Review of Resident #101's Hospice Records revealed, .admitted [DATE] .Had fall, and stroke like symptoms. brought to (Hospital) and found to have had a stroke/Pyuria (pus in urine)/[CONDITION(S)] .date of death : 7/13/22 at 4:10 A.M During an interview on 8/11/22 at 5:24 P.M., Registered Nurse (RN) Q reported that Resident #101 had been been very anxious and agitated during the evening hours on 7/7/22 and stated, .this was not normal for her .she was calling out a lot .she had vomited earlier . RN Q reported that Resident #101 fell later that night, at about 1:30 A.M. (7/8/22), but had no obvious injuries and neurological checks (neuros) were all normal. RN Q reported that Resident #101 then began complaining that her stomach hurt and she had vomited again, so the provider ordered and x-ray, UA and [MEDICATION(S)] (anti-nausea medication). RN Q reported that she had informed the day shift nurse LPN S of Resident #101's status. During a phone interview on 8/9/22 at 1:22 P.M., LPN S reported that on 7/8/22 Resident #101 was becoming more lethargic throughout the day, was not at her baseline for mental status, her response was slow, unable to answer questions and stated, .in report (RN Q) told me that the on-call provider didn't want to send her out to ER (emergency room ) .so I gave report that she was not acting normal but that the MD (medical doctor) did not want to send her out .even though she was acting abnormal . LPN S reported that she thought that she had notified NP I that Resident #101 was not acting normal during her shift (day shift). During an interview on 8/11/22 at 3:03 P.M., NP I reported that she was in the facility most of the day on 7/8/22 and does not remember being notified about Resident #101's change of condition. During an interview on 8/9/22 at 3:45 P.M. DON was unable to locate Resident #101's fall report and subsequent neurological assessments (neuro's) in the medical record. On 8/10/22 at 11:04 A.M., DON reported that Resident #101's fall report and neuro's from 7/8/22 were located in the ADON (Assistant Director of Nursing) office. DON reported that normally neurological assessments are performed every 15 minutes x 1 hour, then every 30 minutes x 1 hour, then every 1 hour x 4 hours, then every 4 hours x 24 hours, and lastly every shift until 72 hours has past following an unwitnessed fall and stated, .(Resident #101's) were only completed through 6:15 A.M. (5 hours after the fall) .I will say that it's not the way I would have liked it to be done . DON reported that the incomplete neurological assessments were supposed to be done by LPN S and stated, .she no longer works here .and will not call us back . DON reported that based on documentation, that Resident #101 was at her baseline until 7/9/22 when she was sent to the hospital due to a change of condition. Review of Resident #101's Neuro's revealed that a full neurological assessment was completed in 4 of 16 opportunities and there were no neurological assessments documented after 6:15 A.M. on 7/8/22. During an interview on 8/10/22 at 12:37 P.M., Certified Nursing Assistant (CNA) L reported that she was assigned to Resident #101 on 7/8/22 day shift along with LPN S and stated, .I didn't know that (Resident #101) had fallen during the night .I told (LPN S) that (Resident #101) wasn't responding to me her face was droopy .she was just laying there doing nothing .clammy . CNA L reported that LPN S refused to check on Resident #101 that day, so she notified another nurse (LPN O) about her concerns. CNA L reported that a couple days later Resident #101 was sent to the hospital. CNA L expressed her concerns about LPN S's neglectful actions to the DON, and as a result CNA L's contract was ended. During an interview on 8/10/22 at 1:09 P.M., LPN O reported that on 7/8/22 day shift, she worked with LPN S, and during report they were notified that Resident #101 had fallen during the night. LPN S was assigned to Resident #101 that day. LPN O reported that CNA L came to her with concerns about Resident #101 and stated, .she said that (Resident #101) didn't seem like herself .and that (LPN S) had refused to listen to her concerns . LPN O reported that she asked LPN S to assess Resident #101, but LPN S said that there was nothing more that she could do. LPN O reported that she felt uneasy about the situation, but didn't know what to do. LPN O reported that Resident #101 was having clear stroke-like symptoms and stated, .she had a fixed gaze .didn't respond to me .normally she knew me .she didn't even know that I was there . The next day Resident #101's condition had gotten worse; LPN O reported that she took it upon herself to call 911 and notify the physician. LPN O reported that when she notified the provider, they were unaware of any previous concern. LPN O reported that she reported her concerns to the ADON and DON regarding LPN S's neglectful actions, and as a result her contract was ended. During an interview on 8/10/22 at 3:14 P.M., LPN T reported that Resident #101 was very confused, agitated, and calling out during the evening hours on 7/7/22 and then fell after midnight. LPN I reported that Resident #101's change of condition began prior to the fall, but then worsened the next day and stated, .she was a lot less responsive . During an interview on 8/10/22 at 3:24 P.M., LPN P worked night shift on 7/8/22 and reported that Resident #101 normally talked a lot and stated, .she wouldn't talk that night .I just thought she was tired from the night before . LPN P reported that she did not contact a physician regarding Resident #101's condition and stated, .it was not a concern for me . During an interview on 8/10/22 at 1:45 P.M., ADON reported that she was notified on 7/8/22 in the middle of the night that Resident #101 had fallen and did not have any injuries. ADON reported that she was not made aware that Resident #101 had vomited or was lethargic, until 7/9/22 when the resident was sent to the hospital. ADON reported that a CNA had reported to her today that they had repeatedly told LPN S that Resident #101 was not acting right on 7/8/22, but that LPN S refused to do anything about it. ADON reported that the on-call service did not receive any calls on 7/8/22, except for the call reporting that Resident #101 had fallen. Resident #104 Review of an Admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #104's Hospital Summary dated 7/6/22 revealed, .presented due to lethargy .He is significantly below his normal function. He spiked a fever at nursing home. He was found to have a [CONDITION(S)] here in the ED (emergency department) and later found to be bacteremic (septic) from E. coli Assessment and plan: .blood cultures grew E. coli . Review of Resident #104's Physician Note dated 7/7/22 at 4:00 P.M. revealed, .Recently admitted to (name omitted) hospital for [CONDITION(S)] from [CONDITION(S)], AKI (acute kidney injury) and altered mental status - u/a (urinalysis) grew ecoli, treated with antibiotics, rehydrated with IV fluids and renal function improved . Review of Resident #104's Nurses Note dated 7/3/2022 at 11:07 A.M. revealed, Resident had a sudden change in condition this morning .BP (blood pressure) dropped to 69/53 .Resident wasn't able to swallow or eat anything. Leaning over to the left side drastically. Felt warm to touch .Resident wasn't responding to touch or talk. resident loves to eat and wasn't able to do that this morning. Called on call Provider .instructed to send to ER for eval and Tx (treat) d/t [CONDITION(S)] (low BP), Non-responsive, not swallowing, choking, leaning drastically to the left side . During an interview on 8/11/22 at 3:49 P.M., regarding Resident #104's multiple falls and [CONDITION(S)]/[CONDITION(S)] diagnosis. NP I reported that the nursing staff had notified her on 6/16/22 that Resident #104 had dark urine and she ordered to push fluids from 6/17/22-6/27/22 and stated, .if the nurses don't tell me that it did not improve, I would not know . NP I stated, .had I been told at that time that (Resident #104) had fallen 4 times in the prior 2 weeks, I would have suspected a [CONDITION(S)] and ordered a UA . Review of Resident #104's Physician Communication Note dated 6/16/2022 at 18:13 (6:13 P.M.) revealed, Resident has dark urine with large amount of sediment and a fowl odor. He has no fever and is not acting unusual. Reported to NP . Review of Resident #104's Fall Reports from the past 60 days indicated: 6/27/22 at 5:44 A.M.-unwitnessed fall, found on floor next to bed 6/22/22 at 1:40 A.M.-unwitnessed fall, found on floor next to bed 6/19/22 at 2:15 P.M.-unwitnessed fall, found on floor next to bed 6/10/22 at 2:52 A.M.-unwitnessed fall, found on floor next to bed 6/9/22 at 8:40 P.M.-unwitnessed fall, found on floor next to bed 6/5/22 at 4:15 A.M.-unwitnessed fall, found on floor next to bed 6/4/22 at 1:15 P.M.-unwitnessed fall, found on floor next to bed During an interview on 8/11/22 at 5:12 P.M., DON reported that the ADON typically tracked falls and would identify a trend related to repeated falls and [CONDITION(S)]'s. DON reported that during the time that Resident #104 had been falling frequently we did not have a ADON, and there was an interim Unit Manager that was supposed to be doing it. This surveyor requested documentation and or communication notes related to identified concerns with the frequency of Resident #104's falls and/or the correlation with symptoms of [CONDITION(S)]. No documentation was received.

There are two (2) Deficient Practice Statements (DPS) for this citation. DPS #1 Based on observation, interview, and record review, the facility failed to 1) fully implement the facility's Covid-19 Infection Control policy to prevent the spread of Covid-19, 2) ensure staff wore the appropriate recommended PPE (Personal Protective Equipment) according to their vaccination status, 3) ensure appropriate PPE was worn in an identified positive Covid-19 resident's room, 4) ensure staff wore PPE appropriately, and 5) follow Transmission-Based Isolation Precautions during an outbreak with a Community level at 22.16% for 8 of 10 residents (R102, R103, R104, R105, R107, R108, R109, and R110) reviewed for infection control, resulting in an immediate jeopardy, when the facility did not prevent the spread of COVID-19 with increased likelihood for serious harm, injury and/or death. Findings include: On 5/26/2022 at 11:56 AM, the Nursing Home Administrator was verbally notified and received written notification of the Immediate Jeopardy (IJ) that began on 5/24/2022, due to the facility's failure to implement infection control for the facility COVID-19 outbreak and the following was verified on 5/27/2022. 1. Residents residing in the facility were tested for C0V1D-19 on 05/26/2022 as part of outbreak testing. Seven (7) total residents were positive as of 05/26. Outbreak testing will be conducted again on 05/30/22. All staff are testing twice weekly. 2. Residents residing in the facility have the potential to be affected by this deficient practice. All residents have been re-tested as of 05/26 with a total of 7 positive cases identified. 3. Staff who are not fully vaccinated with an approved exemption were removed from the building by 1:00PM on 05/26/22. These staff will not be permitted to work until an exemption is accepted or they are fully vaccinated. All staff who are not fully vaccinated were contacted in person or via phone and notified of requirement for vaccination and/or exemption. The Administrator will track vaccination and/or exemption status daily to monitor regulation for staffing within the building, beginning 05/26/22. 4. A one-time audit was conducted by the Administrator on 05/26/22 at 12:34 PM to ensure those who are not fully vaccinated, but have an approved exemption were wearing an N95 mask. The Director of Nursing and/or Designee will conduct an audit of employees, 5 times weekly to ensure any unvaccinated staff with exemptions are wearing N95 masks. Auditing began on 05/26/22, will be completed across shifts, and will be performed by the on-call Nurse Manager when not completed by the DON. 5. A one-time audit will be conducted by 2:00PM on 05/26/22 to ensure residents on COVID-19 isolation have the appropriate signage to indicate transmission-based precautions. 6. The facility policy on Airborne/ Droplet/ Contact Isolation, Infection Prevention and Control Program, Precautions and Isolation, Donning and Doffing PPE will be reviewed by the Administrator and Director of Nursing on 05/26/22. Education for all facility staff, and contract Physicians was initiated immediately, and no staff will be allowed to work prior to completion of this education. As of 3:50 PM on 5/26/22, 38 of 117 staff have completed the education. 7. The Director of Nursing and/or Designee will conduct an audit of residents on isolation 5 times per week to ensure appropriate equipment, PPE, signage and documentation are in place per policy. The Director of Nursing and/or Designee will conduct an audit of employees, 5 times weekly to ensure any unvaccinated staff with exemptions are wearing N95 masks. The Director of Nursing and/or Designee will conduct an audit of resident care, 5 times weekly to ensure any staff are utilizing appropriate PPE for residents on isolation. Results of these audits will be brought to the Quality Assurance Performance Improvement Committee monthly for review. Any changes to the auditing process will be determined by this Committee. The Administrator will be responsible to attain and maintain compliance. Although the immediate jeopardy was removed as of 5/27/2022, the facility remained out of compliance at a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy since not all facility staff have received education, fully vaccination/exemption status, and sustained compliance that had not been verified by the State Agency. Findings include: Upon facility entry on 5/24/2022 at 12:07 PM with notification from Assistant Director of Nursing (ADON) C there were three (3) residents positive with the Covid-19 virus. Resident 102 (R102) who was not vaccinated, R103 who was vaccinated, and R104 who was vaccinated and the roommate of R103 and was on quarantine because roommate status. During an interview on 5/24/22 at 12:53 PM, ADON C stated All visitors must test weekly if they want to come in to visit someone. It is part of the screening process. Everyone that comes through the front door must be screened which includes the daily questionnaire and temperature. Temperatures are taken during the daily screening for anyone that comes in the facility. Whether it is staff, visitors, or someone visiting the Administrator. The receptionist and the people that fill in for her, including nurses know that everyone coming through the doors have to be screened. Weekly screening includes Covid-19 testing. According to the Centers for Medicare and Medicaid memo QSO-20-39-NH revised 3/10/22, Visitor Testing and Vaccination: While not required, we encourage facilities in counties with substantial or high levels of community transmission to offer testing to visitors, if feasible. If facilities do not offer testing, they should encourage visitors to be tested on their own before coming to the facility (e.g., within 2-3 days). CMS strongly encourages all visitors to become vaccinated and facilities should educate and also encourage visitors to become vaccinated. Visitor testing and vaccination can help prevent the spread of COVID-19 and facilities may ask about a visitors ' vaccination status, however, visitors are not required to be tested or vaccinated (or show proof of such) as a condition of visitation. If the visitor declines to disclose their vaccination status, the visitor should wear a face coveringor mask at all times. During an interview and record review on 5/25/2022 at 1:36 PM, DON B stated, Centers for Disease Control (CDC) as of 5/18/2022 states our Community Transmission Rate is Medium at 22.16%. As of April 19-May 5, 2022, our County Positivity Rate is in the RED at 22.59%. DON B stated, Per policy, staff not vaccinated and temporarily delayed should wear a N95 mask unless physically not able to wear a N95. I am not aware of any changes in ventilation that have been done in resident rooms to filtrate air. R102 According to the Minimum Data Set (MDS) dated [DATE], R102 was unable to complete her BIMS (Brief Interview Mental Status), with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R102's Immunization Record did not have the resident receiving any Covid-19 vaccinations. Review of R102's eINTERACT Change in Condition Evaluation reported on 5/23/2022 the resident tested positive for Covid-19. Review of R102's Order Summary reported the resident was placed on Droplet Transmission-Based Precautions on 4/22/2022 and more recently on 5/24/2022. Review of R102's Progress Note 5/23/2022 13:19 (1:19 PM) reported the resident tested positive for Covid-19 and placed on airborne precautions and isolation precautions Review of R102's Care Plan 5/23/2022 reported the resident tested positive for Covid-19 and was placed on Droplet Transmission-Based Precautions. During an observation on 5/24/2022 at 1:56 PM R102's door had signage stating, DOORS MUST REMAIN CLOSED MUST WEAR N95 BEFORE YOU ENTER THROUGH THESE DOORS Droplet Precautions CDC PPE when caring for patients with Confirmed or Suspected Covid-19. Isolation cart outside of room in hallway. Observed on 5/25/2022 at 10:38 AM R102's door had signage stating, DOORS MUST REMAIN CLOSED MUST WEAR N95 BEFORE YOU ENTER THROUGH THESE DOORS Droplet Precautions CDC PPE when caring for patients with Confirmed or Suspected Covid-19. Isolation cart outside of room in hallway. During an observation and interview on 5/25/2022 at 1:30 PM Medical Doctors (MD) S and T donned N95 mask, gown, and gloves before entering R102's room. They did not don a face shield, nor did they perform hand hygiene before donning gloves. On R102's door was signage instructing all that entered to wear Droplet Precautions PPE. MD S stated, We wore a face shield and threw them in the garbage before we exited the room. Surveyor observed all garbage cans in R102's room immediately after MDs left the room and before any other person entered the room with no face shields to be found. During an observation and interview on 5/25/2022 at 1:32 PM LPN P stated, When entering a Covid-19 positive room, you should wear a gown, gloves, and a N95 mask. Hand hygiene should be done before donning gloves and after taking them off. Staff should wear a face shield and clean it after you exit the room. I've not been told what to clean face shields with, I just assumed what was on the isolation cart was good enough. Observed on the isolation cart outside of R102's room was a red top canister of Sani Cloth Plus wipes. During an observation and interview on 5/25/2022 at 3:22 PM red top Sani-Cloth Plus wipes were on the isolation cart outside of R102's room. Alcohol prep wipes were in the cart drawers. LPN P stated, I don't know what the dry time is for disinfectant wipes. According to the Environmental Protection Agency, Sani-Cloth Plus is effective in deactivation of the [CONDITION(S)]-CoV-2 (COVID-19) virus after three mintues of contact time on hard, nonporous surfaces. During an observation and interview on 5/25/2022 at 1:35 PM CNA WW stated, I am assigned to this hall today (West unit) but I help out where needed. I have entered (R102's) room today. I am not fully vaccinated. I am wearing a surgical mask while working on the halls and when I enter a Covid-19 positive room I wear a N95 mask. Observed CNA WW wearing a blue surgical mask while working in the facility. During an observation and interview on 5/27/2022 at 11:30 AM R102 had Droplet Transmission-Based Isolation Precautions signage on her door with the door wide open. Sign on door stated, DOORS MUST REMAIN CLOSED LPN LL stated, (R102) is Covid-19 positive and her door should be kept closed for infection control. Observed Unit Manager (UM) G walking by R102 door while it was open. UM G stated, (R102's) door should be closed and continued to walk by without making an attempt to close the door. R103 According to the Minimum Data Set (MDS) dated [DATE], R103 scored 6/15 (cognitively impaired) on her BIMS (Brief Interview Mental Status), required extensive assistance for bed mobility, transfers, and toileting, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R103's Care Plan revealed R103 received Covid-19 vaccinations on 1/4/2021, 2/1/2021, and a booster 11/30/2021. Review of R103's Progress Note 5/23/2022 15:30 (3:30 PM) reported resident tested positive for Covid-19. Review of R103's Care Plan 5/23/2022 reported the resident was on Droplet Transmission-Based Precautions. Review of R103's Order Summary reported Droplet Transmission-Based Precautions were ordered on 5/24/2022. During an observation on 5/24/2022 at 2:54 PM R103 and R104 had Contact Isolation (droplet TBP was ordered) precautions signage on door. A face shield was hanging on door facing hallway. Outside of door in hallway was an isolation cart. During an interview on 5/24/2022 at 2:56 PM LPN L stated, R103 has tested positive for Covid-19. She is on Contact Precautions. Her roommate R104 is quarantined with her. She has not tested positive for the virus. During an observation and interview on 5/25/2022 at 3:43 there was Contact Precautions signage on door of R102 and R104. Medical Doctor (MD) S stated, Why is (R104) in with (R103) if (R104) is not vaccinated? I was told (R103) tested positive. MD S and MD T stated, Residents should be on Droplet Precautions if they are positive for the Covid-19 virus. I do not know why Contact Precaution is on door. That is not correct. During an observation and interview on 5/25/2022 at 3:55 PM LPN E stated, (R103 and R104) are on Airborne Precautions. (R103) is Covid positive. Observed shared door of roommates R103 and R104 having Contact Precautions signage. LPN E stated, Oh my gosh. No, that is not right. It should have Airborne Precautions. During an observation and interview on 5/25/2022 at 3:50 PM Registered Nurse (RN) YY observed with Surveyor the shared door of roommates R103 and R104. RN YY stated (R103) is Covid-19 positive and (R104) is under quarantine because she was (R103's) roommate. The signage says they are on Contact Precautions. They are on Droplet Precautions. It is the same PPE, so it is okay. I clean the face shield with bleach wipes from another cart even though there is Sani-cloth wipes in their isolation cart. I do not know what the dry time is. During an interview on 5/25/2022 at 4:05 PM, DON B stated, Positive Covid-19 residents should not be on Contact Transmission-Based Precautions. They should be on Droplet Precautions. The type of precautions residents is ordered indicates the level of precautions and what PPE to gear up with. Different Transmission-Based Precautions requires different PPE. R104 According to the Minimum Data Set (MDS) dated [DATE], R104 scored 13/15 ( cognitively intact) on her BIMS (Brief Interview Mental Status), required extensive assistance for bed mobility, totally dependent on two persons for transfers and toileting, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R104's Care Plan reported the resident received the Covid-19 Moderna vaccine on 14/2021, 2/1/2021, and a Moderna booster on 11/30/2021. Review of R104's Care Plan 5/23/2022 reported the resident was at increased risk of contracting Covid-19 as her roommate tested positive. R105 According to the Minimum Data Set (MDS) dated [DATE], R105 scored 3/15 (severely cognitively impaired) on his BIMS (Brief Interview Mental Status), required extensive assistance for bed mobility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R105's Immunization Record reported the resident received 1 dose of Covid-19 vaccine on 11/30/2021. Review of R105's eINTERACT Change of Condition Evaluation reported on 5/24/2022 the resident tested positive for Covid-19. Review of R105's Care Plan reported on 5/24/2022 the resident was placed on Droplet Transmission-Based Precautions. Review of R105's Progress Note 5/24/2022 at 1421 (2:21 PM) reported the resident tested positive for Covid-19 and was placed on isolation. During an interview on 5/24/2022 at 2:56 PM, LPN L stated, (R105) tested positive Covid-19 about an hour ago today. When using a face shield, it can be wiped down after use. Observed on 5/24/2022 at 3:02 PM, R105's door with CDC PPE signage on door. No isolation signage to designate what isolation precautions should be used was on door or to entrance of room. An isolation cart was next to door in hallway. Observed on 5/25/2022 at 3:58 PM, R105's door for Transmission-Based Precaution signage. LPN E stated, There is no Transmission-Based Precaution signage on his door. He is Covid positive. You don't know what to do if you don't see it. R107 According to the Minimum Data Set (MDS), R107 scored 15/15 (cognitively intact) on his BIMS (Brief Interview Mental Status), able to make his needs known, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R107's Immunization Record reported the resident received Dose 1 of Moderna Covid-19 vaccine on 4/8/2022. Review of R107's Order Summary reported the resident was placed on Contact Isolation for [CONDITION(S)] 5/17/2022. Observed on 5/25/2022 at 10:30 AM, R107's door did not have Transmission-Based Isolation Precautions signage on door. Review of a list of residents on Transmission-Based Precautions received from DON B on 5/25/2022 via email reported R107 was on Contact Precautions for [CONDITION(S)]. During an interview and record review with Surveyor on 5/25/2022 at 1:36 PM, DON B stated, (R107) has [CONDITION(S)] [CONDITION(S)] bacteremia (in blood) and should be on Contact Transmission-Based Precautions per orders. Observed on 5/27/2022 at 8:48 AM, R107 had both Contact and Droplet Isolation Transmission-Based Precautions on door. Review of R107's Progress Notes 5/21/2022 to 5/31/2022 with no documentation of resident being placed on Contact Transmission-Placed Precautions. R108 According to the Minimum Data Set (MDS) dated [DATE], R108 scored 00/15 his BIMS (Brief Interview Mental Status), able to make his needs known, understood others, required extensive assistance for bed mobility and transfers, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R108's Immunization Record reported on 4/17/2021 the resident received a Dose 2 of the Covid-19 vaccine. No record of previous vaccinations was available. Review of R108's Order Summary reported on 5/10/2022 the resident was placed on Contact Precautions for MSSA Bacteremia. Review pf R108's Care Plan [CONDITION(S)] reported on 5/11/2022 to instruct caregivers to wear disposable gown and gloves during physical contact with resident and to discard in appropriate receptacle and wash hands before leaving room. During an observation on 5/25/2022 at 10:57 AM R108 was in his room sitting in wheelchair. No Transmission-Based Precautions signage was on door. No isolation cart outside of door. Received on 5/25/2022 from DON B a list of residents on transmission-based precautions including R108. During an observation and interview on 5/25/2022 at 11:36 AM LPN E stated, (R108) has [CONDITION(S)] MSSA Bactermia. Twice before someone takes down his Transmission-Based Precautions signage and it has to be put back up. During an interview and record review on 5/25/2022 at 1:36 PM DON B reviewed R108's medical record with Surveyor and stated, (R108) has [CONDITION(S)] MSSA bacteremia (in blood) and is on Contact Transmission-Based Precautions per physician orders. Review of R108's Order Summary reported the resident was placed on Droplet Transmission-Based Precautions on 5/26/2022. Review of R108's Care Plan reported on 5/26/2022 the resident tested positive for Covid-19 and was being put on Droplet Transmission-Based Precautions. Review of R108's Progress Note 5/26/2022 at 11:22 (AM) reported resident tested positive for Covid-19. Review of R108's Progress Not 5/27/2022 at 05:44 (AM) reported currently on droplet precautions for positive COVID. R109 According to the Minimum Data Set (MDS) dated [DATE], R109 scored 3/15 (cognitively impaired) on his BIMS (Brief Interview Mental Status), usually made his needs known, sometimes understood others, required extensive assistance with bed mobility and transfers, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R109's Immunization Record reported the resident had no documentation of receiving any of the Covid-19 vaccines. Review of R109's Care Plan revised on 2/9/2022 reported the resident was at risk for Covid-19 as he had dementia and could not follow distancing rules or made to wear a mask. He was not vaccinated for Covid-19 and was on Isolation Droplet protection from Covid. Review of R109's Order Summary reported on 5/26/2022 the resident was placed on Droplet Transmission-Based Precautions for testing positive for Covid-19. Review of R109's Progress Note 5/26/2022 12:04 (1:04 PM) reported the resident was tested with positive Covid-19 results. Droplet Transmission-Based Precaution initiated. It was noted in a Care Plan for R109 revised 2/9/202, he was not vaccinated for Covid-19 and was on Isolation Droplet protection from Covid with no orders to discontinue. R110 According to the Minimum Data Set (MDS) dated [DATE], R110 scored 8/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status) required extensive assistance for bed mobility and transfers with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R110's electronic medical record Dashboard reported Special Instructions: NOT VACCINATED. Review of R110's Immunization Record had no documentation of receiving any Covid-19 vaccine. Review of R110's Care Plan initiated on 3/9/2022, reported the resident had an increased risk of contracting the COVID-19 disease due to a recent hospital stay, a goal was revised on 3/17/2022 to not have any signs or symptoms of the COVID-19 disease through the review date, and remained in Droplet Isolation per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation and interview on 5/24/2022 at 2:04 PM, R110's door had posted Droplet Isolation Precautions signage. Isolation cart outside of door in hallway. Resident stated she had been in the facility for about 3 months and had no idea her door had Droplet Isolation signage on it. During an observation and interview on 5/24/2022 at 2:12 PM CNA I was wearing a blue surgical mask while providing direct resident cares on East Unit (location of Covid-19 positive residents). CNA I stated, Isolation signage on doors tells staff what PPE to wear when going in the room. During an interview on 5/25/2022 at 10:41 AM CNA WW stated, I am not fully vaccinated. I have only received one dose of the Pfizer Covid-19 vaccinations sometime in April of this year (2022). I do not have a plan to get the second one. It has been up in the air here at the facility whether or not staff needs a second vaccine to be fully vaccinated. I have no plans at this time to have my second vaccination. During an observation and interview on 5/25/2022 at 1:36 PM CNA WW stated, The resident in room [ROOM NUMBER] was admitted today. He is not fully vaccinated and is on Transmission-Based Isolation Precautions. I have gone in his room wearing a surgical mask. During an interview on 5/25/2022 at 11:03 AM LPN E stated, I am not fully vaccinated for Covid-19. I have a medical exemption. During an interview on 5/25/2022 at 12:26 PM, CNA Z walked by LPN P who was the charge nurse of the Suites 18-29 and stated, (CNA H) is on this hall with a trainee, (CNA Z). All staff is to wear a N95 mask due to the Covid-19 outbreak in building. The N95 mask is to be worn over the nose with both straps in place and be fully tightened. I would hope I would notice if a mask were not worn correctly by my staff. Airborne Transmission-Based Isolation Precaution and Droplet Transmission-Based Isolation Precautions signage should be on the door for (R103 & R104). During an observation and interview on 5/25/2022 at 1:25 PM CNA R stated, I have a non-medical religious exemption and am not vaccinated for the Covid-19 virus. I am assigned R102 today and will wear a N95 mask when entering the room. Observed CNA R wearing a blue surgical mask while working in the facility. CNA R stated, I have never been told I had to wear a N95 mask because I was not vaccinated. I have not been wearing a face shield when entering (R102's room). During an interview and record review on 5/25/2022 at 2:30 PM DON B stated, The resident in room [ROOM NUMBER] was admitted ,d+[DATE] (2022). He is not vaccinated for Covid-19 and on Droplet Transmission-Based Isolation Precautions. Any staff entering should be wearing a N95 mask. During an interview on 5/26/2022 at 2:16 PM NHA A stated, I sent Activities ZZ home because she had not completed the vaccine series. During an interview on 5/25/2022 at 3:30 PM Beautician XX wearing a cloth face mask while helping a resident with her hair. Beautician XX stated, I was not told to wear any other face mask. During an interview on 5/26/2022 at 10:56 AM, NHA A stated, Staff that are not fully vaccinated should be wearing an N95 mask and if staff does not have an exemption they should not be working. During an observation and interview on 5/26/2022 at 1:33 PM CNA BBB was conducting staff and visitor Covid-19 testing. She was wearing a N95 mask with the bottom strap hanging loosely under her chin. The bottom of the mask was hanging open to room air. CNA BBB stated, We sure do make sure visitors test especially with the virus flying around in the air. Employees test on Mondays and Thursday. Employees can test any time during their shift. They can come in, start to work and then when they get a moment come test. They can go work on the floor or wherever they are assigned and if they do not hear back from me, they know they are negative. During an interview on 5/26/2022 at 2:16 PM NHA A stated, When wearing a mask, any type of mask, both straps should be worn to keep the mask in place. During an observation on 5/27/2022 at 11:09 AM, Therapy FF was wearing a N95 mask walking with a resident in the West unit who was not wearing a mask. During an observation on 5/27/2022 at 11:39 AM Therapy FF asked UM G if residents had to wear a mask in the hall. UM replied Yes. Therapy replied she had not heard residents had to wear a mask while in the hall. Observed on 5/27/2022 at 11:47 AM Therapy DD walking with a resident in the West unit hallway. Therapy was wearing a surgical mask under a N95 mask while the resident was not wearing a mask at all. During observations and interview on 5/27/2022 at 11:57 AM, UM G stated, Residents should be wearing a mask while out of their room during facility outbreak of Covid-19. I did not notice Therapy DD with unmasked resident walking in hall. Why would staff want to wear a double mask? It was noted the UM walked past Therapy DD and unmasked resident two times in approximately 9 minutes. (11:55 AM -12:00 PM). During an observation and interview on 5/27/2022 at 11:15 AM Family Member Y visiting family with Droplet Isolation Transmission-Based Precautions signage on door, stated, I did not put on a gown or PPE because I did not realize I was supposed to. I did not look at the signage on the room's door. Yesterday, 5/26/2022, and the days before that I came in, I just wore a regular mask; a blue one. I was not asked if I was tested for Covid-19 until today, and staff made me test per the person at the front desk. During an observation and interview on 5/27/2022 at 12:09 PM FM GG entered facility to visit family. FM was wearing a multi-colored non- N95 mask. FM GG stated, I signed in, but no one was at the front desk. There was not a sign stating I had to wear a special mask. Am I in trouble? Surveyor, Corporate W, and FM GG went to front desk and observed the screening log FM had signed in. NHA A came to the desk and stated, The sign that says Ring Bell for Assistance tells visitors what to do. FM GG stated, I did not need assistance. I have been here before. I know where to go. During an observation and interview on 5/27/2022 at 12:16 PM Corporate D was with Surveyor in front lobby. CNA Z entered facility not wearing her N95 mask appropriately with the bottom strap of the mask hanging loose under chin. Nothing was said to CNA Z by Corporate D. Observed on 5/27/2022 at 12:18 PM CNA Z with Physician's Assistant TT and CNA Trainer HH in East unit pantry. CNA Z's was not wearing her N95 mask appropriately with the bottom strap of the mask hanging loose under her chin. Nothing was said to CNA Z by the other staff. Observed on 5/27/2022 at 12:19 PM Registered Nurse (RN) AA was at the East unit nurse's station with two (2) other nurses. RN AA was not wearing her N95 mask appropriately with a blue surgical mask on and her N95 mask hanging off her right ear. Observed on 5/27/2022 at 12:23 PM CNA Z was passing waters on East unit Suites 18-29 where there were Covid-19 residents. CNA Z was not wearing her N95 mask appropriately with the bottom strap hanging loosely under her chin. Also, on the unit working with CNA Z was Licensed Practical Nurse (LPN) P and CNA HH. Neither staff said anything to CNA Z. Observed CNA Z not wearing her N95 appropriately with the bottom strap hanging loosely under her chin on 5/27/2022 at: -12:24 PM CNA Z while entering room [ROOM NUMBER] -12:25 placing waters on isolation cart for room [ROOM NUMBER] and R105's isolation cart During an observation on 5/27/2022 at 12:32 PM CNA Z entered East Hall Suites 18-29 not wearing her N95 mask appropriately with the bottom strap hanging loosely under her chin. CNA Z entered room [ROOM NUMBER]. There was Airborne Transmission-Based Isolation Precautions signage on door. During an observation on 5/27/2022 at 12:44 PM CNA Z stated, I had just come in from outside when you saw me walking into the front lobby. I was wearing the mask properly. Then, when I realized I did not have it on right and I fixed it. I have been trained on how to use PPE especially this unit because it has Covid-19 positive in this hall (East Hall Suites 18-29). During an observation on 5/27/2022 at 12:56 PM CNA Z donned gown and gloves without performing hand hygiene, room [ROOM NUMBER] with a Transmission-Based Isolation Precautions signage on door to deliver meal trays. CNA HH handed her meals from meal cart and did not perform hand hygiene between trays for the three residents of the room. During an observation on 5/27/2022 at 1:02 PM CNA Z donned a gown and gloves without performing hand hygiene, was wearing a N95 , donned face shield and entered R105's room to assist him in eating his lunch. During an observation on 5/27/2022 at 12:39 PM CNA HH donned gown, gloves, N95, and face shield to enter room [ROOM NUMBER]. CNA Z handed CNA HH meal trays. Droplet Isolation Precautions, PPE use, and Doors Must Remain Closed signage was on the door. Isolation cart outside of room in hall. No hand hygiene was performed before donning PPE by CNA HH or CNA Z before or after handling meal trays. During an observation on 5/27/2022 at 12:41 PM LPN P donned gown, face shield, and gloves without performing hand hygiene. She then entered R103 and R104's room to administer medications and deliver waters. Upon exiting the room, LPN P left door open. It was noted R103 was Covid-19 positive and Transmission-Based Isolation Precautions signage along with a sign stating the door must be closed was on the resident's door. During an observation and interview on 5/27/2022 at 1:04 PM was observed on East Hall Suites 18-29 passing meal trays. CNA HH stated, Hand hygiene should be done prior to and exit of each resident room. Hand hygiene should be done between meal trays, using sanitizer before handling the next tray. I think I used sanitizer each time I handled a tray. After exiting each room, I washed my hands with soap and water. I did enter some of the Transmission-Based Isolation Precautions rooms and Covid-19 positive rooms. No washing hands with soap and water was observed of CNA HH during this time. During an observation on 5/27/2022 at 1:06 PM, Registered Nurse (RN) AA was noted wearing an N95 ma [TRUNCATED]

Based on observation, interview, and record review, the facility failed to: 1.) implement the facility policy for tracking and securely documenting the COVID-19 vaccination status for 9 of 179 staff members reviewed for COVID-19 vaccination status and 2.) implement additional precautions for personal protective equipment (PPE) use for COVID-19 vaccine exempt staff in accordance facility policy for COVID-19 , resulting in the potential to affect all 86 residents who resided in the facility. Findings include: At the time of survey from 5/24/22-6/1/22, a total of 7 resident had tested positive for COVID-19 whom did not require hospitalization at that time. Upon survey entrance, 5/24/2022 at 12:15 PM, this surveyor requested the Staff Vaccination Matrix from Assistant Director of Nursing (ADON) C. ADON replied the Nursing Home Administrator (NHA A) and Director of Nursing (DON) B were at a conference and she did not know how to access the information. Review of facility's Centers for Disease Control (CDC) NHSN (National Healthcare Safety Network) data (report header): 5/15/2022 at 71.3% vaccination rate. During an interview on 5/24/22 at 3:35 PM, NHA A stated The previous ICP (Infection Control Preventionist) quit three (3) weeks ago. The MDS(Minimum Data Set) Coordinator will be working on Infection Control and COVID-19 with (Director of Nursing (DON) B). Documents requested to the NHA A by the end of the day, 5/24/2022, included the Staff COVID-19 Vaccination Matrix for staff and residents, were not received by end of day 5/24/2022 at 4:30 PM. During an interview on 5/25/2022 at 8:46 AM, DON B stated, I am the certified Infection Control Preventionist (ICP). Another nurse and I have been doing the COVID-19 information. Resident vaccination rate is 87%. Human Resources (HR) V is tracking the staff Covid-19 immunizations. I have all the information just not together. Review of facility's Staff Vaccination Matrix that included recent percentage of staff who are fully vaccinated: 5/24/2022 at 83%. Review of facility Staff Vaccination Matrix on 5/25/2022 at 10:00 AM revealed Certified Nursing Assistant (CNA) WW was documented as having Provided as her vaccination status. The Matrix did not include support staff including the facility's Medical Providers, Beauticians, Podiatry, Dental, or contract/agency staff. Requested from DON B and NHA A the facility's completed Staff Vaccination Matrix by end of day. The Staff COVID-19 Vaccination Matrix was not received by end of day 5/25/2022 at 4:30 PM. As of 5/26/2022 at 10:00 AM the Surveyor had not yet received the facility's Staff Vaccination Matrix. Requested on 5/26/2022 at 10:00 AM of NHA A the Staff Vaccination Matrix by end of day. During an interview and record review on 5/26/2022 at 10:42 AM with DON B of the facility's Staff Vaccination Matrix stated, Provided means vaccination dates were not updated on the list by HR. (CNA WW) is fully vaccinated. As far as (Activities ZZ) in progress on her vaccination status, I do not know what that means. During an interview and record review on 5/26/2022 at 10:56 AM NHA A stated, A lot of staff were vaccinated here at the facility and their vaccination dates did not copy over to MICR (Michigan Care Improvement Registry-Michigan Immunization Registry). I am putting together the exemptions and MICR vaccination records for staff. HR has been monitoring and keep the staff COVID-19 records. I did not pull (Activities ZZ) because I thought she submitted an exemption. In Progress on the Staff Vaccination Log means staff is getting an exemption. (CNA WW) did not want the COVID-19 vaccine and was going to submit an exemption. Reviewed CNA WW MICR dated 2/4/2022 which indicated she received the first dose of the Pfizer vaccine. It was noted on the form CNA WW was past due for the second dose of the vaccine. NHA A stated, I did not know (CNA WW) was not fully vaccinated. All staff vaccination status runs through HR. During an interview on 5/25/2022 at 10:41 AM CNA WW stated, I am not fully vaccinated. I have only received one dose of the Pfizer Covid-19 vaccinations sometime in April of this year (2022). I do not have a plan to get the second one. It has been up in the air here at the facility whether or not staff needs a second vaccine to be fully vaccinated. I have no plans at this time to have my second vaccination. During an interview on 5/26/2022 at 11:30 AM, Human Resource (HR) U stated, Staff COVID-19 vaccination information is tracked in the facility's electronic data system. Weekly reports are shared with (NHA A and DON B). I only pull the report and send it out weekly. I do not monitor it. That is done by (HR V). That is why the report is sent out weekly so the teams would know their staff's status. (HR V) oversees staff COVID-19 vaccine exemptions. The exemptions are included in the weekly report I send out. That is why the reports are sent out so the administration can monitor their staff. During an interview on 5/26/2022 at 12:07 PM, HR V stated, I am part of the group that processes the staff COVID-19 exemptions and am aware of those that have exemptions. This information is put in the HR data base. The exemption status is brought to the attention of the Administration weekly. Staff is not allowed to start work at the facility unless they meet the requirement of having an approved exemption or proof of vaccination. HR would follow up with (NHA A) to make sure the requirements with CMS are followed to be able to work. HR is aware there is an issue with current employees and their vaccination status. During an interview on 5/26/2022 at 2:16 PM, NHA A stated, I sent (Activities ZZ) home because she had not completed the vaccine series. I do not know if she was vaccinated. During an interview on 5/27/2022 at 9:23 AM, NHA A stated, I am ultimately responsible for the facility's staff vaccination status. I receive weekly a report from HR to follow-up on. During this interview with NHA A the Surveyor requested: -Staff vaccination matrix -Staff proof-of-vaccination status, medical and non-medical exemptions, temporary delays NHA A stated, (DON B) will be handling this portion of survey and she is currently training a new Unit Manager. I don't have the staff vaccination matrix. -Resident vaccination matrix -List of contracted companies -list of contracted staff while survey in progress -list of Covid-19+ staff and residents including hospitalization s and death in the last 4 weeks. During an interview and record review on 5/27/2022 at 10:50 AM, DON B stated, I should have the staff vaccination matrix done by noon today and should have the Providers status soon. Surveyor requested of DON B and NHA A the facility's Resident Vaccination Matrix, Staff Vaccination Matrix including fully vaccinated, exemption both medical and non-medical, temporary delayed vaccinated, total number of staff vaccinated, total number fully or partially vaccinated, number of Residents COVID-19 positive as of 10:00 AM on 5/27/2022 in which DON B stated, There are a total of 7 residents that have tested positive. In the last four weeks there are no staff that are COVID-19 positive. During an interview on 5/27/2022 at 10:59 AM, NHA A was asked to provide the documents necessary to complete the COVID-19 Vaccine Mandate portion of the survey. Surveyor stated documents should be in her possession by 12:00 PM today, 5/27/2022. NHA A made no comment. Review of facility's Staff Covid-19 Vaccination Matrix revealed on 6/1/2022 at 1:00 PM copy of letters from HR V reporting an exemption was to be granted for seven staff. The letters did not include identifying name of staff or the type of exemption (medical or religous). On two letters on the top of the letter was hand-written Medical Exemption for Licensed Practical Nurse (LPN) E and LPN OO. No medical application was available for review. It is noted these two letters were the same as the letters sent to the seven staff that an exemption had been given. During an interview and record review on 6/1/2022 at 1:00 PM with DON B regarding the Staff Vaccination Matrix revealed two CNA staff had received only one dose of a 2 dose series of the COVID-19 vaccine including CNA WW that was said to have been fully vaccinated by NHA A. Activities ZZ had received one dose of COVID-19 vaccine of a 2 dose series in January 2022 with a dietary staff receiving one dose of a 2 dose series on 9/25/2021. DON B stated, There are no plans that I know of at this time for staff to complete their vaccination status. They may have to start over. I do not know at this time. Review of the facility Staff Vaccination Matrix on 5/27/2022 1:00 PM revealed, Total Number of Staff: 179. Partially vaccinated staff: 3, completely vaccinated staff: 168, pending exemption: 2, granted exemption: 6, temporary delay/new hire: 0, # not vaccinated without exemption/delay: 0. During an interview and record review on 6/1/2022 at 4:22 PM of the Resident Vaccination Matrix with DON B regarding resident immunization refusal for vaccinations, DON B stated, The refusals are either in their chart or with the ADON. I will have to go look it up. Noted refusals not obtained by DON B by end of survey 6/1/2022 at 5:30 PM. Resident with no immunizations were Residents #102, #109, and #110. During an interview and record review on 6/1/2022 at 4:26 PM Surveyor and NHA A reviewed generic letters from HR with two letters indicating in handwriting Medical Exemptions for LPNs E and OO with no application and/or reason for specific exemption. NHA A stated, I did not know these staff had medical exemptions. During an interview on 6/1/2022 at 4:26 PM NHA A stated, I know I was to have staff exemption letters completed and prepared by this morning (6/1/2022) and they are not. I am ultimately responsible for everything that goes on this facility. As of survey exit on 6/1/2022 at 5:30 PM the facility's Staff Vaccination Matrix and staff exemptions were not received/completed. Review of facility policy COVID-19 Vaccination Policy December 5, 2021 revealed, POLICY STATEMENT On November 5, 2021, the Centers for Medicare & Medicaid Services (CMS), an agency within the U.S. Department of Health and Human Services, issued an Interim Final Rule (IFR) on COVID-19 Health Care Staff Vaccination that requires covered facilities to ensure that all staff are fully vaccinated against COVID-19. (Name of facility) has adopted this policy to promote the health and safety of our staff and residents. This policy is based on the IFR and guidance provided by CMS. It is designed, and will be interpreted and applied, to comply with all applicable laws, regulations, and standards. (Name of facility) requires all staff to be fully vaccinated against COVID-19 by January 4 unless they receive a disability or religious accommodation pursuant to federal civil rights law. All staff are required to report their vaccination status to (Name of facility) by December 6 and update their status thereafter if necessary . Staff members must Obtain the first dose of either a single-dose or two-dose vaccine by December 6, 2021; Obtain the second dose of a two-dose vaccine by January 4, 2022 . Staff members may request a reasonable accommodation from this mandatory vaccination policy if they believe individual medical or religious reasons interfere with their compliance .

This citation pertains to intake MI 252 Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement and ensure safety in one (1) resident (R101) of five (5) residents reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 7/30/2021 at approximately 7:00 PM, R101, exited the facility, unbeknownst to facility staff, and was seen in the on-campus apartment dining room at approximately 7:25 PM by campus security who was unaware R101 was a resident of the nursing home and did not intervene. At 7:45 PM campus security again saw R101 outside in the apartment parking in a wheelchair heading towards a side street that led to a main road. R101 was then returned to the facility by campus security. This deficient practice placed seven (7) residents, identified as At Risk for Elopement, at risk for serious harm, injury, and/or death. Findings include: Review of the facility's .Facility Assessment date unknown, revealed, The center is separated into two units. The Short-Term Rehabilitation unit on the West end of the building . The Long-Term Care (LTC) Unit on the East side of the building . Review of an entity reported incident MI-FRI ID: 624 revealed, .Date of Alleged Event: 07/30/2021 Time: 07:35 PM .Incident Summary (R101) was observed in the (name of apartment complex) parking lot when approached by a security staff member who asked where he lived and (R101) pointed to the (name of facility) and he was assisted back to the (name of facility) building where he was met by a staff member Review of R101's Incident Report #3351 dated 7/30/2021 1935 (7:35 PM) indicated, the Director of Nursing (DON) B stated R101 .was visualized in the front parking lot of (name of apartment complex). He was seen by the Security Officer D. Emily approached R101 and he stated that he was ok and was out exploring .he was oriented to place and person .in a wheelchair .confused .wanderer .recent room change .no notifications found for agencies/people . Review of Security Officer's .Incident Report for R101, dated 7/30/2021 7:45 PM, revealed, .Found resident that I had not see before in (name of apartment complex) dining room. He said he was okay and so I continued my round. Locking doors. Returning to (name of apartment complex) he (referring to R101) was in the front parking lot headed onto [NAME] Street in a wheelchair. I stopped him and he said he was just exploring. Tried to determine what building he was from. He didn't know. Found wander guard on his wrist. I pushed him in the wheelchair trying to retrace his travels. He (R101) indicated he came from the direction of (name of facility) and so we went that way. Soon a staff member came and was relieved we had located their missing resident. According to R101's Minimum Data Set (MDS) dated [DATE], R101 scored 3/15 (severely cognitively impaired) on his BIMS (Brief Interview Mental Status), difficulty communicating some words or finishing thoughts, missed some part/intent of message but comprehended most conversation, indicated he wandered, was not steady and only able to stabilize with staff assistance when moving from seated to standing position, no limitations with range-of-motion (ROM) in his upper and lower extremities and diagnoses including fracture and non-Alzheimer's dementia. During an interview on 8/30/2021 at 3:45 PM, Security D stated, On the night of July 30th (2021) I began my rounds of locking doors at 7:30 PM. When I went into the kitchen (R101) was stopped at the door to kitchen. He was trying to get into the kitchen. He was in a wheelchair. He said he was fine, didn't need any help, he just moved it and had to talk to someone to see if his room was ready. I left him and locked the facility doors. I locked the front door to the apartment complex. For some reason I had to come back to the front desk and needed keys to pull a resident car around. I locked a hallway exit door and went to the garage to get the resident's car. This took me about 20 minutes. I saw (R101) as I pulled into the parking lot. He had exited the front doors and wheeled himself to the end of apartment complex driveway with half of wheelchair on [NAME] Street. His anti-tippers (item attached to the wheelchair to prevent backwards tipping) were stuck in a crack in the driveway. I parked the car and ran to him. One of the resident's family saw him through a window and ran out of the building to help. There were cars driving by and some were trying to pull into the parking lot. They were swerving to miss him. I had to swerve around him when I pulled in to try and not hit him. The resident family member helped me wheel him into the apartment lobby. I asked (R101) where he lived, and he didn't remember. I pushed him back through the dining room which he remembered. He remembered the dining room. A nurse came rushing in and said they were looking for him for 20 minutes. It was apparent they had been looking for him. When a resident's family member and I found him on the street the family member saw the wander guards and asked what it was. I thought it might be a wander guard for the skilled facility. I had never been trained on elopements. I didn't know in the facility there are regulations I had to be aware of. During an interview on 8/31/2021 at 1:47 PM CNA H stated, I was assigned to (R101) the day he eloped. When I got report I was warned he was antsy; he can't stay in one spot. After report call-lights were on and I went to help those residents. When I got done with those residents, my first instinct was to look for (R101). No other staff knew where he was at. I went to the (facility) kitchen because residents like it there. Security was bringing him back through the therapy doors. Security found him in the parking lot. (R101's) nurse did not know he was missing. I told his nurse and she said she would take care of the paperwork. During an interview 8/31/2021 at 2:03 PM Licensed Practical Nurse (LPN) I stated, I was (R101's) nurse the night he eloped. At 6:30 PM he was at the East Hall nursing station. I was introduced to him. I didn't really know him. I was told (R101) could be argumentative. After report I started working about 7:15-7:30 PM. After that my aide (CNA H) came to me with (R101) saying someone said they saw him down by apartment complex. My comment was how did he get down there when there were no alarms. I wasn't told he was outside in the parking lot. You can't hear the alarms go off down on C hall (East Hall). I called down to Rehab, where he was transferred from, to ask if he was an elopement risk. Staff said he gets all over the place. I kept him near me. I don't think he had a wander guard on at that time. The alarm was never activated when he left. I didn't hear it. I did not know there was a Resident Elopement Profiles. I was unaware of it. I became aware he had eloped on that night a day or two later from a co-worker. I only thought he got into the back dining room. Then I talked to the DON after two days had gone by and found out he had eloped. Security should have told us more. They did not. There were so many things not put in place to know about (R101's) elopement. The protocol for elopement is a known thing, but I was not told he had made it outside. I know the certain steps to conduct an elopement search. Staff that night didn't even know he was gone. Regular elopement procedure couldn't be done because we didn't know. Staff on the other hall (West) had heard the alarms and turned it off and didn't look through the doors. I didn't report it because I didn't know. During an interview on 8/31/2021 at 8:30 AM VPO M stated, (R101's) elopement; the staff did not respond appropriately. During an interview on 8/31/21 at 11:49 Security Q stated, The security staff were not trained/educated on elopements. Security only makes a presence at the facility when requested by the nurse in charge or the director. There is no way for security staff to identify elopement risk residents at the (name of the facility). When an elopement happens the face sheet would get sent to me over my phone and I'd send it out to security staff that is working. Security staff would then go out and do a perimeter check of the entire campus. During an interview on 8/31/2021 at 11:43 AM Security O stated, Security staff had no training prior to the elopement and no training since. I don't know if there is a book or way or identifying elopement risk. During an interview on 8/31/2021 at 1:24 PM CNA J stated, I don't know who was assigned to (R101) that evening (7/30/2021). I heard a door alarm going off. I went to the therapy doors and didn't see anyone besides the people working in the kitchen. I got (Registered Nurse (RN) K) and we didn't see any residents in that area. There was no overhead page it was only a loud beeping noise. I couldn't shut it off. (RN K) got it to go off. We did not go through the doors to look for a resident. During an interview on 8/31/2021 at 1:00 PM Physical Therapy Assistant (PTA) U stated, (R101) moves pretty good in his wheelchair. He can get around to wherever he wants to go. During an interview on 8/31/2021 at 1:30 PM, NHA A stated, I came into work 8/2/21 and was notified of the elopement on 7/30/2021, from a Security IR (Incident Report) in my email. I had not been notified of (R101's) elopement prior to that. Staff should have done a lot of things that night regarding the elopement, and they did not. Because the back door (therapy gym doors) alerts the West side of the building, nothing is overhead including alarms on the East side of the building. Staff should have never shut off an alarm without looking to see what the cause was. There was no communication between the East side and the West side staff and no head count was done was done that night. Our investigation indicated very little communication between the security guard and facility staff. During an interview on 8/30/2021 at 3:45 PM, Security D stated, Last night (8/29/2021) at 8:51 PM a nurse called me to tell me about a high-pitch beeping noise at the West Hall nursing station. I silenced the fire panel. It went off for mysterious reasons. It happens all the time when it humid. I could not get it to reset. The Rehab (West Hall) nursing station heard the noise. You could not hear it past rehab. At 10:03 PM, a guy from Rehab had keys and went to therapy door, he tried to reset both doors, at that point the doors had no lights. Which indicated the doors were not locked. He tried to reset both doors and didn't know what to do. I told the East Hall nursing station the therapy doors were not locked. I do not know if staff went there. I didn't see any staff there. It seems like staff should have had someone manned at that station (therapy doors). Security never stayed by the therapy doors last night. During an observation on 8/30/2021 at 8:08 AM, the double-exit door by the therapy gym did not have alarms go off when Surveyor walked through them. There was a red light on right door and green light on left door. The green light indicated the door was not locked. A sign on the door indicated Push until alarm sounds door can be opened in 15 seconds. There was no 15-second delay when Surveyor pushed on the door. All fire doors were shut in facility with no staff monitoring exit doors or at the therapy gym doors. It was further observed the hall beyond the therapy gym doors led to an apartment complex. The main lobby entrance/exit of the apartment complex opened into a driveway/parking lot where a busy side street that intersected with a main road with a speed limit of approximately 35 mph. During an interview on 8/30/2021 at 8:34 AM Vice President of Operations (VPO) M stated, Apparently the humidity is making the facility doors not work/stay open (referring to the fire doors). Maintenance is aware. During an interview on 8/30/2021 at 8:45 AM, Certified Nursing Assistant (CNA) N stated, Apparently our fire doors are closed due to the humidity. The humidity is making them close. Yesterday (8/29/2021) on day shift the fire alarms were going off non-stop. At 11 PM until midnight they started back up again non-stop. Maintenance came in last night and put fans out to try and keep the doors open and alarms off. For the residents that are elopement risks, rounds were done every 30 minutes to make sure everyone was accounted for. Security was standing at therapy doors. There are chirp alarms for wander guards at the fire doors staff can turn off and on manually. At each fire door a chirper was put up to notify when someone went through them. VPO M, CNA N and Surveyor observed chirp alarm outside dining room. CNA N attempted to activate alarm. Chirp alarm did not work. CNA N stated, The battery is probably dead. CNA N flipped the on/off switch. When switched to ON the chirp alarm worked. CNA N stated, Staff probably turned if off so residents could come through into the dining room. During an observation and interview on 8/30/2021 at 8:42 AM, Security O was sitting on the other side of the therapy gym doors. Security O stated, I was asked this morning at 8:30 AM to sit here and make sure no residents come through the door. The alarm on doors is not working. There was only one security person on duty here last night and he would not have been sitting here. During an interview on 8/30/2021 at 8:44 AM Rehab P stated, The alarms should be working but they haven't been. (referring to the therapy door alarms). During a observational tour of the facility exit doors on 8/30/2021, this Surveyor and Maintenance C the following was observed: -8:46 AM fire doors closed and chirp alarm not working by dining room. -Maintenance C stated, The fire alarm system has got issues with humidity. The fire alarm company thought they had it fixed a week to a week and a half ago. Last night the humidity was so high the fire doors closed and the fire alarm system did not work correctly. The main panel will state the fire alarms have been triggered and there will be a problem with resetting the alarms. The doors lock with mag-locks, but when the alarms are triggered the mag-locks release and can not be reset correctly to relock the doors. When the therapy gym doors have issues with the alarms and locks, a speaker and alarm goes on overhead by therapy and the West Hall. Observed the exit alarm at end of C-Hall was not working. Maintenance C stated, This exit door is not locked. None of the exit doors are locking right now. There are no staff standing by them to monitor them. The exit door at the back hall is not locking or alarming. It gives direct access to the back alley which goes to Golden Drive out to [NAME] Street with access to Portage Street. The back hall fire doors are not working. They lead to the multiple purpose hallway which leads to the apartment complex. The therapy door alarm is not working. That alarm announces just over to the West side and is not heard anywhere else in the facility. The fire alarm is in test mode for 2 hours right now. It was turned on at 0800 and does not alert to fires in the facility. During an observation and interview on 8/30/2021 at 9:45 AM right side door of the double therapy gym doors had a red light requiring a code to pass through. The left side door had a green light, allowing it to be passed through without an alarm sounding. Security O tried the key to turn on the alarm for the left side door and it did not work. Security O stated, The door alarm should reset, and it is not. During an interview on 8//30/2021 at 9:59 AM Nursing Home Administrator (NHA) A stated, I was contacted last night when the door alarms began to have issues. There are no Alarms only pages overhead at nursing stations overhead if a door is opened. Residents could go through the exit/alarmed doors at that time. The facility had rounds done every 30 minutes by the Campus Security. During an interview on 8/30/2021 at 10:35 AM Security Q stated, I'm the supervisor of Security. There was one security person at the campus from 3p-11p, one from 11p-7a and I came in last night at 1AM. I got several calls last night, first one at 5:40 PM from (Security D) that the fire panel went off in the (name of facility) indicating that wherever the North Pole station was located the fire alarm was activated. I told her to check for fires and after walking the building to reset it. Resetting the panel clears it and sets it up to be active. I assumed all the alarms and door locks were working. At 7:15 PM, (Security D) called again saying the alarms were activated again. I don't know what time the door locks were an issue. At 1 AM the door by the therapy gym had been opened. But there was no one in therapy gym. It does an audible (speaker overhead) that the door was opened. It was blaring at the West nurse's station all night. I can't tell you when the therapy door was opened. When I spoke to the West nurses station, they said everything was secure and all accounted for at the therapy door. The only thing I knew about was the exterior door by the therapy door had been opened and needed resetting. No one was assigned to sit outside the door. During an interview on 8/30/2021 at 12:31 PM Security R stated, Security did not have to look for residents going through exit doors because staff said they did a head count. Otherwise, security would have asked for the number of residents for each hallway, and we would have done a count. And we would have notified the Administrator we were doing a head count. Part of the issue with the exit doors may have had to do with the fire panels. The nursing staff tried to reset the door alarm for the door at the therapy exit but could not. No nursing staff was stationed at the therapy door. During an interview on 8/30/2021 at 2:12 PM VPO M stated, The facility validated that the doors were not working today. During an interview on 8/30/2021 at 11:30 AM Facilities Supervisor T stated, The exit doors are linked to the fire alarm system. If the fire alarm system goes off, the exit door's mag-locks will shut off. That allows staff and residents to exit the building. Today (8/30/2021) the door by therapy was green on the left side and (name of the fire alarm company) used a key to reset the door. Review of facility policy Elopement Prevention Procedure Reporting effective date unknown, revealed, Policy Statement: (name of facility) will strive to provide a safe and secure environment for its residents at all times .Residents found to be at risk will remain in a safe environment at all times. It is the responsibility of staff to aid in providing a safe environment, responding, and acting promptly to an incident. Definition of Elopement: When a cognitively impaired resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. Procedure/ Guidelines Elopement Prevention .2. Residents found to be at risk shall be identified to the staff .4. Residents determined to be at risk for elopement will have a wander guard signaling device as appropriate .The wander guard is an electronic monitoring system with an audible warning signal for entrance/exit doors that is activated by a signaling device worn by a resident .6. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 7. If the warning system is not functioning properly, the affected doors will be continuously monitored until repaired. In case of power failure; all residents at risk will be checked on every 15 minutes until power has returned. 8. A Missing Resident Profile form will be initiated for all residents who are determined to be at risk for elopement These forms will be maintained at the nurse's station. Photographs of residents determined to be at risk for elopement will be maintained and updated as needed to reflect changes in a resident's appearance . 11. All new staff will be trained on the wander guard system, along with elopement drills throughout the year .PROCEDURE IN THE EVENT OF AN ELOPEMENT 1. All search efforts/actions should be documented in the resident's record including areas searched, individuals who were notified, timelines of events, etc. 2. When a staff member believes that a resident is missing from his/her usual location and is personally unable to locate the resident in his/her care, he/she is to immediately notify the Nursing Supervisor/Manager on Duty and Security. 3. When notified that a resident is missing, the Nursing Supervisor/Manager on Duty will initiate preliminary search efforts, which include: a. Note the time the resident was determined missing. b. Review Leave of Absence book c. Immediately notify other supervisors and department heads, which in turn, will notify all available personnel of the resident's absence, the resident's description, and the last time and place the resident was seen. d. Search needs to be cooperative effort with other supervisors and department heads by assigning staff to search specific areas. e. Initiate a resident-by-resident visual inspection for accuracy. f. immediately report resident's absence to Community Director (if not on site). g. The Community Director will notify the CEO as deemed appropriate .WHEN THE RESIDENT IS FOUND 1. The person discovering the resident is to notify other personnel. 2. The supervisor/nurse will: a. notify all staff that the resident has been found. b. performs a thorough physical assessment of the resident for injuries (including: evaluating for pain and range of motion before attempting any movement, identifying if there are any cuts or contusions, complete neuro check, obtain vital signs, etc.) and document findings in the clinical record. c. Contact the residents attending physician, responsible party/family/DPOA and inform of status. d. Transfer the resident to the nearest emergency room for evaluation, if necessary. e. If remaining in the building, provide observation checks as needed. These checks will be discontinued by Community Director/Administrator/designee only. f. The physician will give further orders for the care of the resident. g. Complete the incident/accident/unusual occurrence report. h. Investigate the causal factors related to the elopement and provide a corrective action. i. Update the resident's care plan to reflect elopement precautions initiated to prevent further occurrence REGULATORY AGENCIES . Per CMS, elopement may be considered neglect, so refer to the Abuse Prohibition Policy for reporting guidelines Review of the facility's policy Door Alarm Response dated 7/14/2020, revealed, Policy Statement Any time that a door alarm is triggered it is irresponsibility of all staff to respond and investigate the origin of the alarm. Procedure/ Guidelines: 1. Staff will immediately respond to the door that is alarming. 2. Staff will investigate who triggered the alarm (i.e. resident, family, staff). 3. If staff is unable to determine who triggered the alarm, staff will immediately complete a resident head count of entire facility. 4. If resident head count does not match current facility census, Elopement Procedure will be immediately initiated. On 8/30/2021, the Nursing Home Administrator was notified of an Immediate Jeopardy that began on 7/30/2021 and was identified on 8/30/2021 when Resident #101, who was identified as an elopement risk, eloped from the facility, unbeknownst to facility staff. On 8/31/2021, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: -On 08/02/21 R101 was assessed by LPN, with no negative findings . The resident was also interviewed by LMSW. Documentation states, Met with R101, very pleasant and interactive this am. R101 is at this baseline cognition and mood. R101 also stated that he had a great weekend and did not recall any incidence of elopement. -On 08/02/21 a complete headcount of the facility was completed by the Director of Nursing with all residents accounted for. -On 08/02/21 the Director of Nursing contacted the family/ DPOA for R101 to notify them of the incident occurring. -On 08/02/2021 R101's Elopement Care Plan and interventions were reviewed and updated as needed by the DON. -On 08/02/21 an audit was completed by the Maintenance Director to ensure all exit door alarms were operating, with findings that all exit alarm doors were functioning properly. -On 08/02/21 an audit was completed by the Assistant Director of Nursing, for all residents with wander guards to ensure proper function. Six of six wander guards were found to be functioning appropriately. -On 08/02/21 Director of Nursing reviewed and implemented the facility's disciplinary policy as appropriate. -On 08/02 all staff re-education was initiated on the Elopement Policy & Procedure, to include a quick reference guide for staff during an elopement event. 56 of 128 staff received education on 08/02 and 121 of 128 staff received education by 08/14. These numbers include contract staff. -On 08/02 an audit of resident elopement assessments and care plans was completed to ensure appropriate interventions are in place for each at-risk resident. 81 of 81 elopement assessments were reviewed and updated as necessary on 08/02. -On 08/30/21 the contractor for the Fire Panel came in to evaluate the system. All Exit Doors are secured and alarms functioning properly as of 08/30/21. -On 08/30/21 the Vice President of Operations and the Administrator reviewed and revised as necessary the policy and procedure on fire system malfunction to ensure monitoring for fire and potential elopement risks. -On 08/31 education of Security Personnel regarding the Elopement Policy and Procured was initiated. No Security Staff will be allowed to work after 1600 on 08/31 until the education has been completed. Although, the Immediate Jeopardy was removed on 8/31/2021, the facility remained out of compliance at a scope of no-actual harm with the potential for more than minimal harm that is not immediate jeopardy, and severity of isolated due to not all education had been completed, door security systems were not functioning correctly at time of surveyor entry, and sustained compliance had not yet been verified by the State Agency.

This citation pertains to MI- 6, 45, and 7 Based on interview and record review the facility failed to provide to a.) transcribe and obtain ordered medications; and b.) assess and treat an acute change of conditon, for 3 of 5 residents, reviewed for medications and assessments, resulting in delayed treatment, hospitalization , pain, and psychosocial harm. Findings include: Resident #101 Review of the Face Sheet revealed Resident #101 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #101's Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was cognitively intact. [MEDICAL CONDITION] ophthalmicus (eye) is reactivation of the [MEDICATION NAME] virus infection (shingles) involving the eye. Symptoms and signs, which may be severe, include dermatomal (area of skin supplied with nerve fibers of a shingle) forehead rash and painful inflammation of all the tissues of . the eye .Treatment is with oral [MEDICAL CONDITION] ([MEDICATION NAME]) .Complications .keratitis . postherpetic neuralgia . Roat, M.I.MD, FACS. [MEDICAL CONDITION] Ophthalmicus. Retrieved from: merck manuals.com/eyedisorders/[MEDICAL CONDITION]-[MEDICATION NAME]-opthalmics Review of #101's .GERIATRIC MEDICAL SERVICES POST ACUTE SNF PRIMARY NOTE, dated 6/14/19, revealed .His pain control has been a challenge but has improved . He will continue with IV [MEDICATION NAME] ([MEDICAL CONDITION]) until 6/16 .He has been c/o (complaint of) his eyebrows being ripped off . He has [MEDICAL CONDITION] on his left forehead and outer eye which could account for the burning sensation . (sic) Review of a Resident #101's Progress Note, dated 6/1/6/19 at 3:00 PM, revealed Resident was admitted on friday and was to receive [MEDICATION NAME] every 8 hours. The pharmacy did not deliver the IV antibiotics until the afternoon on the next day. Resident missed 3 doses. While the midnight dose was infusing, the IV infiltrated.unable to restart IV, (outside IV nurse) was called and was unable to start a peripheral and recommended a PICC (peripherally inserted central catheter) . (6/16/19 4:00 PM) dose of [MEDICATION NAME] was given. Resident missed 5 doses total . (sic). Review of Admission Summary note, dated 6/14/19 at 5:56 PM, revealed .He was admitted for [MEDICAL CONDITION] and shingles .The shingles are on his forehead and screams out in pain due to the shingles . In an interview on 7/22/19 at 11:30 AM, Licensed Practical Nurse J (LPN) indicated worked on 6/14/19, 7:00 PM to 7:00 AM on 6/15/19. LPN J indicated Resident #101 admitted to the facility from the hospital at approximately 4:00 PM on 6/14/19. LPN J indicated his first dose of the [MEDICAL CONDITION], [MEDICATION NAME], was due on 6/15/19 at midnight. LPN J indicated the [MEDICATION NAME] had not come from the pharmacy with his other medication. LPN J indicated Resident #101 was in extreme pain due to the shingles rash on his face on and eye. In an interview on 7/24/19 at 10:30, Registered Nurse L (RN) indicated worked with Resident #101 on 7/15/19 from 7:00 AM to 7:00 PM. RN L indicated Resident #101 had missed 3 doses of his IV [MEDICATION NAME] when he received his first does on 6/15/19. RN L indicated Resident #101 screamed out in pain most of the shift, despite pain medications. In an interview on 7/24/19 at 1:00 PM, Resident #101 indicated while he was at the facility he was in excruciating pain from the shingles on his face and eye. Resident #101 indicated when admitted the facility had trouble getting all his medications on time and did not get his antibiotic ([MEDICAL CONDITION], [MEDICATION NAME]) the first few days. Resident #101 indicated was screaming in pain, chewing on a washcloth, and was out of his mind. Resident #103 indicated once all of his mediations arrived and were being given his sores started to clear up and the pain lessened. Resident #103 Review of the Face Sheet revealed Resident #103 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #103's Minimum Data Set ((MDS) dated [DATE], revealed Resident #103 was moderately cognitively intact. Review of Resident #103's Discharge Medication Instruction from the hospital, dated 10/13/18, revealed .[MEDICATION NAME] (Lialda 1.2 g oral delayed release tablet) 1 tab(s) By Mouth 3 times a day for 30 Days. Refills: 5 .(maintenance drug to treat ulcerative [MEDICAL CONDITION]). Review of Resident #103's Order Summary Report, dated 10/17/18, revealed .Lialda Tablet Delayed Release 1.2 GM ([MEDICATION NAME]) Give 1 tablet by mouth three times a day for [MEDICAL CONDITION] .(hand written in) for 30 days ., checked and signed by Register Nurse H (RN), Licensed Practical Nurse F (LPN), and RN T. Review of Resident #103's Medication Administration Record [REDACTED]. Resident #103 missed 42 doses of Lialda (14 days times 3 tabs a day) from 11/17/18 to 12/1/18. Resident #103 was transferred to a home for the aged on 12/1/18. In an interview on 7/22/19 at 5:00 PM, Family Member U (FM) indicated Resident #103 has had ulcerative [MEDICAL CONDITION] (inflammation and ulcers of the colon and rectum) for many years and has been well controlled with the medication Lialda. FM U indicated Resident #103 was transferred in (MONTH) of (YEAR) to a home for the aged (HFA) on the facility's property. FM U indicated at the HFA Resident #103 began to have issues with alternating diarrhea and constipation around (MONTH) of 2019. FM U indicated in the beginning of May, received a phone call from the HFA reporting 1 week of diarrhea and bloody stools. Resident #103 was admitted to the hospital and remained for almost 2 weeks for acute ulcerative [MEDICAL CONDITION]. FM U indicated in the hospital it was discovered the facility did not place Resident #103's Lialda on his discharge medication list when transferred to the HF[NAME] FM U indicated while Resident #103 was a resident in the facility only received his Lialda for 30 days of his 44 day stay. FM U indicated Resident #103 was in the hospital for a long time, incurred multiple expensive hospital bills, suffered pain, depression and was physically debilitated because of a simple medication error. Review of Resident #103's discharge paperwork, Order Review Report provided to the HFA by the facility revealed the medication for ulcerative [MEDICAL CONDITION], Lialda, was not on the discharge report. Review of Resident #103's hospital records from the encounter dates 5/14/19 to 5/23/19, revealed H&P (history and physical) .Patient .present to the ER .for several days of hematochezia (fresh blood in the stool). Patient reports multiple episodes of diarrhea daily with bright red blood per rectum. He reports left lower quadrant abdominal pain .weakness and fatigue .is prescribed (Lialda), however this is not on his medication list provided by his facility .Assessment .Acute ulcerative [MEDICAL CONDITION] .Hospital Course .Patient placed on high dose IV steroids .ongoing slow and partial improvement .added (antibiotic) rectal retention enemas to be performed nightly .and then patient had an additional colonoscopy . Resident #104 Review of the Face Sheet revealed Resident #104 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #104's Minimum Data Set ((MDS) dated [DATE], revealed Resident #104 was cognitively intact. Review of Resident #104's Nurse Practitioner Q's (NP) Physician's Progress Note, dated 6/18/19, revealed Seen for productive cough for last 5 days. She has been using [MEDICATION NAME] which has not been helping. Cough has been described as wet productive with clear to green sputum .describes being tired . Review of Resident #104's next documented Progress Note, dated 6/24/19, .Resident's (Family Member W (FM)) came in to take resident to the ED (Emergency Department). (FM W) stated .I've decided to get her evaluated .NP also evaluated resident today . e-signed by Licensed Practical Nurse P. Review of Resident #104's documented vital signs, revealed no vital signs were document after the 6/18/19 visit until Resident #104 returned from the hospital 7/8/19. Review of Resident #104's EMR (electronic medical record), revealed no assessments were found completed or documented on 6/24/19 by either NP Q or LPN P. In an interview on 7/23/19 at 9:00 AM, Certified Nursing Assistant I (CNA) indicated worked frequently with Resident #104. CNA I indicated Resident #104 had cold with a cough for about 2 weeks. On 6/24/19, Resident #104 reported to CNA I that she felt very tired and did not feel well. CNA I indicated took her vital signs (did not document them) and reported to LPN P that Resident #104 felt and looked very ill. In an interview on 7/14/19 at 10:00 AM, NP Q indicated on 6/24/19, LPN P reported Resident #104 was feeling tired and unwell, no other assessment information was relayed. NP Q indicated Resident #104 had had a bad cough for about 2 weeks. NP Q indicated on 6/24/19 visted Resident #104 and discussed her illness but NP Q did not listen to her heart or lungs. NP Q indicated no clinical assessment was done. NP Q indicated offered Resident #104 a few options for further treatment and they decided to obtain labs the next morning. NP Q indicated did not touch Resident #104 so did not write a progress note attesting to talking with Resident #104 and agreeing upon a plan of treatment. In an interview on 7/23/19 at 2:00 PM, Resident #104 indicated had a cough for a while before going to the ER. Resident #104 indicated the day FM W took her to the ED she felt horrible. Resident #104 indicated laid in bed all day, except to eat but hardly ate. Resident #104 indicated was very tired and her cough had gotten worse. Resident #104 indicated felt ill and did not realize how sick she was. Resident #104 indicated she was short of breath, in a-fib and had pneumonia; stayed in the hospital for almost two weeks. FM W indicated was doing better now but was a lot more independent prior to the hospital stay. In an interview on 7/22/19 at 8:40 AM, FM W' indicated called Resident #104 on 6/24/19 and she sounded weak and out of it. FM W indicated knew immediately something was wrong. FM W indicated immediately drove to the facility and saw that Resident #104 was short of breath and extremely weak. FM W indicated the facility tried to persuade Resident #104 to stay but went to the ED anyway. Review of Resident #104's hospital encounter History and Physical 6/24/19, revealed .presented to ER with dyspnea (difficulty breathing) and cough of 2 week duration .Patient was found to have [MEDICAL CONDITION] with RVR (rapid ventricular response or irregular heartbeat) was started on [MEDICATION NAME] drip with bolus (IV medication to control heart rate) .Respiratory: positive for cough and shortness of breath .Heart: Irregularly irregular rate and rhythm .Lungs: Rales (clicking, bubbling or rattling sounds on inhalation) at bilateral lung bases . In an interview on 7/24/19 at 9:30 AM, Director of Nursing B indicated it was not evident or documented in the record that Resident #104's vital signs were taken on 6/24/19, or that NP Q or LPN P assessed Resident #104 on 6/24/19, the day of her admission to the ED.

This citation pertains to intake numbers MI 003 and MI 914. Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls in 1 of 5 sampled residents (Resident #101) reviewed for falls, from a total sample of 5 residents, resulting in an immediate jeopardy when on [DATE] at approximately 6:30 p.m., Resident #101, who was a high fall risk, was discovered on the floor by a visitor who then notified facility staff. Resident #101 sustained a head injury and subsequently died on [DATE] at 1:28 a.m. Findings include: Review of a Face Sheet for Resident #101 revealed she was a [AGE] year-old female admitted on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was moderately cognitively impaired and required extensive assistance with 2 staff members for transfers. Review of a Fall Risk Assessment for Resident #101 dated [DATE] revealed a fall risk score of 16 which indicated Resident #101 was a high risk. Review of an Order Summary Report for Resident #101 revealed orders for: [MEDICATION NAME] (blood thinner) 75 milligrams (mg), Give 1 tablet by mouth in the morning. Review of a Care Guide dated (MONTH) (YEAR) revealed: ADL (Activities of Daily Living) transferring -1 staff assist, ADL Toilet use - 2 staff assist, ADL Locomotion on unit - 1 staff assist, ADL Eating - 1 person assist, needs supervision . Review of a Fall Care Plan dated [DATE] revealed, Focus: I am at risk for falls related to AMS (Altered Mental Status), Impaired Gait/Balance, Impaired safety awareness, and dementia. Goal: To minimize and prevent injury during my stay. Interventions/Tasks: Anticipate my needs, round to my room frequently and ask if there is anything I need 30-minute checks for safety for 72 hours . See my task list for how I transfer and ambulate Review of the Task List Report for Resident #101 revealed, 30 minute checks X 72 hours, ADL Transferring X1 person assist, Toilet use X2 person assist, ADL-Locomotion on unit X1 assist and wheelchair, ADL-Eating X1 person assist, needs supervision and lids on hot liquids Review of Occupation Therapy Evaluation and Plan of Treatment dated [DATE] for Resident #101 revealed, Functional Skills Assessment (ADL's) and Instrumental ADL's: Self Feeding= Supervised, Toileting=Max Assist, Wheelchair Mobility= Moderate Assist; Distance=5 feet; Method of Propelling=bilateral lower extremity, Functional Mobility During ADL's = Max Assist.Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: Anxiety, behavioral outbursts, decreased ability to return prior level of assistance, decrease in level of mobility, falls, and further decline in function. In an interview on [DATE] at 11:10 a.m. Family Member (FM) #1 reported Resident #101 had a 24-hour sitting nurse at the hospital before she was discharged to the nursing facility. FM #1 reported the family was concerned about Resident #101's safety because she would get up on her own and was not steady. FM #1 expressed concerns that other family members had talked to facility staff about getting bed rails on the bed and the facility declined implementing bed rails and did not provide an alternative solution. FM #1 reported the expectations of Resident #101 were to recover from surgery and return to the Assisted Living Facility. FM #1 reported that Resident #101 had a history of [REDACTED]. Review of a Progress Note dated [DATE] at 9:47 p.m. for Resident #101 revealed: At 1830, informed to go to patient's room (Resident #101) by a visitor. Says patient was laying on the floor. Nursing report was stopped. Three nurses and two nursing assistants went to the room. This nurse observed patient laying on her left side at the end of her bed. Her head was towards the doorway with her feet towards the rooms' window. There was a dinner napkin next to her with blood. By the window wall, it appeared someone had attempted to wipe the blood up. It was dried and smeared. Blood observed at the top edge end of the heater. Patient had a blue jacket under her head with a significant amount of blood on it. The blood had clotted. There was fresh red blood on the floor by her jacket. During assessment, a large hematoma was at the back of her head. Her hair was matted with dried blood. Patient had some blood on her hands. Patient was alert throughout the incident. Blood pressure ,[DATE] lying. Pulse 57. Her pupils were not reacting to light. She would move her right leg back and forth. Her eyes were tearing, and her right arm started shaking. When asked what happened, she did not respond. Her hair was cleaned with saline as much as possible to assess extent of the injury. A pressure bandage was applied due to injury still bleeding. Call light was not on. Light over bed was not on. Room main lighting was on. Floor was dry. Patient was barefoot. Her socks were next to her bed. There was a dinner tray still on her bedside table with the bedside table partially pushed away from the bed. One nurse left room to call the on-call for (hospital). She was unable to locate an on-call list for (hospital). This nurse left the room. 6:30 p.m. Writer called Life EMS (Emergency Medical Services) 6:51 p.m . Review of a statement (undated) by Registered Nurse (RN) P revealed Around 6:30 p.m. the resident (Resident #101) was found on the floor. There was blood on the floor and some of the blood was wiped up by the resident I think The residents eyes did not constrict or dilate appropriately and she was unable to follow an object with her eyes. She stated her hips and her eyes hurt. She (Resident #101) stated that she was very nauseous and was dry heaving. There was a large amount of blood on the floor and on the towels that she may have cleaned up the floor with. In an interview on ,[DATE] at 12:10 p.m., Licensed Practical Nurse (LPN) C who does the new admissions to the facility reported that when Resident #101 arrived to the facility, she was cognitively not there and was not stable on her feet. Resident #101 had a fall risk bracelet on her wrist from the hospital. LPN C then reported that Resident #101's daughter was with her upon arrival to the facility and the daughter told LPN C that Resident #101 was a high fall risk, and clarified Resident #101 was not a small fall risk. LPN C reported that the hospital reported Resident #101 was a fall risk, frail, had dementia, was not a big eater, and walked in and out of the room by herself. LPN C then reported implementing a pancake call light for Resident #101 as well as grab bars for fall precautions. LPN C then reported she told a Case Manager that when a room closer to the nurses' station became available that Resident #101 should move for safety reasons but could not remember which case manager she told. LPN C reported answering the call light for Resident #101 a couple days later and when LPN C entered Resident #101's room, Resident #101 was observed sitting on the edge of the bed rocking back and forth like she was trying to stand up. LPN C reported that Resident #101 had to use the bathroom and asked Resident #101 if she was trying to get up and Resident #101 told her she was. Review of a Facility Incident Summary dated [DATE], CNA L reported On [DATE], I saw a residents family member approach the nurses station, seconds later CNA J and three nurses started towards A hall, so I followed. Upon reaching the room, I saw (Resident #101) lying on the floor at the bottom of the bed. The resident was laying on her left side, her head was cushioned by her jacket and was covered with blood. She had no socks on. It looked as if she had taken them off in bed. There was a bloody tissue laying at her feet from her attempting to clean up her own blood. The resident was conscious but unable to tell us what happened. The nurse and I tried to rinse away some of the blood from her head so she could see the wound In an interview on [DATE] at 3:06 p.m., CNA J reported working [DATE], and that when he got report from other CNA's from previous shifts, the CNA's reported Resident #101 was self-transferring. CNA J reported he did not feel comfortable with Resident #101 self-transferring without assistance. CNA J stated Resident #101 was toileted after lunch, but was seen by another CNA transferring from the bathroom unassisted back to her bed. CNA J reported he did not put Resident #101 to bed, but when he saw Resident #101, she was already in bed. CNA J then reported dinner trays came to the halls around 5:00 p.m. and he went to Resident #101's room between 5:15 p.m. and 5:30 p.m. to wake her up and sat Resident #101 at the edge of the bed for dinner. CNA J reported that Resident #101 needed motivation to eat but not direct supervision. CNA J left Resident #101's room to check on other residents down the hall. CNA J reported that Resident #101 was to be on 30-minute checks for the first 3 days after admission and was not on 30-minute checks on [DATE]. CNA J stated that between 6:00 and 6:30 p.m. he was at the nurses' station when a visitor came to let them know that Resident #101 was on the floor. CNA J then reported that he went to Resident #101's room with another nurse and saw Resident #101 on the floor with blood in the corner of the room next to the window sill and a bloody napkin next to Resident #101. Review of a Fall Investigation report dated [DATE] at 6:30 revealed: CNA J reported Resident #101 had her last meal or snack at 5:00 p.m. and sitting on her bed having supper and that the current care plan interventions were 30 minute checks. Review of the Pre-Hospital Care Summary Report by EMS (Emergency Medical Services) for Resident #101 dated [DATE] revealed Call received at 18:50, On Scene at 18:55, Patient contact at 19:00, Left Scene at 19:19, at Destination at 19:24. Describe events leading to illness/injury: fall. Initial scene findings/presentation: on the ground. Patient was found in the following position: left lateral recumbent (lying down) .Additional Assessment Notes: Patient on the floor with bandaged head due to bleeding Patient is able to roll over to her back and then sheeted up to the cot. Patient is alert. Patient does not seem to have shortness of breath or any distress. Staff states she is weaker than normal as she isn't talking much as she usually does. Patient does not moan in pain as we move her head and is negative to rotation and shortening . Review of a Hospital Records for Resident #101 with an admission date of [DATE] revealed: Chief complaint: fell at nursing home and now has hematoma and small laceration to back of head, patient on blood thinners. A computerized tomography scan (CT) at 9:51 p.m. revealed CT brain and CT cervical spine reviewed with physician at 9:40 p.m.; findings show massive acute [MEDICAL CONDITION] including subdural, subarachnoid, intraparenchymal, and intraventricular hemorrhage. The most significant is a large right subdural hematoma with mixed attenuation consistent with active bleeding date of death : [DATE] at 1:28 a.m. In an interview on [DATE] at 10:00 a.m., Director of Nursing (DON) B reported that the fall precautions that were in place for Resident #101 were frequent checks, and the enabler bar on the bed. DON B reported that the frequent checks were every 30 minutes on [DATE] even though the care plan said frequent checks every 30 minutes for the first 72 hours. DON B was unable to provide documentation that 30-minute checks happened and continued after 72 hours post admission. DON B did recall family members wanting Resident #101 to have bed rails because they were concerned about safety. On [DATE], NHA A was notified of the immediate jeopardy that was identified on [DATE] and began on [DATE] as a result of the facilitys' failure to adequately supervise and prevent a fall. On On [DATE], this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. Resident #101 no longer resided in the facility. 2. On [DATE] at 2:00pm, leadership team audited all residents to ensure that a Fall Assessment was completed and up-to-date. 3. On [DATE] from 2:00pm-3:30pm, leadership team reviewed all resident's care plans for fall interventions and updated as needed. 4. Initial intervention on new admissions read 30 min checks x 72 hours, we are now aware that staff would stop the 30 minute checks after 72 hours even if this was still listed as an intervention. As of today, [DATE], the new initial intervention will be 30 minute checks for orientation to new environment, and will remain until it is no longer appropriate. 5. On [DATE] at 5:30, the Resident Accident/Incident Report policy was revised to add the Stop and Watch procedure to the policy. 6. On [DATE] at 6:00 pm, Interact Stop and Watch forms were placed at both nurse's stations and in other departments. These Stop and Watch forms added an additional line for New Impulsive Behavior/Increased Fall Risk. Procedure will be as follows: anyone can complete the Stop and Watch form. Non-clinical staff will give the form to the resident's charge nurse. C.N.A.s will complete the Stop and Watch form (either in PCC or on paper), alert the resident's nurse, communicate to on-coming staff in shift report; they will also work with the nurse to develop an appropriate intervention for the resident. Nurses who receive the Stop and Watch form will address the concern and work with their team to develop an appropriate intervention; this intervention will be documented in the Care Plan and Task list and communicated to the on-coming shift. 7. On [DATE] at 1:15pm the Resident Accident/Incident Report policy was reviewed by Administrator and found to be appropriate. 8. On [DATE] at 1:20pm the members of the leadership team were in-serviced on the Resident Accident/Incident Report policy. 9. As of [DATE] at 3:30pm 66 of 198 employees have been in-serviced on the Resident Accident/Incident Report by members of the Leadership staff. All employees who have been in the building since 2:00pm on [DATE] have been in-serviced on the Resident Accident/Incident Report. 10. As of [DATE] at 6:45pm 40 of 198 employees have been in-serviced on the procedure of completing a Stop and Watch and what to do with the form. All employees who have been in the building since 6:00pm on [DATE] have been in-serviced on the Stop and Watch form. 11. All staff will be in-serviced on the Resident Accident/Incident Report policy and the Stop and Watch form prior to working their next shift. 12. All new admissions will be audited by DON or designee the within 48 hours to ensure that their baseline fall care plan is complete. Fall Assessments and Care Plan completion will be audited quarterly by the Case Manager with the MDS process. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to all facility staff had not yet received the education and the state agency had not yet verified sustained compliance.

This citation pertains to intake number MI 114, MI 150, MI 143, MI 417, MI 449, MI 455, and MI 415. Based on interview and record review, the facility failed to notify residents and/or representatives and the Office of State Long-Term Care Ombudsman at least 30 days prior to a facility initiated impending discharge or provide notices of involuntary discharge with appeal rights for 17 of 27 sampled residents (Resident #107, #108, #109, #110, #111, #112, #115, #116, #123, #125, #103, #114, #118, #119, #120, #121, and #122) reviewed for proper transfer/discharge notification, resulting in residents and families not knowing their rights, confusion, anger, and increased stress for residents and families. Findings include: Review of facility sent documents, Letter Number 1 and Number 2, dated (MONTH) 19,2018, reflected that the first 2 paragraphs were the same, in the 3rd paragraph, the language changed. Letter #1 indicated, We are happy to let you know that your residence at (facility name) will not be affected. There may be changes to your room location, be assured that these will be communicated with you promptly. If you have any questions about this plan, you can contact the (name of Administrator) or (name of President). (new paragraph) We hope you share our excitement about the future as we strengthen our ability to enhance the experience and quality of life for those we serve. Letter #2 indicated, Change of this kind can be challenging, that's why we are offering out personal support. By Monday, (MONTH) 22nd, please call (name of Administrative Assistant) .to schedule an in-person or phone meeting with (name of Administrator) to discuss this change at a time that is convenient to you. (new paragraph) Our goal is a smooth transition for each person as we strengthen our ability to enhance the experience and quality of life for those we serve. Review of the Question and Answers insert with Letter 1 or 2 sent (MONTH) 19, (YEAR): Why are we changing out bed capacity? What physical changes are we making? When will all the changes occur? Residents will begin moving within the next ,[DATE] weeks. Once Amber Gardens space is empty, remodeling will begin in that area; including turning those rooms into private rooms. Rooms on West and East will be converted to private rooms as resident turnover allows. The entire process will take approximately 6 months. What residents are leaving and how were those those choices made? Some of our current residents will have to leave because there will be fewer rooms available. The leadership team has a list of residents who will most likely stay or leave .continuum members, prior to coming to (name of the facility), are required to meet eligibility qualifications as part of the application process. Once qualified, they are granted priority status for continued care services. We will also consider the length of time one has resided at (name of facility). Where will our residents go? We are committed to supporting all residents affected and creating individualized plans. Some of our residents may qualify to stay on campus and be served in Assisted Living. We will also assist in identifying and setting up services at another local skilled nursing facilities. Review an excel spreadsheet provided by the facility (no date) revealed Resident #107, #108, #109, #110, #111, #112, #115, #116, #123, #125, #103, #114, #118, #119, #120, #121, and #122 all received a copy of letter #2 and were not part of the facility continuum of care. Review of the complaint information received [DATE] by the State Agency revealed Residents/families received a letter from (facility name) stating that a certain number of residents had to leave the nursing based on (facility name) remodeling resident rooms .Residents have not been given Proper notice or their Right to Appeal this Involuntary discharge violating their protected rights . During an interview on [DATE] at 11:12 a.m., Administrator A reported that when letters were sent out to residents about the facility remodeling project and the facility implied that some of our resident would have to leave the facility she did not feel that it implied an involuntary discharge. Administrator A reported that on the question and answer paperwork there was resources listed for families, but a list of residents who received the letters and an individual letter notifying the Ombudsman of the potential transfer/discharges was not sent. Resident #107 Review of the Admission Record revealed Resident #107 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7 out of a total possible score of 15, which indicated that the resident was cognitively impaired. Review of Case Management Note dated [DATE] at 11:56 p.m., reflected Met with family, does not want to move forward with bed offer from (name of facility) at this time. Long discussion regarding eventual need to move. Will pursue placement at (name of facility) in the future. (family) aware timeframe is end of March. Review of the Case Management Note dated [DATE] at 2:40 p.m., reflected a Late Entry written by Administrator A on [DATE] at 12:42 p.m., Met with (family) regarding concerns about his (Resident #107) potentially moving facilities. He expressed that she has been declining physically for the last couple weeks and he doesn't know what to do. I assured him that we are most concerned about (Resident #107's) health status; I suggested that he meet with his Case Manager and NP (Nurse Practitioner) to discuss possible hospice. I assured him that we would never require someone to leave the facility if they are declining. During an interview on [DATE] at 11:00 a.m., Family Member (FM) L reported that the meeting he had right after receiving the first letter they slide a piece of paper across the desk about moving in ,[DATE] week. FM L reported that he informed them that it would kill Resident #107 to move her. FM L reported that the facility wanted them to look at different facilities, and he did not feel it was right to have her move. FM L reported that Resident #107 was crying and asking if she did something wrong, and asking if I forgot to pay the bill. FM L reported that he told Resident #107 he would fight the facility for her to stay. Resident #108 Review of the Admission Record revealed Resident #108 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #108, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15, which indicated that the resident was cognitively intact. Review of a MDS assessment, with a reference date of [DATE] and [DATE], revealed Resident #107 required extensive assistance with a one to two person physical assist for transfers, bed mobility, and toileting care. Review of the Case management Note dated [DATE] at 3:08 p.m., reflected CM (case manager) met with guest (Resident #108) and her (family member). Resident #108 is now stating that she wants to go to assisted living where she can have her own apartment. She would also like therapy so that she can get stronger and do more things for herself. She has complaints of pain in her R arm that she says is from [MEDICAL CONDITION]. Referral made to the transition specialist at Senior Services to assist with placement. Referral to therapy made. Review of the Case management Note dated [DATE] at 2:58 p.m., reflected CM spoke with (Resident #108) regarding Senior Services. She stated she has now changed her mind and wishes to stay within the facility at the insistence of her (family members). She asked if Medicaid was paying for her stay. CM explained that she would receive a bill that would be the equivalent to her social security check minus $60. She verbally understood. She had no other questions or concerns at this time. Review of the Case Management Note dated ,[DATE]//2017 at 5:03 p.m., reflected Spoke with resident (#108) regarding moving to room [ROOM NUMBER]. She stated that she would move to 53 but is hesitant about having 3 roommates. She stated she would like to be placed on the waiting list for a semi-private room. She has seen the room and offered to introduce her to roommates. Plan is to move rooms on Monday. Review of the Case Management Note dated [DATE] at 2:31 p.m., reflected, (family member) name of family member) asked to speak to CM. She asked if there were any other rooms available on the East wing. She said she, her brother and her mother are not happy in the room that she is in. CM explained to her that she is on the list to be in a semi-private room, but am not able to give a time frame of when that would happen. She stated that they would start to look at other facilities to have her mom moved. She feels like her mother does not have any privacy, even more so than when she was on the rehab wing. CM explained that each resident has a right to privacy and asked if there was something specific. She said no, just that there were other people in the room all the time and there was never a time when her mom was alone in her room. They prefer a private room and are hoping to find that elsewhere. CM offered to assist in any way with that move and that when they found the right facility, CM would be able to coordinate the move with them. Review of the Case Management Note dated [DATE] at 2:57 p.m., reflected Spoke with resident (#108) regarding (facility) building changes that will be occurring regarding the decrease in beds. Informed resident (#108) that we would help her find an alternate residence. Resident informed me that she has actually already been working on finding placement at an ALF and that she is working with Senior Services and the waiver program. Read resident the letter and left her with the original. During an interview on [DATE] at 2:50 p.m. and 4:00 p.m., Resident #108 reported that when she moved from rehab to long term care she was told she would be coming to a 2 bed room and she came to a 4 bed room. Resident #108 reported that if she had a 2 bed room she would want to stay in the facility, but not in a 4 bed room. Resident #108 reported that the letter she received would not have made her happy if she had been in a 2 bed room, but since she was in a 4 bed room and wanting to leave due to that the letter did not matter. During an interview on [DATE] at 2:45 p.m., Family Member (FM) M reported that Resident #108 was happy at this facility over on the rehab unit when she was in a 2 bed ward, but when they moved her to this 4 bed ward she hates it and wants to leave. Resident #109 Review of the Admission Record revealed Resident #109 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #109, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 out of a total possible score of 15, which indicated that the resident was moderately cognitively intact. Review of a MDS assessment, with a reference date of [DATE] and [DATE], revealed Resident #109 required extensive assistance with a one to two person physical assist for transfers, bed mobility, and toileting care. Review of the Physician's Progress Note dated [DATE] 15 3:00 p.m., reflected Late Entry: Post Acute/Long Term Care Progress Note -Result Date: (MONTH) 14, (YEAR) at 1:30 p.m. - Resident #109 - . overall functional decline - This is a [AGE] year-old female She returned to hospital again on [DATE] after being found by staff aphasic, right sided weakness, and substantially elevated blood pressure. During most recent hospitalization , she had noncontrast head CT which showed no evidence of any hemorrhage, large territorial infarct, or mass. CT angiogram was attempted but she had allergy to contrast dye and therefore was not completed. She is unable to have an MRI secondary to pacemaker. The family declined any further imaging. She was also found to have urinary tract infection and was treated with [MEDICATION NAME]. She returned to (name of the facility) to again attempt rehab. Her participation in therapy has been limited with failure to make any measurable improvement and she has been discharged from skilled services. She was noted to show evidence of dysphagia yesterday. Speech eval notable for significant dysphagia, downgrade to pureed diet with NTL. She is seen today in follow up for functional decline Plan: Long discussion with (family) (30) regarding current condition, diagnostic work up to date, current plan of care, along with goals of care. (Family) wishes to transition to palliative care at this time. Will consult hospice .per POA preference. Case manager updated. Review of the Case Management Note dated [DATE] at 2:34 p.m., reflected Spoke with (name of family member) regarding changes at (name of the facility). (Family member) states that she does not want (Resident #109) moved anywhere, and that she is filing a complaint with the State and has contacted the Ombudsman. Review of the Case Management Note dated [DATE] at 8:52 a.m., reflected I spoke with (family member). She had several questions and was referred to the administrator. Review of the Case Management Note dated [DATE] at 4:04 p.m. documented late entry dated [DATE] at 10:03 a.m. by Administrator A, Meeting held with (family members), local State Ombudsman, the President/CEO EE, and Administrator A. Family voiced concern over confusion of all the letters being sent out about (name of the facility) changes. Voiced concern about resident's history of poor adjustment when moving rooms and she is very concerned about her potentially having to move facilities. President/CEO EE assured family that we would never ask a resident to move who has history of this type of trauma, assured her that we want her mother to stay here. Let her know that we are in a holding pattern right now waiting for clarification from LARA and CMS. During an interview on [DATE] at 12:59 p.m., Ombudsman (OM) P reported that she met with President/CEO EE, Administrator A, and the family of Resident #109. OM P reported that the facility personal reported that the whole situation with the facility updates was getting blown out of proportion and that no one was asking residents to leave. OM P reported that the family of Resident #109 stated you absolutely ask (Resident #109) to leave, she cried for over a week the last time we moved her. OM P reported that after much discussion President/CEO informed the family of Resident #109 she can stay. During an interview on [DATE] at 3:00 p.m., Family Member (FM) J reported that after receiving the letter on [DATE] she was told she had to find a place for Resident #109 to move, the facility was going to downsize. FM J reported that she was angry and upset, called the local Ombudsman and the news. Resident #110 Review of the Admission Record revealed Resident #110 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #110, with a reference date of [DATE] and [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15, which indicated that the resident was cognitively intact. Review of a MDS assessment, with a reference date of [DATE], revealed Resident #110 required assistance of one person physical assist for transfers, bed mobility, and toileting care. Review of the Clinic Document dated [DATE], reflect that Resident #110 lacks the mental capacity to make informed decisions. During an interview on [DATE] at 9:10 a.m., Resident #110 was dressed appropriately for the day sitting at a table working a puzzle. Resident #110 stated that the facility gave her a letter and when her family came she gave it to them, that her family members make her decisions. During an interview on [DATE] at 5:07 p.m., Family Member (FM) I reported that Resident #110 was deemed mentally incompetent and that she was very upset by a letter that she received 2 weeks ago. FM I reported that she questioned the facility about giving the letter to Resident #110 and was informed that they could have a physician at the facility deem her competent. During an interview on [DATE] at 2:35 p.m. Case Manager (CM) CC reported that she did not consider updating Resident #110's status when her BIMS scores increased on her quarterly MDS evaluation and again on her yearly MDS evaluation, she did not know it was part of her job to update have the Determination of Inability to Participate in Medical Treatment Decisions. CM CC reported that Resident #110 was a good fit to transition to assisted living as she was not meeting the needs to remain here with the improvements she has made. CM CC reported that she did discuss possible move to assisted living with Resident #110 prior to discussing the information with her Durable Power of Attorney (DPOA). Review of the Case Management Note (CM CC ) dated [DATE] at 4:41 p.m., reflected that a care conference held today, resident (#110) is stable she has no complaints or issues. advance directive reviewed and will remain the same. she still verbalizes an interest in assisted living if she can financially afford it. at this time she would like to discuss this option with family first. Review of the Case Management Note (Nursing) dated [DATE] at 12:29 p.m., reflected that a Late entry for [DATE] was entered, I spoke with resident (#110) regarding the changes here and the possibility of her transitioning to director's hall. (Resident #110) is in favor of moving and having her own room. she expressed wanting to tour the building sometime before she would move there. She asked that other members in her family be notified of the changes and Administrative Assistant (AA) J was informed so that she could send the letter out to them as well. Review of the Case Management Note (Social Services) dated [DATE] at 11:21 p.m., reflected Entry for [DATE]. Had discussion with (name of physician) regarding patient competency level. Currently she is deemed unable to make medical decisions. (Name of physician) plans to make a visit with (Resident #110) as per BIMS scores are above 11 and her SLUM score is ,[DATE] and review medical decision making capacity. Review of the Case Management Note (Nursing) dated [DATE] at 3:51 p.m., reflected follow up conversation with resident (Resident #110) regarding her possibly moving to assisted living here on our campus. resident continues to exhibit an interest in assisted living but expressed to me that her (family member) stated Your not moving anywhere you are going to stay right where you are. based on my conversation with resident I believe both the family and they resident may benefit from a care conference and a tour of our assisted living facility. I will try and follow up with family ASAP and attempt to set up an informational care conference. Resident #111 Review of the Admission Record revealed Resident #111 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #111, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 out of a total possible score of 15, which indicated that the resident was moderately cognitively intact. Review of a MDS assessment, with a reference date of [DATE], revealed Resident #111 required assistance of one person physical assist for transfers, bed mobility, and toileting care. Review of the Case Management Note dated [DATE] at 4:37 p.m., reflected Met with sisters, today regarding upcoming transition r/t bed capacity decrease. Options discussed and both sisters agreed that top preference would be for (Resident #126) to transition to placement at Director's Hall (DH) if he meets their admission criteria. In the event he does not, they chose their top two SNF (Skilled Nursing Facility) preferences. Information given to social worker .to follow up with DH to schedule Locat etc. Review of the Case Management Note dated [DATE] at 2:52 p.m., reflected (Late Entry)- Met with sisters, .on [DATE] to answer any questions and discuss transition options. Discussed possibility of transitioning to (name of assisted living) as assisted living may be more appropriate for (Resident #111) and increase his overall QOL(Quality of Life). They were also given a list of SNF's in the local and surrounding area. Sisters requested that (name of assisted living) be their first preference if it is determined that (Resident #111) is appropriate for assisted living environment. Information and preferences relayed to ., Social Worker. Review of the Plan of Care Note dated [DATE] at 12:30 a.m., reflected Resident (#111)consults with sister for decision making when needed. During an interview on [DATE] at 11:30 a.m., Senior Services (SS) O reported that Resident #111 was referred to the our services by the facility, but he refused to transfer to (name of assisted living). During an interview on [DATE] at 5:10 p.m., Family Member (FM) H reported Resident #111 had been at the facility since 2014 and he loves it there it it his home. I don't know if he would have to leave, don't know what to do about it. He has made so many friends there he is happy there and staff are good to him and know him. FM H reported that the Case Manager thought they would transfer him to (name of assisted living), but he is in a wheelchair and that has an elevator with 3 floors and he needs to be around people, I just do not think this was right. FM H reported it should be illegal for them to make residents leave if they don't want to. Resident #112 Review of the Admission Record revealed Resident #112 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #112, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) (staff assessed) severe which indicated that the resident was cognitively impaired. Review of a MDS assessment, with a reference date of [DATE], revealed Resident #112 required assistance of one person physical assist for transfers, bed mobility, and toileting care. Review of the Long Term Care Plan dated [DATE], reflected I (Resident #112) require 24 hour care and plan to remain in SNF for LTC. Date Initiated [DATE] Revision on [DATE]. Goal * I am here for Lon term / custodial care. Date Initiated [DATE] Revision [DATE] Interventions/Tasks *Honor my choice to remain in SNF for LTC Date Initiated [DATE] *I am comfort care only. Date Initiated [DATE]. Review of the Case Management Note [DATE] at 4:09 p.m., reflected Spoke with resident (#112) legal guardian . regarding changes to (facility). Prefers referrals to locked unit at #1 and #2 Referrals made. Review of the Case Management Note dated [DATE] at 9:35 a.m., reflected Spoke with guardian regarding dc [DATE]. Guardian unable to come in that day to discuss paperwork but prefers to be called. D/C planned for 10 am via w/c transport. Guardian aware she needs to assist with personal belongings. Review of Discharge Summary Note dated [DATE] at 10:34 a.m., reflected Resident (#112)was discharged to .via . ambulance accompanied by a staff . at 10.20 AM. Resident left with all the paperwork, documentation of all medications plus control meds and one box with personal belongings. Resident was calm/stable and comparative to staff. The staff was briefed on resident needs and safety. Resident was escorted to the outer door by the nurse and a CNA. A voice mail message was left for . nursing station to call back for discharge report. Review of the Case Management Note dated [DATE] at 12:26 p.m., reflected Confirmed with at that all paperwork has been received including: DC Summary, DC orders, med rec, Care Plans, task list, immunizations. During the on site investigation attempts were made to contact the guardian of Resident #112 but were unsuccessful. During an interview on [DATE] Administrator A reported that Resident #112 had been at the facility longer than other residents, but he was not a good fit when going from the closed unit out into the main facility. Administrator A reported that they had attempted to move him there prior (did not state when), but that it had not worked. Administrator A reported that Resident ##112 needed a controlled quiet environment, and the facility could not offer him what he needed at this time. Administrator A reported that possibly this should have been an involuntary discharge. Resident #115 Review of the Admission Record revealed Resident #115 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #115, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15, which indicated that the resident was cognitively intact. Review of a MDS assessment, with a reference date of [DATE], revealed Resident #115 required assistance of one person physical assist for transfers, bed mobility, and toileting care. Review of the 24 hour Care Plan My family is not able to care for me at home. I require 24 hour care/supervision. Resolved Date: [DATE] Goal *I will verbalize my needs through the review date. Canceled Date: [DATE] Interventions/Tasks *Honor my choice to remain here for LTC. *Discuss dc with son and resident. * Review of the Health Status Note dated [DATE] at 8:40 a.m., reflected Late Entry: I spoke with (name of family) concerning the letter they received about (name of facility) downsizing. They asked how we determined who would/would not have a spot. I explained that residents from the continuum had a spot and the rest were determined by longevity. They mentioned knowing someone at another facility and asked what they should do next to inquire about it. I referred them to the social worker. Review of the Case Management Note dated [DATE] at 1:31 p.m., reflected Met with family, prefers referral to name of (SNF) Skilled Nursing Facility), referral made. Review of the Discharge Summary Note dated [DATE] at 1:30 p.m., reflected D/C (discharge) folder reviewed with res son . by (LPN) Licensed Practical Nurse along with meds and d/c instructions. Res stable and tearful at time on d/c . All meds and belongings given to family for transportation. Ems in facility to transport to (name of) Nursing Home. Res exited building at 1:10 p.m .LPN called report to . at (name of receiving) Nursing Home via phone. During an interview on [DATE] at 4:50 p.m., Family Member (FM) D reported that Resident #115 had been at the facility since 2013 and had used up most of her funds and had to go on Medicaid. FM D reported that after receiving the first letter they had a limited meeting and were informed that the facility was a non profit and had to make money and Resident #115 did not have enough seniority so she would need to look for another place. FM D reported that Resident #115 was not happy at the new SNF she hates the food, and the facility, misses her friends, and her home. FM D reported that Resident #115 was part of the resident council when she was at the facility and very involved with her life there. FM D reported that they felt short changed, we felt Resident #115 would have been at the facility until she died , but it was a corporate decision. FM D reported after not sleeping well when receiving the letter, they felt there was no choice, but to move resident #115 so she would get a spot in a facility they chose rather than wait and have no choice of SNF's to choose from now that her funds were gone and she was on Medicaid. FM D reported that he had consulted an attorney who felt the facility broke the agreement they had made with Resident #115 when she became a resident of the facility in 2013, but he did not want to chance missing a Medicaid bed to fight them. During an interview on [DATE] Administrator A reported that when they were putting the list of residents together for longevity she must have made an error, when another resident with and admitted (MONTH) 2013 was placed ahead of Resident #115 (whose admitted was (MONTH) 2013) and the other resident was put on a list that did not have to leave the facility. During an interview on [DATE] at 10:05 a.m., Assistant Director of Nursing (ADON) C reported that when she spoke with FM D of Resident #115 she had a list, that someone else had already determined the longevity and I was assigned to talk to the family. ADON C reported that Resident #115 was not happy to be discharging and ask how we came to the determination, and ask about the next steps. ADON C reported that she did not give Resident #115's family information on the right to appeal. ADON C reported that she had a copy of letter number 2 that was sent to the families and used the information on the letter to discuss what residents were to do next. Resident #116 Review of the Admission Record revealed Resident #116 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #116, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15, which indicated that the resident was cognitively intact. Review of a MDS assessment, with a reference date of [DATE], revealed Resident #116 required assistance of one person physical assist for transfers, bed mobility, and toileting care. Review of the Case Management Note dated [DATE] at 10:02 a.m., reflected Per ./DPOA, ., a request has been made to submit documentation to (name of facility 1) and name of facility 2) as facilities of choice for potential transfer. Will notify social work to follow up. Review of the Case Management Note dated [DATE]

This citation pertains to intake number MI 114, MI 150, MI 143, MI 449, MI 45. Based on interview and record review, the facility failed to: 1.) prevent a facility initiated discharge and allow for opportunity to appeal an involuntary discharge and, 2.) document in the medical record a reason for the discharge that meets the federal requirements for discharge in 17 of 26 sampled residents (Resident #103, #114, #118, #119, ##120, #121, #122, #107, #108, #109, #110, #111, #112, #115, #116, #123, and #125) reviewed for transfer and discharge with documentation, from a total sample of 27 residents, resulting in feelings of sustained confusion, anger, frustration for residents and resident representatives. Findings include: Resident #103 Review of the Face Sheet and MDS (Minimum Data Set) dated 11/22/17 revealed Resident #103 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #103 had a BIMS (Brief interview for mental status) score of 2 out of 15, which indicated she was severely cognitively impaired. The MDS revealed Resident #103 required total assistance with transfers, and extensive assistance of one to two staff for dressing, eating, and personal hygiene, and was incontinent of both bowel and bladder. Review of the physician progress notes [REDACTED].#103 was on hospice and was receiving palliative (end of life) care. Review of the Progress Note dated 1/25/18 at 4:15 p.m. revealed Met with (family) regarding possibility of her mom seeking alternate placement. We talked about possible places that would be able to meet her mother's needs. (Family) were open to go look at some of the facilities. This writer offered go with them to tour if would help. They were curious about the date, and this writer let them know there is no official notice at this time and that will be at a later date, and it will be clearer than the information letter that recently received to let them know the facilities intent and future notices possible. The note was signed by Director of Nursing (DON) B. Review of the Hospice Note dated 2/1/18 (no time) revealed Call placed to daughter how is tearful about changing pts (patient - Resident #103) location to (name of new facility) next week. Reassurance and supportive listening provided.' In an interview on 2/21/18 at 10:05 a.m., Family Member #N stated, (Resident #103) transferred to another long term care facility. I didn't want to transfer her, it was forced on me. I was really thrown off. There was no warning. I was very confused when I got a letter in the mail that said I had to have her (Resident #103) moved by (MONTH) 31, (YEAR). I got a meeting with the people at the facility and a list of nursing homes given to me and was told that likely my mom (Resident #103) would be part of the first wave of residents to leave. I needed to have her moved with a spot was still open somewhere. With all the residents having to leave, spots would fill up fast, so I moved her while I could. I didn't get a second letter until after the transfer was done. They (the facility she resided in prior to transfer) did not handle it properly and added so much stress on me with the uncertainty of the transition. It put a lot on my husband and I to handle. It was very stressful. Review of the entire medical record revealed no documentation that included the basis for the transfer of the resident that met the State Operations Manual regulations. Resident #114 Review of the Face Sheet and MDS (Minimum Data Set) dated 7/9/17 revealed Resident #114 was a [AGE] year old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #114 had a BIMS (Brief interview for mental status) score of 13 out of 15, required extensive assistance with ambulation and personal hygiene and minimum assistance with dressing. Resident #114 was incontinent of bowel and bladder. Review of the quarterly MDS dated [DATE] revealed Resident #114 had no active discharge anticipated back to the community, had no desire to leave the facility, and there was no referral needed for the local agency. Review of the care plan titled No Discharge Plan dated 3/21/17 for Resident #114 revealed, LTC (long term care) I have made the decision to remain in the facility for LTC, please honor my wishes. Review of the Progress Noted dated 1/23/18 at 8:27 a.m. revealed, Late Entry: Note Text: I spoke with (son named) who stated he had received the letter about (facility name) downsizing. I mentioned his mother may be able to move to (another part of the facility continuum). He didn't think she had the financial means to do that. He asked what the next step was that he needed to take, I referred him to the social worker for more information. Review of the care plan regarding discharge date d 3/21/17 and revised 1/24/18 revealed I am working with (facility name) staff for discharge regarding transfer/discharge to an alternative facility. Interventions included My DPOA will make decisions regarding my LTC placement. Please honor my DPOA's decision to remain in LTC. Review of the Progress note dated 1/29/18 at 12:13 p.m. revealed, Met with patient son regarding changes at (facility name). Son has toured area SNF's and has requested referral be sent to (another facility). Referral made. Son states he will transport on dc (discharge). This writer and family met on 1/24/18 and discussed LTC vs Waiver. Son has spoken to social services. At this time, resident son prefers SNF and not interested in pursuing ALF (adult living facility). Review of the Physician's Progress Noted dated 2/5/18 at 3:29 p.m. revealed, This is a [AGE] year-old female long-term care resident of (facility name). She has been a resident of (facility name) since (MONTH) (YEAR) after attempting rehab after hospitalization and reached a functional plateau, then transition to long-term care. She has past medical history of [REDACTED]. Over the past year, she has not had any falls, major illnesses, or hospitalization s. She was referred to dermatology for chronic [MEDICAL CONDITION] flare after multiple interventions failed in the SNF setting. She was prescribed topical Cutivate as needed. She is transferring to alternative skilled nursing facility this week. She has been a bit anxious about this . In an interview on 2/22/18 at 1:29 p.m., Family Member O stated, My mother left to another facility. The facility she was at let go 41 patients because of changing them to private rooms. If they couldn't afford to stay, that facility just let them go. This happened right out of the blue, there was no warning. She (Resident #114) was very upset about it. It made her feel very sad that she had to leave and she didn't understand why. She thought she was going to be at that facility forever. She said it felt like she was 'kicked out of here'. I ended up talking to a patient advocate and Medicaid and they said they could do nothing about it. The facility she was at only cared about the business, they didn't care about her. They (the facility) was no help in finding a new place for my mom. Mom was there one and a half years and just had to leave. She still has much of her faculties so it was so hard on her and it was so stressful for all of us. It seemed like they (the facility) was 'cherry picking' the residents that they wanted to leave. Resident #114 discharged to another long term care facility on 2/6/18. Review of the entire medical record revealed no documentation that included the basis for the transfer of the resident that met the State Operations Manual regulations. Resident #118 Review of the Face Sheet and MDS (Minimum Data Set) dated 12/28/17 revealed Resident #118 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #118 had a BIMS (Brief interview for mental status) score of 10 out of 15 which indicated he was moderately cognitive impaired. The MDS indicated Resident #118 had no behaviors, required one person assist with transfers, dressing, eating, and extensive assistance with bathing. Review of the quarterly MDS dated [DATE] revealed Resident #118 had no active discharge anticipated back to the community, had no desire to leave the facility, and there was no referral needed for the local agency. Review of the care plan titled No Discharge Plan dated 3/18/17 and revised on 8/24/17 for Resident #118 revealed, LTC (long term care) My DPOA will make decisions regarding my LTC placement. Please honor my DPOA's decision to remain in LTC. In an interview on 3/2/18 at 9:02 a.m., Durable Power of Attorney (DPOA) P stated, I was given a letter that said the facility was decreasing beds and was downsizing. I called social services at the facility to start the moving process so that he would have a bed to go to. With the downsizing and him being on Medicaid, I knew there wouldn't be many openings for him. I was not told that he could stay and I was afraid if I waited to long, there would be no beds available. I never told him (Resident #118) that he was being forced to leave, just that I found a place with only 2 beds for him. I did come in one day prior to his transfer and overheard him (Resident #118) and anothe resident talking. He said to the other resident 'If they don't like you, the just get rid of you here at (name of facility)'. I didn't know he knew about what was going on, but clearly he did. Resident #118 discharged to another facility on 2/9/18. Review of the entire medical record revealed no documentation that included the basis for the transfer of the resident that met the State Operations Manual regulations. Resident #120 Review of the Face Sheet and MDS (Minimum Data Set) dated 1/12/18 revealed Resident #120 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #120 had a BIMS score of 11 out of 15 which indicated mild cognitive impairment, required assistance with transfers, bathing, and dressing, was incontinent of both bowel and bladder. The MDS revealed Resident #120 had no active discharge anticipated back to the community, had no desire to leave the facility, and there was no referral needed for the local agency. Review of the Progress Noted dated 1/9/18 at 12:01 p.m. revealed Resident #120 was to remain at the facility for her long term care needs. Review of a letter sent by the facility to Resident #120's family dated 1/19/18 indicated we will begin a six-month journey to create 56 updated private rooms. This will help us meet these changing needs while reducing our total accommodations from 118 to 76 residents. We're dedicated to ensuring a smooth transition for all. Changes will begin within the next two weeks as we work towards repurposing Amber Gardens (a wing of the facility) .While this will affect some residents who have called (facility name) home, will help transition them to other locations on campus or to other facilities .By Monday (MONTH) 22nd (2018), please call (facility staff names) to schedule an in-person or phone meeting to discuss this change .Our goal is for a smooth transition for each person as we strengthen our ability to enhance the experience and quality of life for those we serve. The letter was signed by Nursing Home Administrator (NHA) A. Review of the Progress Note dated 1/24/18 at 11:31 a.m. revealed Met with (family) to discuss placement options. Resident does require a LT (long term) care setting and family is receptive to explore other LT care facilities. Family was understanding to the need for the resident to have alternate placement into another facility. A list of LTC facilities was provided to the family, family will be visiting facilities to determine their top choice. Did reassure the family that this was not an easy decison for the facility and the facility staff will assist in making the transition to another facility as easy as possible for the resident and family .Tentative goals is to have placement done by (MONTH) 31st (2018). In an interview on 2/28/18 at 2:03 p.m., Family Member (FM) Q stated, We received a letter about the changes and making private rooms and that they were lowering the bed count by 40 beds. It indicated some residents would have to move. I called for the appointment as the letter indicated and I asked if (Resident #120) had to move and I was told 'Yes, she would have to move'. (Case Manager W) said she had to move and the sooner the better. (Case Manager W) said everyone had to be moved by 3/31/18. She (Resident #120) has lost ground since we moved her, she even looks different. She no longer knows who we are and had a very serious decline in her mental function since the move. The move really took a toll on her, she's [AGE] years old, it was rough. On the day of the move, she (Resident #120) saw us loading the cart and kept saying 'Where are you taking me? Why? How long will I be gone? How long do I have to stay here (at the new facility)?'. She was crying all that day after the move. We felt rushed to move her since we didn't know how long other beds would be open. They never once said we could stay. Review of the care plan regarding discharge date d 1/26/17 and revised 2/6/18 revealed I am working with (facility name) staff for discharge regarding transfer/discharge to an alternative facility. Interventions included Case management and social work will assist with my placement into (another facility name). The care plan was initiated after the above letter was sent to the family. The care plan was not initiated until after the letter had been sent. Resident #120 was discharged to another facility on 2/8/18 via transport paid for by the receiving facility. Review of the entire medical record revealed no documentation that included the basis for the transfer of the resident that met the State Operations Manual regulations. Resident #121 Review of the Face Sheet and MDS (Minimum Data Set) dated 12/29/17 revealed Resident #121 was a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #121 required extensive assistance with transfers, ambulation, dressing, eating, and bathing. The MDS revealed Resident #121 had no active discharge anticipated back to the community, had no desire to leave the facility, and there was no referral needed for the local agency. Review of the care plan titled No Discharge Plan dated 4/11/17 and target date of 1/19/18 for Resident #121 revealed, I have chosen to have hospice provide extra care and support for me as my overall health condition has declined. LTC (long term care) I have made the decision to remain in the facility for LTC, please honor my wishes. LTC (long term care) My DPOA will make decisions regarding my LTC placement. Please honor my DPOA's decision to remain in LTC. Review of a letter sent by the facility to Resident #121's family dated 1/19/18 indicated we will begin a six-month journey to create 56 updated private rooms. This will help us meet these changing needs while reducing our total accommodations from 118 to 76 residents. We're dedicated to ensuring a smooth transition for all. Changes will begin within the next two weeks as we work towards repurposing Amber Gardens (a wing of the facility) .While this will affect some residents who have called (facility name) home, will help transition them to other locations on campus or to other facilities .By Monday (MONTH) 22nd (2018), please call (facility staff names) to schedule an in-person or phone meeting to discuss this change .Our goal is for a smooth transition for each person as we strengthen our ability to enhance the experience and quality of life for those we serve. The letter was signed by Nursing Home Administrator (NHA) A. In an interview on 2/28/18 at 1:19 p.m., Durable Power of Attorney (DPOA) R stated, I received a letter that said they were downsizing and (Resident #121) would not be able to stay. I came in and talked to the administrator who said she (Resident #121) would have to move. I asked if there was anything I could do to allow her to stay and I was told 'no'. I was told she has to leave, they (the facility) couldn't 'run in the red' and they had to make money. When she (Resident #121) moved, she didn't handle it well with her dementia and all the new people. She had increased confusion, was very disoriented, and 'didn't know where to go'. She is still trying to adjust. Review of the care plan regarding discharge date d 4/11/17 and revised 1/24/18 revealed I am working with (facility name) staff for discharge regarding transfer/discharge to an alternative facility. Interventions included I/family/DPOA /etc. will be involved with the transfer/discharge process. I/family/DPOA /etc. will coordinate with staff regarding my preferences for placement. The care plan was initiated after the above letter was sent to the family. Resident #121 discharged from the facility to another facility on 1/31/18. Review of the entire medical record revealed no documentation that included the basis for the transfer of the resident that met the State Operations Manual regulations. Resident #122 Review of the Face Sheet and MDS (Minimum Data Set) dated 1/10/18 revealed Resident #122 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #122 had a BIMS score of 2 out of 15 which indicated she was severely cognitively impaired. The MDS revealed Resident #122 required assistance with transfers, ambulation, dressing , eating and bathing. The MDS revealed Resident #121 had no active discharge anticipated back to the community, had no desire to leave the facility, and there was no referral needed for the local agency. Review of the care plan for Impaired Cognitive Function/Dementia dated 4/12/16 and revised 1/12/16 revealed, I have impaired cognitive function/dementia or impaired thought process related to short term memory loss. Interventions included, Keep my routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of the Progress Note dated 1/23/18 at 5:46 p.m. revealed, Late entry: At center for LTC per family and POA wishes. In an interview on 2/28/18 at 11:24 a.m., Family Member (FM) S stated, On Saturday (1/20/18) I received a letter that residents had to leave on my mommy's side of the facility. I had to move quickly to find alternate placement so there would be a bed open. I asked them if she could stay and they said 'No'. They said it wasn't related to Medicaid. We (family) were under the impression that she had no right to a slot here at the facility due to the remodeling project. They never said I had a right to keep her there at the facility. Mom was very disoriented after the move and her transition to the new facility was very difficult. She passed away just last night. Review of a care plan regarding discharge date d 4/12/16 and revised on 1/29/18 revealed, I require 24 hour care, my family plans to transfer me to alternative facility of my family's choosing. Interventions included, My family will coordinate with staff regarding my preferences for placement. My family/DPOA will be involved with the transfer/discharge process. Resident #122 discharged from the facility on 1/31/18. Review of the entire medical record revealed no documentation that included the basis for the transfer of the resident that met the State Operations Manual regulations. Resident #119 Review of the Face Sheet and MDS (Minimum Data Set) dated 12/19/17 revealed Resident #119 was a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #119 had a BIMS score of 12 out of 15 which indicated she was moderately cognitively impaired. The MDS revealed Resident #119 required extensive assistance with transfers, dressing, eating, and bathing, was always incontinent of both bowel and bladder and had no active discharge anticipated back to the community, had no desire to leave the facility, and there was no referral needed for the local agency. According to the Face Sheet, Resident #119 was her own responsible party. Review of the Speech Therapy referral dated 11/3/17 revealed the reason for referral was Case manager and NP (nurse practitioner) requested evaluation of patients current cognitive-communication skills. The Cognition portion indicated Resident #119 presented with impaired alertness, impaired insight, and moderately severe ability to recall memory. The overall impression was Resident appeared to present with moderate-severe cognitive-communication deficits in orientation, memory, attention, language, motor speech and executive functioning resulting in significant communication breakdown, poor safety awareness. According to case manager, patient unable to participate in skilled services at this time as unable to make financial decisions required for treatment. Resident #119 scored an 11 out of 30 on the M[NAME]A (Montreal Cognitive Assessment) which indicated a greater than moderate cognitive impairment. Review of the Comprehensive Level II OBRA assessment dated [DATE] revealed Resident #119 had [DIAGNOSES REDACTED]. Recommendation of other professionals included, Case Management to continue to follow up on the process of obtaining Guardianship. Under Cognitive Abilities was documented, (Resident #119) has asked that her significant other no longer be her advocate or decision maker. The facility has again pursued filing for legal guardianship. Recommendations included, Consistency of staffing, routine, and approach are helpful for (Resident #119). Review of the Petition for Appointment of Guardian of an Incapacitated Individual dated 12/19/17 revealed the facility petitioned for permanant guardianship due to the patient advocate is not acting consistent with the ward's best interest and the adult (Resident #119) lacks sufficient understanding or capacity to make or communicate informed decisions because of mental deficiency and physical illness or disability. According to the Attachment to Petition for Appointment of Guardian (no date), Resident #119 presents moderate to severe cognitive communication deficits in orientation, memory, attention, language, motor speech and executive functioning .Because of her mental and physical challenges, (Resident #119) has difficulty making or communicating informed decisions regarding her care, custody, and control and requires a guardian. At present, (Resident #119) owes a debt to the petitioner for nursing services, room and board, and related products and services provided. If petitioner does not begin recieving payment in full each and every month for the care provided, the petitioner will soon be obliged to file a Notice of Involuntary Discharge If (Resident #119) were to be involuntarily discharged , her physical disabilities and mental deficiencies would be exacerbated as a result of her being moved from an environment with which she has assimilated to once which she has not. Review of the care plan titled No Discharge Plan dated 9/27/17 and revised on 2/19/18 for Resident #119 revealed, No discharge plan: I require 24 hour care/supervision and assistance with my ADL's (activities for daily living). I will remain in the facility for long term/custodial care. Interventions included, I have made the decision to remain in the facility for LTC, please honor my wishes. Review of the Progress Note dated 1/19/18 at 1:23 p.m. revealed, Spoke with (Resident #119) about the changes in the building and that we would need to find another placement for her. I read the letter to her with the information and she said 'understand'. I asked her how she felt about it and she said 'weird' .She the asked 'you aren't going to throw me out into the street are you?' No other persons or guardians were consulted regarding the need or decisions to be made for alternate placement. There was no documentation noted in the medical record to indicate the resident was ever told she was allowed to stay, nor was there documentation of an involuntary discharge. Review of the Progress Note dated 1/31/18 at 8:32 a.m. revealed Resident #119 was accepted at another facility and that Resident #119 was assured her belongings would be taken care of. Review of the Progress Note dated 2/9/18 at 7:10 p.m. revealed Resident #119 discharged via ambulance to another facility. In an interview on 3/28/18 at 8:25 a.m., Social Worker (SW) FF stated, When (Resident #119) arrived, I had to keep explaining to her what she was signing. I called the previous facility and they stated they had been working on getting a guardian for her. She (Resident #119) didn't know why she had to be here and didn't know why she was transferred to this facility. Review of the entire medical record revealed no documentation that included the basis for the transfer of the resident that met the State Operations Manual regulations. Review of emails dated 2/5/18 at 10:10 a.m. and a 11:48 a.m. revealed a question to the facility by the law firm working on guardianship paperwork for Resident #119 revealed, What was the reason for her going there (to a new facility)? Did she ask for it? The response from the facility was, We are downsizing our facility and based on seniority and who belongs to our continuum those residents had the first choice to stay. Then we spoke with each resident/family who will need to move within the next 6 months and she chose a facility and they came to assess her, they had a bed, and she agreed to move and they are moving her 2/9/18. Resident #107 Review of the Admission Record revealed Resident #107 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 9/16/17, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of a total possible score of 15, which indicated that the resident was cognitively impaired. Review of the Case Management Note dated 1/22/2018 at 4:26 p.m., reflected Met with family , today regarding recent transition r/t (related to) decreased bed capacity. We discussed options and they chose their top three SNFs (Skilled Nursing Facilities). Family, . left meeting to go tour (name of facility), faxed over referral. Review of Case Management Note dated 1/24/2018 at 11:56 p.m., reflected Met with family, does not want to move forward with bed offer from (name of facility) at this time. Long discussion regarding eventual need to move. Will pursue placement at (name of facility) in the future. (family) aware timeframe is end of March. During an interview on 3/2/18 at 11:00 a.m., Family Member (FM) L reported that the meeting he had right after receiving the first letter they slide a piece of paper across the desk about moving in 1-2 week. FM L reported that he informed them that it would kill Resident #107 to move her. FM L reported that the facility wanted them to look at different facilities, and he did not feel it was right to have her move. FM L reported that Resident #107 was crying and asking if she did something wrong, and asking if I forgot to pay the bill. FM L reported that he told Resident #107 he would fight the facility for her to stay. Resident #108 Review of the Admission Record revealed Resident #108 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #108, with a reference date of 2/10/18, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15, which indicated that the resident was cognitively intact. Review of the Case Management Note dated 1/19/2018 at 2:57 p.m., reflected Spoke with resident (#108) regarding (facility) building changes that will be occurring regarding the decrease in beds. Informed resident (#108) that we would help her find an alternate residence. Resident informed me that she has actually already been working on finding placement at an ALF and that she is working with Senior Services and the waiver program. Read resident the letter and left her with the original. During an interview on 2/21/18 at 2:50 p.m. and 4:00 p.m., Resident #108 reported that when she moved from rehab to long term care she was told she would be coming to a 2 bed room and she came to a 4 bed room. Resident #108 reported that if she had a 2 bed room she would want to stay in the facility, but not in a 4 bed room. Resident #108 reported that the letter she received would not have made her happy if she had been in a 2 bed room, but since she was in a 4 bed room and wanting to leave due to that the letter did not matter. During an interview on 2/21/18 at 2:45 p.m., Family Member (FM) M reported that Resident #108 was happy at this facility over on the rehab unit when she was in a 2 bed ward, but when they moved her to this 4 bed ward she hates it and wants to leave. Resident #109 Review of the Admission Record revealed Resident #109 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #109, with a reference date of 2/16/18, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of a total possible score of 15, which indicated that the resident was moderately cognitively intact. Review of the Case Management Note dated 1/22/2018 at 2:34 p.m., reflected Spoke with (name of fam(TRUNCATED)

This citation pertains to intake number MI 144. Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers for 1 of 1 sampled residents (Resident #107) reviewed for skin concerns, from a total sample of 27 resident, resulting in coccyx ulcers and a heel ulcer, the potential for systemic infection, and continued potential for skin breakdown. Findings include: Review of the Admission Record revealed Resident #107 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 9/16/17, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of a total possible score of 15, which indicated that the resident was cognitively impaired. Review of a MDS assessment, with a reference date of 9/16/17 and 12/15/17, revealed Resident #107 required extensive assistance with a two person physical assist for transfers, bed mobility, and toileting care, and one person physical assist for eating. Review of the Care Area Assessment (CAA) Tool dated 9/16/17, reflected Resident #107 was a PRESSURE ULCER RISK (Therapy) triggered due to resident requires up to two to assist with mobility ADL's due to [DIAGNOSES REDACTED]. Resident is also incontinent of bowel and bladder. This places her at risk for pressure ulcers. Staff to assist with turning and repositioning every 2 hours and prn (as needed), encourage adequate po (by mouth) fluid intake, monitor labs prn, pressure relieving mattress to bed, pad bony prominence's, prevent skin on skin contact, keep linen clean and wrinkle free, toilet per schedule, head to toe skin assessment weekly and prn. Therapy as ordered and encourage resident to participate in therapy daily. Review of the Nutrition Care Plan dated 9/21/17, reflected Focus * I (Resident #107) have a nutritional problem or potential nutritional problem .Goal * I will maintain adequate nutrition status as evidenced by maintaining weight within 3 lbs in 1 week .and consuming at least (75)% of at least (2-3) meals daily through review date. Intervention/Tasks *Provide, serve diet as ordered. Monitor intake and record every meal. Review of the Mobility Care Plan date 9/21/17, reflected I (Resident #107) have limited physical mobility related to Stroke with left side [MEDICAL CONDITION] ([DIAGNOSES REDACTED]), Weakness Date Initiated 9/21/17 Goal I will use a high back wheelchair with left lateral thigh support to help me maintain neutral trunk positioning when I am seated in my wheelchair through the review period. Date Initiated: 9/21/17 Interventions/Tasks * Please make sure that I am centered in the wheelchair and that the left lateral thigh support is in place to prevent me from leaning to my left. Date Initiated 9/21/17 * Please reposition me often throughout the day when I am either in my bed or up in my wheelchair. Date Initiated: 10/4/17. Review of the Kardex printed 2/21/18, reflected Resident #107 Eating/Nutrition- *ADL (Activities of Daily Living) - Eating - Assist Dining, Lids on hot liquids, Monitoring *Monitor/document/report to MD PRN for s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Resident Care- *Float heels while in bed. * Pressure reducing boots on at all times Toileting - * ADL - Toilet Use - Use bedpan Review of the Nursing Note dated 11/9/2017 at 11:48 a.m., reflected Resident (#107) is up in wheelchair with assist of Hoyer and 2. Is able to communicate needs and is alert and oriented. Denied pain but did state she was uncomfortable in wheelchair and wanted to be in bed. Addressed getting a new or different chair but resident declined and stated she was fine with the one she has as long as she is not in it all day. Ate meals in the dinning room with restorative assistance, and needs extensive encouragement to eat. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring. (1.) yes, other (checked) no further documentation noted on the skin assessment. Review of the Nursing Notes dated 11/10/17, did not reflect any notation of any skin concerns. Review of all the Care Plans did not reflect a Skin Care Plan in dated for this timeframe. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring. (1.) yes (2) Skin area description; Describe area and interventions; (d.) Duoderm (dressing) Signal Patch. Apply to the coccyx for protection, change q (every) 3 days and PRN Body diagram (f.) coccyx red area not open. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence (3.) Paralysis; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring. (1.) no. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence (3.) Paralysis; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring. (1.) no (2) Skin area description; (d.) Describe area and interventions: Duoderm placed on coccyx for protection. Review of the Skin assessment dated [DATE], reflected (1.)Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence (3.) Paralysis; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring. (1.) no (2.) Skin area description (c.) Exudate (substance secreted): none (d.) Describe area and interventions: Duoderm placed on coccyx for protection (e.) Odor present: none. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence (3.) other; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring. (1.) yes (2.) Skin area description (d.) Duoderm on coccyx. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring. (1.) yes (2) Skin area description (d.) Duoderm to coccyx for protection. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring. (1.) yes (2) Skin area description (d.) Duoderm to coccyx for protection. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring. (1.) yes (2) Skin area description (d.) Duoderm to coccyx for protection. Review of the Braden Scale for Predicting Pressure Score Risk dated 1/12/18, reflected a score of 14 which indicated moderate risk. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring. (1.) no. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring (1) yes (2) Skin area description (d) duoderm to coccyx; body diagram- (f.) Coccyx- 2 open areas to coccyx measuring 1 cm L x 0.8 cm W and 0.8 cm L x o.7 W, superficial clean pink surface. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring (1) yes (2) Skin area description (d) duoderm to coccyx. Review of the Skin Care Plan dated 1/23/18, reflected I am at risk for skin breakdown related to acute kidney failure, Afib, weakness, rhabdomyolysis, triggering for anticipated significant weight loss, at risk for skin breakdown, receiving comfort care, current openings to coccyx, and intact UN L heel. Date Initiated: 01/23/2018 Intervention * Standards of care for pressure relief and skin breakdown prevention. Date initiated: 1/23/18 * Standards of Care to prevent skin breakdown. Date Initiated : 1/23/18 * Pressure reducing boots on at all times. Except while bathing. Date Initiated: 1/23/18 * Float heels while in bed. Dated Initiated: 1/23/18 * While in bed I need to be turned hourly or more often off of bony prominence's. I like my body pillow and would like to use it in between my legs while I am on my side. Date Initiated: 1/23/18 * Please offer to assist me into bed after meals I have skin breakdown and should not be up for more than 1 hour at a time, honor my wishes if I wish to stay up longer. Revision Date: 2/1/18 Review of the Skin/Wound Note dated 1/23/2018 At 6:45 p.m., reflected, Resident #107 was Observed intact UN pressure injury to residents L heel area measured: 4 cm X 5.5 cm area appeared with a brown to red discoloration non blanchable. NP (Nurse Practitioner) notified and observed area V.O. (verbal order) to offload the heel and pressure reducing boots on at all times except while bathing. notified of two superficial openings to residents coccyx covered with duoderm signal for protection. Called (Family Member) to update her and notify her that this writer would like to order an alternating pressure mattress for prevention of further breakdown. (Family Member) asked about the cost I explained the cost and she stated she would like to hold off until she could speak with her brother tomorrow. Interventions in place for hourly turning, and assistance to bed after meals, not staying up for longer than one hour at a time, offloading residents heels, RD notified, RBC (red blood cell count) and Hgb (hemoglobin) low NP aware. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring (1) no. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence, (7.) end Stage disease, (8.) Pressure Ulcer, (9.) Other; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring (1) yes. (2) Skin are description; Body diagram (f.) Other; Coccyx 2 superficial openings Duoderm signal in place. see skin wound note. Other; Unstageable pressure injury to left heel [MEDICATION NAME] (dressing) foam covering and in place. Pressure reducing boots in place. Review of the Skin Care Plan Revision on: 02/07/2018, I am high risk for unavoidable skin breakdown related to poor po (oral) intake disease process, acute kidney failure, Afib, weakness, rhabdomyolysis, triggering for anticipated significant weight loss, at risk for skin breakdown, receiving end of life comfort care with hospice, current healing openings to coccyx, and intact UN L heel. Date Initiated: 01/23/2018 No updated revisions to the Interventions/Tasks dated 2/7/18. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence, (7.) end Stage disease, (8.) Pressure Ulcer, (9.) Other; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring (1) yes. (2) Skin are description; Wound bed (b.) (3.) eschar; Describe area and interventions (d.) Left heel unstageable; Odor (e.) none; Body diagram (f.) Right buttock, Pink granulation; Right lower leg (front) fading bruise; left lower leg (front) skin tear with steri strips; Left heel, black hard eschar. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence, Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring (1) yes. (2) Skin are description; Describe are and interventions (d.) left heel unstageable, duoderm to coccyx, left calf skin tear. Review of the Skin/Wound Note dated 2/20/2018 at 2:44 p.m., reflected Resident (#107) is receiving end of life comfort care with Hospice and remains high risk for skin breakdown. Preventative measures are in place including, pressure reducing boots on at all times except while bathing, float heels while in bed, offer to assist resident into bed after meals as resident should not be up for long periods of time honor my wishes if I prefer to stay up longer, staff to assist in turning resident Q 1 hour or more often off of bony prominence's, along with standards of care for pressure relief and skin breakdown prevention. Resident has a poor appetite and does not get the recommended amount of protein per meal r/t resident refusal. Observed unstageable pressure injury to residents L heel area measures: 2.2 cm X 4.5 cm no change noted from previous week will communicate with NP for treatment recommendations, area continues with intact dark brown scabbed appearance, firm to touch no c/o or s/s of pain during treatment and assessment. [MEDICATION NAME] in place for protection along with pressure reducing boot. Observed healing open area to residents coccyx which is now intact though fragile. Wound # 2 intact though fragile. Mild maceration noted to the area r/t heavy incontinence. New order for sensi care to be applied Q shift and after each incontinent episode. Resident is utilizing an alternating pressure mattress as well as a pressure reducing roho cushion to wheel chair. Review of the Skin assessment dated [DATE], reflected (1.) Contributing Factors to risk of breakdown (b.) (2.) Daily Incontinence, (9.) Other; Skin issues (c.) Any skin conditions requiring treatment or monitoring, including any current areas receiving treatment or monitoring (1) yes. (2) Skin are description; Describe area and interventions (d.) left heel dark eschar [MEDICATION NAME] treatment, coccyx reddened sensicare treatment. Review of the Skin/Wound Note dated 2/27/2018 at 4:40 p.m., reflected Resident (#107) is receiving end of life comfort care with Hospice and remains high risk for skin breakdown. Preventative measures are in place including, pressure reducing boots on at all times except while bathing, float heels while in bed, offer to assist resident into bed after meals as resident should not be up for long periods of time honor my wishes if I prefer to stay up longer, staff to assist in turning resident Q 1 hour or more often off of bony prominence's, along with standards of care for pressure relief and skin breakdown prevention. Resident has a poor appetite and continues to not get the recommended amount of protein per meal r/t resident refusal. Observed unstageable pressure injury to residents L heel area measures: 2.2 cm X 4.5 cm continues to have no change noted from previous week area continues with intact dark brown scabbed appearance, firm to touch no c/o or s/s of pain during treatment and assessment, wound edges are dry and flaky. [MEDICATION NAME] in place for protection along with pressure reducing boot. Healing open area to residents coccyx remains intact though fragile. Wound # 2 remains intact though fragile. Maceration noted to the area r/t incontinence. Continue order for sensi care to be applied Q shift and after each incontinent episode. Resident is utilizing an alternating pressure mattress as well as a pressure reducing roho cushion to wheel chair. This surveyor requested a copy of all full care plans with all resolved and revised sections to each care plan to be provided prior to exit. The Skin Care Plan dated 1/23/18 was the only one noted for Resident #107. During an observation on 2/22/18 at 3:15 p.m., Certified Nursing Assistant (CNA) G and CNA M transferred Resident #107 to her bed, a scratch was noted to her left elbow with a scab (the scab was approximately 1/4 inch x 2 inches long). Resident #107 was placed on her back and her brief was loosened, her bottom was slightly red over the bony prominence of her coccyx extending over the sides (approximately the size of a softball). Boot was noted to left foot only. Resident #107's brief was not notable wet. CNA's repositioned her after lying her down and gave her the call light. Right foot had a sock only and was rubbing on the bed with resident movement. During an observation on 3/2/18 at 10:20 a.m., Resident #107 was lying on her back, Nurse Practitioner (NP) Q and Registered Nurse (RN) U entered the room in isolation wear (gown, mask, gloves), (hand care had been completed prior to coming to bedside). NP Q removed the old dressing from the left heel of dated 2/27/18, no drainage was noted on the old dressing, (the area on the left heel appeared brown and dry like a scab was covering) NP AA stated looks good we want it to heal from underneath out. RN U measured the heel wound 2.1 cm x 4 cm no redness noted. Neither RN U or NP Q removed their gloves and cleaned their hands. RN U put normal saline on a 2 x 2 piece of clean gauze and handed it to NP AA who wiped across the heel and RN U placed [MEDICATION NAME] foam to heel. NP AA and RN U went to the bathroom used by the resident in isolation to wash their hands NP AA re-gowned, masked and gloved to go care for the resident was in isolation. During observation on 2/21/18 through out the day Resident #107 was observed with only the left pressure reducing boot on when she was up in the wheelchair or lying in bed. During observation on 2/22/18 through out the day Resident #107 was observed with only the left pressure reducing boot on when she was up in the wheelchair or lying in bed. During observation on 2/23/18 through out the day Resident #107 was observed with only the left pressure reducing boot on when she was up in the wheelchair or lying in bed. During observation on 2/27/18 through out the day Resident #107 was observed with only the left pressure reducing boot on when she was up in the wheelchair or lying in bed. During observation on 2/28/18 through out the day Resident #107 was observed with only the left pressure reducing boot on when she was up in the wheelchair or lying in bed. During observation on 3/1/18 through out the day Resident #107 was observed with only the left pressure reducing boot on when she was up in the wheelchair or lying in bed. During observation on 3/2/18 through out the day Resident #107 was observed with only the left pressure reducing boot on when she was up in the wheelchair or lying in bed. During an interview and observation on 3/2/18 at 10:10 a.m., Certified Nursing Assistant (CNA) I reported that he was going in to get Resident #107 cleaned up, he repositioned her and was looking for the other pressure reducing boot, the Director of Nursing informed him there was (2) one for each heel. Resident #107 had a brief on.

Based on observation, interview and record review the facility failed to prevent, stage and treat a pressure wound according to current standards of care for 2 of 3 sampled residents (#1, #7) reviewed for pressure wounds, from a total sample of 21 residents, resulting in the development of pressure wounds and pain. Findings include: Resident #1 According to the facility admission record, dated 8/26/15. Resident #1 was an [AGE] year old female admitted to the facility on [DATE], and readmitted on [DATE] after a fall with [MEDICAL CONDITION], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS-resident assessment), dated 3/18/15, Resident #1 rejected care on occasion, had moderate memory loss, exhibited inattention, verbal and physical behaviors towards staff and other residents, wandered, was independent with her walker, needed 1 staff assist for dressing, hygiene, bathing and toileting and was frequently incontinent of bladder. Resident #1 had a pressure relief mattress on her bed and could feed herself after set-up. Resident #1 had no signs and symptoms of pain. After her surgery, the MDS, dated [DATE], indicated that Resident #1 needed 1 staff assist for repositioning in bed and bathing, 2 staff for transfers, dressing, hygiene and toileting and reported occasional moderate pain relieved by as needed pain medications. According to the care plan for activities of daily living, dated 1/2/15, Resident #1 was offered toileting/brief change every 2 hours and staff cues to reposition in bed. According to facility documents titled, Quarterly Nutrition Review, Resident #1 was losing weight as follows: On 12/18/14, she weighed 142.4 pounds (lbs). On 2/19/15 she weighed 136.8 lbs. On 3/12/15, she weighed 133 lbs. Up to this point, Resident #1 was accepting 50 to 75 % of her meals. After the the fall and [MEDICAL CONDITION], Resident #1 weighed 129.4 lbs on 5/29/15, was started on a protein/calorie supplement and was determined to have significant weight loss. On 7/13/15, she weighed 126.9, and a multivitamin was added. On 8/10/15, she weighed 125.4 lbs, a different supplement was added for wound healing and Resident #1 was eating 75 to 100% of her meals. According to facility documents titled, Weekly Skin Assessment, documentation by the licensed nurse was missing for Resident #1's weekly skin assessments, which indicated that no skin assessments were done on the following dates: 5/18/15, 6/18/15, 7/2/15, 7/9/15, and 7/23/15. An off-schedule skin assessment was documented for Resident #1 on 7/13/15. After development of the pressure wound on the right heel, Resident #1's care plan for the potential for pressure ulcer development, dated 6/10/15, included: reposition every 2 hours in bed and wheel chair, left walking boot during the day and left soft boot at night. According to physician's orders [REDACTED].#1's left foot. On 6/25/15, Resident #1 was ordered a low-air-loss, alternating pressure mattress to provide a higher level of pressure relief to her skin. A walking, pressure relief boot was ordered on or about 7/7/15. According to the National Pressure Ulcer Advisory Panel, a stage 1 pressure wound was intact, but reddened skin. Stage 2 was the loss of the top layers of skin with a pink base. Stage 3 was full thickness loss of skin with the fatty layer exposed. Stage 4 was with bone, ligaments and tendons exposed. Slough was yellow, tan, gray, green or brown tissue in the wound bed. Until enough slough are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage 3 or 4. According to interdisciplinary progress notes, dated 6/12/15, Resident #1's pressure wound was documented as stage 2. The progress note described the wound as, stage 2 serosang (serosanguinous - blood-tinged, clear fluid) fluid filled appears partially reabsorbed with loose skin - 4 cm (centimeters=about 1/2 inch) X 3.3 cm. Since the bottom of the wound was not documented as being visualized, determination of the stage was not possible. On 7/7/15, the base of the wound was documented as brown/yellow; indicating slough and the possibility of a stage 3 or 4 pressure wound, not a stage 2. Once the stage of a pressure wound was correctly determined, it would not change. On 8/26/15 at 2:50 p.m., Assistant Director of Nursing (ADON) D was interviewed. When asked what interventions were in place prior to the development of Resident #1's pressure wound on the left heel, ADON D stated that her heels were to be floated heels (elevate feet so no pressure was on the heels), encourage to turn every 2 hours, moisturize dry skin and do not massage skin over bony areas. A product used to dry/toughen skin was not used on Resident #1's heels. When asked, ADON D said that Resident #1 disliked not having her heels elevated, and often refused to reposition in bed. When asked if a fall with fractured left hip, surgical repair and increased pain would increase Resident #1's chance of developing pressure ulcers, ADON D said, Yes, they would. When asked if other interventions were developed before the pressure wound occurred, ADON D said that Resident #1 was care planned as rejecting care, but agreed that rejecting cares was not a new behavior. When asked if protective boots or a better mattress were considered after surgery, but before the pressure wound was discovered, ADON D said that Resident #1 had those now, and often refused the boot. When this surveyor, again, asked if anything else was considered before the development of the pressure wound, ADON D said, No, and agreed that the low-air-loss, alternating pressure mattress and/or pressure-relief boots could have been tried. On 8/27/15 at 8:25 a.m., Licensed Practical Nurse (LPN) P was observed as she applied a dressing to Resident #1's left heel. ADON E was also present to measure the wound, and stressed that she was not a wound nurse, I just measure wounds. Resident #1 had just had her bath in the bathtub, and was still sitting in the tub chair. No dressing was observed on her left heel. The pressure wound was measured by ADON E as 2.5 cm long by 2.3 cm wide by 0.2 cm deep. The open area was observed to be somewhat round in appearance and filled with a soft-appearing, yellow-brown material (slough) with a thin perimeter of pink tissue around the edge. Black specks were observed in the middle of the wound. The intact skin around the pressure wound appeared very pink in color,turned white when touched with this surveyor's finger-tip, and caused Resident #1 to inhale quickly and make a noise. Resident #1 said, I know it's going to hurt, but that was just reflex, you know. It's very tender. LPN P had placed the dressing supplies on a towel on a chair. Instead of using the single-use, saline irrigation container to irrigate the wound, LPN P squirted the saline on 3 by 3 inch gauze and patted the wound, twice. Without performing hand hygiene and changing gloves, LPN P applied a salve with a cotton-tipped applicator and dressed the wound with 3 by 3 gauze, tape and a stretchy gauze bandage. On 8/27/15 at 8:45 p.m., ADON E was asked if the container of saline was designed to provide the correct force to irrigate a pressure ulcer, and she said that it was. When this surveyor stated that LPN P failed to perform hand hygiene and change gloves between irrigating the wound and applying the dressing, ADON E said that she had not noticed that. When asked if soaking Resident #1's open wound in the bath tub was a good idea, ADON E said that whirlpool was often used to debride (remove dead tissue) wounds. When asked if the dirty bath water from a frequently incontinent resident was good for an open wound, ADON E shook her head back and forth and said, No. On 8/27/15 at 10:00 a.m., Nurse Practitioner (NP) Gg was interviewed. When asked about the dirty bath water on Resident #1's open pressure wound, NP Gg didn't think that was a good idea. When asked if she preferred that the saline containers be used to irrigate open wounds or used on gauzes for Resident #1's pressure wound cleansing, NP Gg said that she wanted the wound irrigated, not patted. On 8/27/15 at 1:15 p.m., Certified Nurse Assistant (CNA) N was interviewed. When asked how Resident #1 tolerated having her feet up on a pillow or a heels-up cushion, CNA N said, about 50% of the time. She (Resident #1) grabbed the cushions and threw them on the floor when she'd had enough, said CNA N, and she does the same, now, with the soft and walking boots. She demands to have them removed or refuses them. ( ) Resident #7 Resident #7 was admitted to the facility on [DATE] with a medical history according to the facility face sheet which included debility, falls, anxiety, depression, [MEDICAL CONDITIONS], asthma, reflux and [MEDICAL CONDITION]. Review of the facility MDS (minimum data set an assessment tool) Resident #7 was severely impaired for daily decision making skills, displayed verbal behaviors, required extensive one person assistance with dressing, hygiene, bathing, extensive two person assistance with bed mobility (ability to turn/move oneself in bed) supervision with eating and was incontinent of both bowel and bladder. Resident #7 was observed on 8/26/15 at 9:50 AM lying in bed dressed in a hospital gown and brief covered to the hips with a sheet, head of the bed was toward the wall (as you face the bed on the left) call light at the foot of the bed not within reach of the resident. Noted present was a fall mat on the right side of the bed, an alternating air pressure mattress, a pillow against the resident's back and nothing between the knees. Resident #7 was noted to be lying on her left side facing the wall, with her left knee pressed against the wall and multiple areas of dark-reddish brown areas present on the wall. Upon closer inspection an area of the reddish-brown material was under the resident's left knee pressing against the wall. This surveyor touched the wall which had a rough textured surface. Review of the facility document titled Braden Scale-For Predicting Pressure Sore Risk dated 7/9/15 Resident #7 scored 10. (Total score of 12 or less represents high risk). On 8/21/15 the score documented was 12. Resident #7 was observed on 8/26/15 at 10:53 AM lying on her left side facing the wall in the same position as noted at 9:50 AM with her left knee pressed against the wall. During the observation on 8/26/15 at 10:53 AM, this surveyor observed Certified Nurse Aides (CNA's) G and I enter Resident #7's room at 11:05 AM. CNA I turned Resident #7 onto her back, upon removing the sheet an undated dressing was noted on Resident 7's right hip. While on her back it was noted Resident #7 had two nickel size broken skin condition areas noted on her left knee. (The areas will be referred to here as Area A and Area B). Area A had a top layer of skin that was loosened/raised and open (appeared like a blister that had broken). Area B was an area crusted with dark reddish brown substance. CNA G commented she has had that a couple of days. I think the nurse knows. She is suppose to have a pillow but refuses. It hurts her. We last checked her at 8:30 AM. Upon entering the room on 8/26/15 at 12:15 PM, this surveyor noted Resident #7 was lying in bed turned onto her right side facing the room door. Resident #7 was observed again at 1:30 PM lying on her right side facing the room door. Resident #7 was observed a third time at 3:25 PM still lying in bed on her right side. Resident #7 was observed on 8/27/15 at 9:15 AM lying in bed with the head of the bed turned to the window (on the right as you face the bed). Noted absent were the reddish-brown areas on the wall observed on 8/26. During an interview on 8/28/15 at 11:25 AM, CNA G reported, I saw it on Monday 8/24 I think I reported to my nurse. Review of the facility provided document titled Weekly Skin Assessment dated 7/9/15 and 8/16/15 documented no skin issues related to the left knee. Review of the facility provided document Treatment Administration Record (TAR) reviewed for 7/15 weekly skin assessment Wednesday 7-3 revealed on documentation for 7/8, 15, 22, 29 indicating the assessment were not done. Review of the facility provided document dated 7/9/15 on the TAR weekly skin assessment Thursdays 3-11 7/9/15, 16, 23, 30 no documentation was present. Review of the facility provided document on the TAR reviewed for 8/15 for weekly skin assessments on Thursday 3-11 8/6/15, 13, 20, 27 no documentation was present. Review of the facility Physician orders [REDACTED]. Review of the facility provided Nursing Care Plan titled at risk for impaired skin integrity reviewed 5/23/15 revealed no information related to the areas on the left knee. Present were the interventions assess skin daily with care and weekly with bath assist to turn and reposition every 2 hours, heels bridged when in bed (elevated off bed onto pillow) keep resident off right hip. Review of the facility provided document referred to as CNA care guide in section titled skin listed as information at risk for skin breakdown, do not lie on right side. Review of the facility provided document titled Interdisciplinary Notes dated from 8/1/15 to 8/27/15 revealed on 8/27/15 at 10:11 AM attempted to assess resident knees, yelled and stated 'don't touch it'. When I reached for the covers, denied pain but wanted her covers left in place. During an interview on 8/28/15 at 11:25 AM, Assistant Director of Nursing (ADON) E reported, I tried to see it yesterday she wouldn't let me touch it (the knee). I don't know when it occurred. There is no treatment. Nothing in the nursing care plan. The skin assessments were not done. I don't remember anyone telling me about that, I first knew about it yesterday. I do the wound measurements. Review of the Nurse Practitioner Progress Noted titled Skin Breakdown Review dated 8/25/15 revealed no documentation related to the areas on the left knee. During an interview and observation of Resident #7 on 8/28/15 at 12 PM, Licensed Practical Nurse (LPN) J stated, I was told by a CNA about the knee and told the NP (Nurse Practitioner) and ADON Tuesday (8/25/15) probably between 8:30 AM - 9 AM. They were going down to check her out, so I thought they would look at that also. When LPN J rolled up Resident 7's pant leg the left knee was noted to be two areas slightly larger than a 5 cent piece. The areas were noted to be light red-pink with two dry red-brown scabbed areas, no dressing was present, Resident #7 it feels like it was burned. ( )

This citation pertains to intake number MI 015 and MI 233. Based on interview and record review the facility failed to prevent a significant medication error and administer medications per the physician order [REDACTED].#102) reviewed for medication, from a total of 3 sampled residents, resulting in Resident #102 being sent to the hospital in acute kidney failure. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 was a [AGE] year old male admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS reflected that Resident #102's ability to make daily decisions was moderately impaired and he required supervision of one staff member to transfer, dress, toilet, and bath. Review of the Hospital Discharge Medication Instruction dated 3/18/15, revealed that Resident #102 was ordered [MEDICATION NAME] (a diuretic), 10 mg oral tablet, 0.5 tab (5 mg), by Mouth, once a day. Review of the Facility Physician order [REDACTED].#102 was to recieve a total of 10 mg instead of the ordered 5 mg). In an interview on 4/21/15 at 1:15 p.m., Licensed Practical Nurse (LPN) C reported that she admitted Resident #102 to the facility using his discharge orders from the hospital. LPN C reported that she had missed the error for the [MEDICATION NAME] 10 mg tablet. Review of the physician progress notes [REDACTED].#102 had decreased oral intake, [MEDICAL CONDITION], decreased urine output, history of [MEDICAL CONDITIONS]. Plan .Begin IV (intravenous) fluids NS (normal saline) @ 100 cc/hr x 40 then 75 cc/hr x 48 hr, check BMP, CBC in AM. Review of the Physician Phone Orders dated 3/31/15 (no time), revealed Resident #102 was to Start IV NS @ 100 mL/hr 1 L total., indication dehydration. Review of the Physician Phone Orders dated 3/31/15 (no time), revealed Resident #102 was to receive IV NS @ 100 cc/hr x 4 hours, then 75 cc/hr x 48 hours. Review of the Physician Phone Orders dated 4/1/15 at 10:15 a.m., revealed Resident #102's Potassium was elevated [MEDICATION NAME] 15 gm PO 1 x now. Review of the Physician Phone Orders dated 4/1/15 (no time), revealed Resident #102 was sent to the Hospital to evaluate and treat for acute [MEDICAL CONDITIONS], leukocytosis, recent [MEDICAL CONDITION], and worsening pain at Stage IV pressure ulcer. Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED]. According to the Medical Administration Records from March - April 2015, Resident #102 was administered a total of 14 doses of [MEDICATION NAME] at 10 mg, and not the 5 mg dose ordered by the physician. Review of the Laboratory Values dated 4/1/15 at 10:31 a.m., revealed that Resident #102's Blood Urea Nitrogen (BUN) (used to evaluate kidney function) was elevated at 72 (8-20 normal range), and Creatinine (a tests that measures kidney function) was elevated at 4.2 (0.4-1.2 normal range) which indicated Resident #102 was in acute [MEDICAL CONDITION] and was dehydrated. Review of the Hospital Progress Notes dated 4/6/15 (no time), revealed Resident #102 was administered excess diuretics. while at the nursing home. #

This citation pertains to intake number MI 015 and MI 233. Based on interview and record review the facility failed to ensure the accuracy of transcribed physician's orders [REDACTED].#102) reviewed for medication, from a total of 3 sampled residents, resulting in Resident #102 being sent to the hospital in acute kidney failure. Findings include: According to the Fundamentals of Nursing, 6th edition (Mosby, Patricia A. Potter, Anne G. Perry, 2005 page 419) the physician should write all orders, and the nurse must make sure that they are transcribed correctly. Medication errors may result from inaccurate documentation. Therefore it is essential that nurses ensure the appropriate documentation exists before giving medications. (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 was a [AGE] year old male admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS reflected that Resident #102's ability to make daily decisions was moderately impaired and he required supervision of one staff member to transfer, dress, toilet, and bath. Review of the Hospital Discharge Medication Instruction dated 3/18/15, revealed that Resident #102 was ordered [MEDICATION NAME] (a diuretic), 10 mg oral tablet, 0.5 tab (5 mg), by Mouth, once a day. Review of the Facility Physician order [REDACTED].#102 was to recieve a total of 10 mg instead of the ordered 5 mg). In an interview on 4/21/15 at 1:15 p.m., Licensed Practical Nurse (LPN) C reported that she admitted Resident #102 to the facility using his discharge orders from the hospital. LPN C reported that she had missed the error for the [MEDICATION NAME] 10 mg tablet. Review of the Physician Phone Orders dated 4/1/15 (no time), revealed Resident #102 was sent to the Hospital to evaluate and treat for acute [MEDICAL CONDITIONS], leukocytosis, recent [MEDICAL CONDITION], and worsening pain at Stage IV pressure ulcer. Review of the Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. According to the Medical Administration Records from March - April 2015, Resident #102 was administered a total of 14 doses of [MEDICATION NAME] at 10 mg, and not the 5 mg dose ordered by the physician. Review of the Laboratory Values dated 4/1/15 at 10:31 a.m., revealed that Resident #102's Blood Urea Nitrogen (BUN) (used to evaluate kidney function) was elevated at 72 (8-20 normal range), and Creatinine (a tests that measures kidney function) was elevated at 4.2 (0.4-1.2 normal range) which indicated Resident #102 was in acute [MEDICAL CONDITION] and was dehydrated. Review of the Hospital Progress Notes dated 4/6/15 (no time), revealed Resident #102 was administered excess diuretics. while at the nursing home. #

This citation pertains to intake number MI 397. Based on interview and record review, the facility failed to prevent an accident with injury causing death for in 1 of 3 sampled residents (Resident #102) reviewed for falls, from a total sample of 5 residents, resulting in an Immediate Jeopardy when on [DATE] at 1:30 a.m. Resident #102, was transferred contrary to the resident ' s care plan by not having both the assistance of one staff member and a gait belt. Resident #102 fell to the floor and was placed back in bed. It was determined later that Resident #102 sustained a fracture of the right hip. Resident #102 was transferred to the hospital 9 ? hours later on [DATE] at 10:56 a.m., where she died from a complication of the right hip fracture on [DATE] at 6:05 a.m. This deficient practice placed all residents who required transfer assistance and are at risk for falls, at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #102 was cognitively intact for daily decision-making skills. Review of the Fall Risk Evaluation dated [DATE], revealed Resident #102 scored 12, "If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." Review of the Fall Care Plan, dated [DATE], revealed Resident #102 was at risk for falls related to recent illness with weakness/debility and balance deficits per therapy evaluation. The Fall Care Plan interventions were that Resident #102 was to have "1 person assist with transfers using the walker and gait belt." Review of the Accident/Incident Report dated [DATE] at 1:30 a.m., revealed Resident #102 was in her room with staff "transferring from wheelchair to bed when she fell on her right side next to bed." In an interview on [DATE] at 10:55 a.m., Certified Nurse Aide (CNA) "D" reported that on [DATE] at 1:30 a.m., he went in to assist Resident #102. CNA "D" stated, "We were short staffed that night and in a crunch, so I figured she could pivot and transfer (independently)." CNA "D" reported that Resident #102 was supposed to be a one person assist with a walker and a gait belt. CNA "D" reported that he stood behind Resident #102's wheelchair, told her to stand, and before he could step around beside her, she fell . CNA "D" reported that Resident #102 stood, lost her balance, and fell . In an interview on [DATE] at 6:03 p.m., Licensed Practical Nurse (LPN) "C" reported that CNA "D" informed her that Resident #102 had fallen. LPN "C" reported that she found Resident #102 on the floor laying on her right side between the wheelchair and the foot of the bed and there was a lot of blood. LPN "C" reported that her supervisor came to assist her and they sat Resident #102 up to assess where the blood was coming from, which was a large skin tear on her right arm. LPN "C" reported that Resident #102 did complain about her right hip and that it was tender when she touched it, but she administered a pain pill and Resident #102 did not complain about pain the remainder of her shift. LPN "C" reported that Resident #102 told her (LPN "C") that "(CNA "D") would not help me. He told me I could do it myself, you can do it on your own" and that (CNA "D") was standing, holding the wheelchair." LPN "C" reported that the wheelchair was pointed toward the end of the bed. LPN "C" reported that CNA "D" did not come back to the room to assist after telling her about the fall. LPN "C" reported that no one asked her to make a statement during the investigation and that she did not document this on the Accident/Incident Report. In an interview on [DATE] at 9:10 a.m., LPN "H" reported that on [DATE] she was called by radio to Resident #102's room, where LPN "C", LPN "G", and CNA "I" were in the room. LPN "H" reported that Resident #102 was in front of the wheelchair on the floor, she had a large skin tear on her one arm, and a smaller one on the other arm. LPN H" reported that when she asked how this happened Resident #102 stated "he (CNA "D") did not help me," and that CNA "D" "was behind the wheelchair and told her to go ahead and get up." LPN "H" reported that Resident #102 was being transferred from the wheelchair to bed and it appeared her arm hit where the leg of the wheelchair and foot pedal attach, and possibly the other arm hit the footboard of the bed "the larger skin tear on the right arm." LPN "H" reported that her focus was to look at the wounds on Resident #102 arms, but she did check to make sure her legs were straight and not rotated. LPN "H" reported that she spoke to CNA "D" about not following the care plan and transferring Resident #102 with one person assist using the walker, and a gait belt. LPN "H" reported that CNA "D" stated, "I don't transfer her that way she's pretty much independent." LPN "H" stated, "(CNA "D") did not transfer Resident #102 according to the care plan, she should not have fallen. I wrote him up the next night for not following the care plan." In an interview on [DATE] at 3:00 p.m. Physical Therapist (PT) "E" reported that Resident #102 was not able to transfer alone because she did not have the strength to stand alone and transfer, and that she was to be transferred with one person assist with a gait belt. PT "E" reported that she saw Resident #102 some time prior to breakfast on [DATE] between 8:00 a.m. and 8:30 a.m.. Review of the Physical Therapy Notes dated [DATE] (no time), revealed Resident #102 "complained of pain on posterior right hip post fall. Pain with range of movement. Patient now a Hoyer lift." Review of the Occupation Therapy Notes dated [DATE] (no time), revealed Resident #102 "had a fall yesterday transferring from the commode to bed and reports increased hip pain. Spoke with nursing and pain medication administered. Pain ,[DATE] in left (DIC) hip. Spoke with nursing placing order for x-ray-no bruising noted but significant to pain and unable to stand and weight bear-sitting pain ,[DATE], no active range of motion tolerated." Review of the Physician's Progress Notes dated [DATE] (no time), revealed "fall at 1:30 a.m. onto right side by bed, pain-right hip, severity ,[DATE],..abdominal x-ray right hip-possible nondisplaced femur fracture." Review of the Physician's Phone Orders dated [DATE] (no time), revealed "x-ray to right hip STAT, not able to bear weight, pain with range of motion." Review of the Interdisciplinary Notes dated [DATE] at 11:00 a.m., revealed Resident #102 had an x-ray to right hip at 10:00 a.m. and went out to the hospital at 11:00 a.m. for an evaluation for a possible right hip fracture. Review of the Radiology Report dated [DATE] at 10:26 a.m., revealed possible fracture was to have an x-ray due to pain after fall of right hip. The Radiology Report revealed in the conclusion that Resident #102 had a possible hip fracture. Review of the Certificate of Death, dated [DATE], revealed Resident #102 died on [DATE] while at "other care center". Cause of death was listed as "Complications of right hip fracture. Approximate interval between onset and death - days." There were no additional [DIAGNOSES REDACTED]. In an interview on [DATE] at 4:15 p.m., Administrator "A" reported that he was aware CNA "D" did not follow the care plan and use the gait belt while transferring Resident #102. Review of the Facility Progressive Discipline dated [DATE], revealed CNA "D" received a final written warning which indicated "(CNA "D") was assisting a Resident (Resident #102) and instead of using a one person assist with gait belt as care plan states, he told the resident to stand up independently. The resident fell and sustained a severe injury." In an interview on [DATE] at 2:00 p.m., Registered Nurse (RN)/Interim Director of Nursing (DON) "B" reported that a Progressive Discipline note for CNA "D" was written because he did not follow the care plan for Resident #102. DON "B" reported that no other staff other than CNA "D" was educated on following care plans to prevent falls. On [DATE] at 4:25 p.m., Administrator "A" was notified of the Immediate Jeopardy that began on [DATE] at 1:30 a.m., and was identified on [DATE], when the facility failed to prevent the fall and ensure the safety of Resident #102, who was identified as a high risk for falls and who fell on [DATE] at 1:30 a.m. On [DATE], this surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. Resident #102 no longer resided at the facility. 2. On [DATE], 91 residents assessed as being at risk for falls had their care plans reviewed. 3. On [DATE], the Facility Fall Prevention Policy was reviewed and found to be sufficient. 4. On [DATE], 34 of 95 CNA's, 18 of 36 LPN's, 12 of 19 Dining Service Members, 8 of 16 Housekeeping/Laundry 6 of 16, and 4 of 10 Administration/Life Enrichment/Maintenance have been trained on the facility policy, interventions used to prevent falls and departmental roles for prevention of falls. Staff coming on shift will not work until they receive training on the facility policy, interventions used to prevent falls and departmental roles for prevention of falls. 5. Beginning [DATE], the Director of Nursing or designee with begin auditing 10% of residents identified as risk for falls care plans to ensure accuracy. In addition, the DON will observe staff completing resident transfers at least 1 day per week for 3 months. 6. The Administrator is responsible for compliance and implementation of the removal. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, as all staff had not yet been educated and sustained compliance had not been verified by the State Agency. #

This citation pertains to intake number MI 397. Based on interview and record review, the facility failed to implement resident's care plans in 1 of 5 sampled residents (Resident #102) reviewed for care plans, from a total of 5 sampled residents, resulting in a fall with fracture and death. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #102 was cognitively intact for daily decision-making skills. Review of the Fall Risk Evaluation dated 11/8/14, revealed Resident #102 scored 12, "If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." Review of the Fall Care Plan, dated 11/25/14, revealed Resident #102 was at risk for fall related to recent illness with weakness/debility and balance deficits per therapy evaluation. The Fall Care Plan interventions were "1 person assist with transfers using the walker and gait belt." Review of the Accident/Incident Report dated 12/16/14 at 1:30 a.m., revealed Resident #102 was in her room with staff "transferring from wheelchair to bed when she fell on her right side next to bed." Review of the Safe Resident Handling and Transfers Policy dated 1/26/15, revealed "This policy describes ways to ensure that employees use safe resident handling and movement techniques..." The Safe Resident Handling and Transfers Policy revealed the Procedure Guidelines: "A. Compliance: It is the duty of employees to take reasonable care of their own health and safety, as well as that of their co-workers and their resident during resident handling activities by following this policy...B. Patient Handling and Movement Requirements: 1. Avoid hazardous resident handling..Delegation of Authority and Responsibility... C. Employees shall: 1. comply with all parameters of this policy. 2. Use proper techniques, mechanical lifting devices, and other approved equipment/aids during performance of resident handling tasks..." In an interview on 2/4/15 at 10:55 a.m., Certified Nurse Aide (CNA) "D" reported that on 12/16/14 at 1:30 a.m. he went in to assist Resident #102. CNA "D" stated, "We were short staffed that night and in a crunch so I figured she could pivot and transfer (independently)." CNA "D" reported that Resident #102 was supposed to be a one person assist with a walker and a gait belt. CNA "D" reported that he stood behind Resident #102's wheelchair, told her to stand, and before he could step around beside her, she fell . CNA "D" reported that Resident #102 stood, lost her balance, and fell . In an interview on 2/3/15 at 6:03 p.m., Licensed Practical Nurse (LPN) "C" reported that CNA "D" informed her that Resident #102 had fallen. LPN "C" reported that she found Resident #102 on the floor laying on her right side between the wheelchair and the foot of the bed and there was a lot of blood. LPN "C" reported that her supervisor came to assist her and they sat Resident #102 up to assess where the blood was coming from, which was a large skin tear on her right arm. LPN "C" reported that Resident #102 did complain about her right hip and that it was tender when she touched it, but she administered a pain pill and Resident #102 did not complain about pain the remainder of her shift. LPN "C" reported that Resident #102 stated "(CNA "D") would not help me. He told me I could do it myself, you can do it on your own" and that (CNA "D") was standing behind her holding the wheelchair." LPN "C" reported that the wheelchair was pointed toward the end of the bed. LPN "C" reported that CNA "D" did not come back to the room to assist after telling her about the fall. LPN "C" reported that no one asked her to make a statement during the investigation and that she did not document this on the Accident/Incident Report. In an interview on 2/5/15 at 9:10 a.m., LPN "H" reported that on 12/16/14 she was called by radio to Resident #102's room, where LPN "C", LPN "G", and CNA "I" were in the room. LPN H" reported that when she asked how this happened Resident #102 stated "he CNA "D" did not help me," and CNA "D" stated that "he was behind the wheelchair and told her to go ahead and get up." " LPN "H" reported that she spoke to CNA "D" about not following the care plan and transferring Resident #102 with one person assist using the walker, and a gait belt, LPN "H" reported that CNA "D" stated "I don't transfer her that way she's pretty much independent." LPN "H" stated "CNA "D" did not transfer Resident #102 according to the care plan, she should not have fallen, I wrote him up the next night for not following the care plan." In an interview on 2/3/15 at 3:00 p.m. Physical Therapist (PT) "E" reported that Resident #102 was not able to transfer alone because she did not have the strength to stand alone and transfer, and that she was to be transferred with one person assist with a gait belt. In an interview on 2/4/15 at 4:15 p.m., Administrator "A" reported that he was aware CNA "D" did not follow the care plan and use the gait belt while transferring Resident #102. Review of the Facility Progressive Discipline dated 12/16/14, revealed CNA "D" received a final written warning which indicated "(CNA "D") was assisting a Resident (Resident #102) and instead of using a one person assist with gait belt as care plan states, he told the resident to stand up independently. The resident fell and sustained a severe injury." In an interview on 2/4/15 at 2:00 p.m., Registered Nurse (RN) Interim Director of Nursing (DON) "B" reported that a Progressive Discipline note for CNA "D" was written because he did not follow the care plan for Resident #102. #

This citation pertains to intake MI 965. This citation has 4 deficiency practice statements, A, B, and C. Based on observation, interview and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical well-being (adequately assess and monitor a resident for [MEDICAL CONDITION]) in 1 of 4 sampled residents (#101) resident with [MEDICAL CONDITION], from a total sample of 4 residents, resulting in Resident #101 having pain, shortness of breath, being transferred to the hospital where he was diagnosed with [REDACTED]. Findings include: Resident #101: Review of Resident #101's medical record revealed an [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].), unspecified nutritional deficiency, [MEDICAL CONDITION], chronic ischemic [MEDICAL CONDITION] and [MEDICAL CONDITION]. His minimum (MDS) data set [DATE] indicated he required physical assistance of one person for transfers, and dressing and supervision for personal hygiene. Review of Resident #101's Record of Death revealed he passed away in the hospital on [DATE]. Review of Resident #101's facility weight record indicated his weight upon admission to the facility on [DATE] was 187.7 pounds (lbs.). The facility weight record for Resident#101 indicated the following weights for Resident #101 from his admission until he was transferred to the hospital on [DATE]: 8/17/13 of 190.2 lbs, 8/19/13 of 191.6 lbs, 8/21/13 of 194.8 lbs, 8/23/13 of 198.2 lbs, 8/25/13 of 202.4 lbs, 8/31/13 of 212 lbs, 9/1/13 of 214.8 lbs, 9/2/13 of 215.6 lbs, and nurse's notes dated 9/3/13 indicated a weight for Resident #101 to be 216.8 lbs, which indicated a weight gain of 29.1 lbs in 18 days. Review of nurse's notes for Resident #101 revealed a documented assessment of lung sounds for Resident #101 on 8/16/13 during the nursing admission assessment. Nurse's note for Resident #101 dated 8/19/13 indicated a stat (immediate) chest X-ray was ordered due to cough, dyspnea (shortness of breath), and lung congestion and Resident #101 was diagnosed with [REDACTED]. No assessment of lung sounds is indicated in the notes. Nurse's note for Resident #101 dated 8/21/13 at 4:00 am, indicated Resident #101 was on antibiotic for pneumonia, had discoloration to bilateral legs with [MEDICAL CONDITION] ([MEDICAL CONDITION] is swelling caused by fluid in the tissues which leaves a dent in the skin after you press the area with a finger for about 5 seconds). No assessment of lung sounds was seen in the nurse's note. Nurse's note for Resident #101 dated 8/21/13 at 5:20 pm indicated Resident #101 complained of a cough at 11:45 am and was given cough medication, was on antibiotic for pneumonia, had a pulse of 105 (normal 60 - 100), and both legs were very [MEDICAL CONDITION], very taut and shiny. No assessment of lung sounds was seen in the nurse's note. Nurse's note for Resident #101 dated 8/22/13 at 4:45 pm indicated Resident #101 had 3 plus [MEDICAL CONDITION], and weeping fluids from his lower legs, his outer abdomen had [MEDICAL CONDITION], Resident #101 complained of shortness of breath when ambulating and complained of feeling light headed. The note indicated Resident #101 was coughing up thick, yellow phlegm and was given medication for the cough. No assessment of lung sounds was seen in the nurse's note. Nurse's notes dated 8/28/13 at 7:05 pm indicated Resident #101 had a pulse of 121, nurse's note dated 8/29/13 at 3:00 pm indicated Resident #101 had a pulse of 120, was short of breath when ambulating, had [MEDICAL CONDITION] and redness to his legs, had a new order for increased diuretic medications (medications meant to decrease the fluid in the body). No assessment of lung sounds were seen in the above mentioned nurse's notes. Nurse's notes dated 8/31/13 at 6:00 pm for Resident #101 indicated Resident #101 stated he was unable to urinate, his testicles were very swollen with obvious fluid. Nurse note dated 9/1/13 at 5:00 pm indicated Resident #101 had increased shortness of breath, was unable to void, increased [MEDICAL CONDITION], increased heart rate and his testicles were elevated to relieve [MEDICAL CONDITION], with I and O (Record of intake and output of fluids) started. Nurse's note dated 9/2/13 (no time) indicated Resident #101 had a pulse of 139, respiratory rate of 22, and had been uncomfortable due to fluid with 2 plus (Slight indentation. 15 seconds to rebound) [MEDICAL CONDITION] noted on his trunk. Nurse's notes dated 9/3/13 at 3:10 pm indicated Resident #101 continued with [MEDICAL CONDITION] in groin area and lower extremities (legs). The note also indicated Resident #101's urine was amber colored. Nurse's note on 9/3/13 at 11:00 pm indicated Resident #101 was feeling short of breath at 10:30 pm with a pulse of 111 and stated he was feeling very anxious about all of his new orders. The note indicated facility Nurse Practitioner was notified, who ordered anti-anxiety medication. Nurse's note dated 9/2/13 (no time) indicated Resident #101 was very swollen and tight from the waist down, complained of shortness of breath, was seen by the nurse practitioner and sent to the hospital for evaluation. Review of the entire medical record revealed no documentation of intake and output of fluids for Resident #101. Review of the entire medical record did not reveal a physician order [REDACTED]. Review of Resident #101's laboratory values revealed on 8/23/13 a sodium level of 133 (normal 135 - 145), [MEDICATION NAME] 2.8 (normal 3.5 - 4.8 Proteins circulate throughout your blood to help your body maintain fluid balance) total protein 5.7 (normal 6.1 - 7.9). Laboratory result on 8/26/13 revealed a [MEDICATION NAME] of 8.5 (normal 18.0 to 38.0 blood test to see whether you are getting proper nourishment from your diet. Specifically, the test finds out if you have been getting enough protein and if not, whether you are at risk for [MEDICAL CONDITION] or already suffering from it). In an interview on 10/10/13 at 10:20 am, facility Director of Nursing #1 (DON #1) stated Intake and Output was never done on Resident #101. DON #1 stated she had reviewed the entire chart and did not see any documented intake and output records. DON #1 stated she believed a resident's weight was more accurate than intake and output. The surveyor asked DON #1 if Resident #101 was on daily weights (being weighed daily) and DON #1 stated no, it was never ordered. The surveyor asked DON #1 how facility staff assess and monitor a resident with [MEDICAL CONDITION] and DON #1 stated nursing staff use a form (provided to surveyor) titled "Care Path: Symptoms of [MEDICAL CONDITIONS]". DON #1 handed a [MEDICAL CONDITION] Care Path with Resident #101's name on it to the surveyor. The surveyor asked DON #1 if the Care Path had been filled out and used while Resident #101 was residing in the facility or after he had been discharged to the hospital. DON #1 told the surveyor to ask ADON (assistant director of nursing for West Hall) #2. In an interview on 10/10/13 at 10:55 am, ADON #2 stated she filled out the [MEDICAL CONDITION] pathway for Resident #101 after he left to see if they were following the pathway. The surveyor asked ADON #2 when exactly she filled out the [MEDICAL CONDITION] pathway and ADON #2 stated she filled it out "this morning". In an interview on 10/11/13 at 10:45 am, Nurse Practitioner #9 (NP #9) stated Resident #101 should have had an order for [REDACTED]. NP #9 stated Resident #101's nutrition was bad, his [MEDICATION NAME] was very low. NP #9 stated nobody at the facility ever told her that Resident #101 wasn't eating well. NP #9 stated she should have put Resident #101 on intake and output with the fluid changes he had. NP #9 stated when she saw Resident #101 on 9/4/13 she was shocked at the [MEDICAL CONDITION] that had developed in him since she had seen him on 8/29/13. In an interview on 10/17/13 at 11:05 pm, LPN (licensed practical nurse) #13 stated when she cared for Resident #101 on 9/1/13 and 9/2/13 he was very full of fluid, his testicles were very swollen, he was short of breath and very uncomfortable from the fluid. LPN #13 stated Resident #101 was [MEDICAL CONDITION] from his legs up to the sides of his body and his chest. LPN #13 stated NP #15 was notified on 9/1/13 and he wanted intake and output started. LPN #13 wasn't sure where the intake and output would be documented but thought there should be an "I and O" sheet. In an interview on 10/17/13 at 11:20 am, LPN #14 stated when she cared for Resident #101 on 9/2/13 she contacted the Nurse Practitioners regarding his condition and they wouldn't do much of anything. LPN #14 stated Resident #101's legs, and stomach were [MEDICAL CONDITION]. LPN # 14 stated Resident #101 just didn't feel right. In an interview on 10/17/13 at 11:40 am, NP #15 stated he didn't remember getting contacted regarding Resident #101. NP #15 stated, "I get so many". The surveyor reviewed resident information with NP #15 and NP #15 stated he did not remember. The surveyor reminded NP that it would have been Labor Day weekend and NP #15 stated he did not remember. In an interview with DON #1 on 10/17/13 at 12:45 pm, DON #1 stated licensed nursing staff all have a laminated copy of "Medicare Documentation Guidelines for Skilled Care" and that is what they are to use for documenting assessments of residents. DON #1 provided of copy of the laminated guidelines to the surveyor. Under the section titled, "[MEDICAL CONDITION]" the guideline indicated lung sounds: rales, wheezing?, SC8 with activity (ability to maintain blood oxygen level with activity), endurance, oxygen needs/breathing treatments, [MEDICAL CONDITION] pitting or non, +1 -+4, Diuretic Therapy/signs or symptoms of dehydration (medications to remove fluid from the body), fluid restrictions, intake/output, weakness, position changes. Review of hospital records for Resident #101 revealed emergency room physician progress notes [REDACTED]. The note indicated Resident #101's respirations were increased, he spoke in 2 to 3 word sentences and he was completely [MEDICAL CONDITION] from his chest was to abdomen to lower extremities; likely due to his diastolic dysfunction (heart dysfunction) and retaining fluid. The note indicated Resident #101's chest wall [MEDICAL CONDITION] was restricting his ability to take in a full breath. Review of hospital progress note dated 9/8/13 for Resident #101 indicated working discharge [DIAGNOSES REDACTED]. # B. Based on observation, interview and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical well-being (adequately assess and monitor oxygen status and lung sounds) in 1 of 4 sampled residents (#102) reviewed for respiratory concerns, from a total sample of 4 residents, resulting in Resident #102 being found without physician ordered oxygen, in respiratory distress and being transferred to the hospital where she was treated for [REDACTED]. Findings include: Resident #102: Review of Resident #102's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #101's hospital physician progress notes [REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated she was cognitively intact, required limited assistance of one person for transfers, ambulation, dressing, and personal hygiene. Review of hospital discharge orders for Resident #102 dated 9/24/13 revealed an order for [REDACTED].#102 to have laboratory tests BMP (basic metabolic panel - used to evaluate kidney function, blood acid/base balance, and your levels of blood sugar, and electrolytes. A basic metabolic panel may also check your levels of calcium and a protein called [MEDICATION NAME]) and CBC (complete blood count - used to detect or monitor infections or allergies [REDACTED]. Review of the entire medical record for Resident #102 did not reveal an order for [REDACTED]. Review of facility physician progress notes [REDACTED].#102 was in the hospital for pneumonia and back pain and was to have follow CBC and BMP on 9/30/13. The section titled "Physical Exam...Respiratory" was left blank. Review of admission nurse's note for Resident #102 dated 9/24/13 at 9:00 pm indicated she had a [DIAGNOSES REDACTED]. Review of all nurse's notes for Resident #102 from 9/24/13 until she was discharged to the hospital on [DATE], revealed the only documented assessment of lung sounds for Resident #102 was on admission on 9/24/13 at 9:00 pm. Nurse's note for Resident #102 dated 10/5/13 at 10:00 pm indicated Resident #102 had a loose, non-productive cough. The nurse's notes do not indicate any vital signs with the exception of oxygen saturation of 94 percent on 2 liters of oxygen per minute. There is no documented assessment of Resident #102's lung sounds in the nurse's note. Nurse's note for Resident #102 dated 10/6/13 at 4:15 am indicated Resident #102 was found in her room with rapid, labored respirations and was "mouth breathing". The note indicated Resident #102 was mouth breathing responded slowly and after staff called her name twice could only answer with "yes" or "no". The nurse's note indicated "audible gurgling could be heard" and Resident #102's oxygen saturation was 69 percent (normal is 95 to 100 percent) on room air. The note also indicated that Resident #102's oxygen was not on at the time she was found. The nurse's note indicated Resident #102's vital signs included a temperature of 100.5 (normal 98.6) and respirations of 44 (normal 12 - 18 breaths per minute), and oxygen saturation of 75 to 84 percent on oxygen, so a mask with 10 liters of oxygen was placed on Resident #102 and her respirations continued to be rapid and labored. The nurse's note indicated Resident #102 was transferred to the hospital. Review of hospital emergency physician note for Resident #102 dated 10/6/13 revealed Resident #102 was recently admitted and discharged from the hospital with bilateral pneumonia (fluid in both lungs) and on current exam currently had bilateral rhonchi of the lungs (course rattling sound heard in the lungs), and is noted to be hypoxic (low levels of oxygen in the blood. Resident #102 had leukocytosis with a white blood cell count of 24.5 (increased white blood cell count most likely due to infection). Her [DIAGNOSES REDACTED]. According to the Medicare Documentation Guidelines for Skilled Care provided to the surveyor by DON #1, a resident with a history of [MEDICAL CONDITION] and/or vent dependent would require the following documentation: breath/lung sounds, [MEDICAL CONDITION] care, shortness of breath,/dyspnea (shortness of breath), precipitating factors, cough (productive/non-productive, sputum: color, consistency, odor, amount, suctioning, needs, oxygen needs, labs results, weaning, respiratory medication effectiveness, confusion, restlessness, anxiety, skin color, pneumonia, antibiotic therapy. In an interview with DON #1 on 10/17/13 at 12:45 pm, she stated that nursing staff would use the [MEDICAL CONDITION] category to document for pneumonia residents. # C. Based on observation, interview and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical well-being (assess and monitor for aspiration) in 1 of 4 sampled residents (#103) reviewed for respiratory concerns, from a total sample of 4 residents, resulting in Resident #104 being found in respiratory distress and being transferred to the hospital where she was treated for [REDACTED]. Findings include: Resident #103: Review of Resident #103's record revealed an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated she was severely impaired with cognitive skills, required limited physical assistance of one person for eating and extensive physical assistance of two persons for transfers and dressing. Review of speech therapy discharge note for Resident #103 dated 9/5/13 revealed Resident #103 had ongoing cognitive, linguistic deficits requiring 24 hour supervision and also continued to have signs and symptoms of aspiration, however lung sounds remained clear. Review of Resident #103's activity of daily living plan of care revealed she had a mechanical soft diet with thin liquids and was to have no straws. physician progress notes [REDACTED]. Review of nurse's note for Resident #103 dated 9/20/13 at 11:10 am indicated Resident #103 was without fever, blood oxygen level was normal at 96 percent on room air and was pleasant and cooperative while participating in activities and therapy. Review of nurse's note for Resident #103 dated 9/21/13 at 7:30 am, signed by RN #8, indicated Resident #103 was found in her room when RN #8 went in to give 6:00 am medication, breathing with great difficulty with a blood oxygen level of 71 percent on room air. The note indicated after oxygen was applied to Resident #103 at 5 liters per minute via nasal cannula Resident #103 continued to be uncomfortable with rapid breaths, stomach breathing, admitted to fatigue and requested RN #8 to "do something". The note indicated Resident #103 emitted a "food like substance" from her mouth along with a "frothy liquid like substance". The note indicated facility Nurse Practitioner was notified and an order was obtained to send Resident #103 to the hospital. The note then indicated family was notified. Then the nurse's note went on to indicate that on 9/20/13 Resident #103 had been emitting the "frothy substance" from her mouth. The note indicated Resident #103 had no evidence of discomfort, shortness of breath, anxiety or pain and denied pain or discomfort. The note indicated at 5:00 am Resident #103's breath sounds were audible without a stethoscope. The nurse's note indicated Resident #103 went to the hospital by ambulance around 5:45 am. In an interview on 10/11/13 at 10:10 am, RN #8 stated around 7:00 pm on 9/20/13, he observed Resident #103 with a white foaming substance coming out of her mouth. RN #8 stated he checked her "pulse ox" (oxygen level) and she was fine. The surveyor asked RN #8 if he documented the pulse oximetry he checked at 7:00 pm and RN #8 stated after Resident #103 was sent to the hospital on [DATE], he thought he did. RN #8 stated he thought the white foaming substance coming from Resident #103's mouth was regurgitation, so he gave her a cup to spit into and she went to bed as normal. RN #8 stated when he went in to do morning pills for Resident #103 around 5:00 am, she had really labored breathing, was gasping, fatigued, had oxygen level in the 70's (normal 95 to 100) and there was more foaming. RN #8 stated there was a food substance in her mouth that came out, which was fleshy colored, circular and Resident #103 spit the food substance out. RN #8 stated he attempted to use oxygen by nasal cannula to bring Resident #103's oxygen level up, but her level stayed down, so he (RN #8) called for a nurse on another unit to help him. RN #8 stated RN #10 came and they put an oxygen mask on Resident #103. RN #8 stated Resident #103 was still gasping for air and "doing the foaming stuff" even though her oxygen level was up to the 90's. RN #8 stated he could hear Resident #103's lungs without a stethoscope and they just sounded "wet". RN #8 stated he could tell from the strained look on Resident #103's face she was struggling to breathe. RN #8 stated he did not get a set of vital signs on Resident #103, did not listen to Resident #103's lungs, or notify anyone, including Resident #103's family or physician when he observed her foaming from the mouth at 7:00 pm on 9/20/13. RN #8 stated he did call and get an order on 9/21/13 to have Resident #103 sent to the hospital and Resident #103 went to the hospital by ambulance on the morning of 9/21/13. In an interview on 10/11/13 at 10:45 am, NP #9 stated she received a call from RN #8 very early in the morning regarding Resident #103. NP #9 stated RN #8 reported Resident #103 had been eating and started foaming at the mouth, and he wanted to send Resident #103 to the hospital. NP #9 stated code status doesn't matter when it's a possible aspiration, because choking isn't a normal way to die. NP #9 stated if it was an aspiration it gets checked out, and with Resident #103 it was an aspiration. In an interview on 10/11/13 at 12:30 pm RN #10 stated he was working on East wing, during the night shift when around 2:00 in the morning RN #8 called him and said Resident #103 seemed short of breath with lung sounds congested. RN #10 stated when he got to Resident #103's room, she was short of breath, her oxygen level was low, so he told RN #8 to put her on 100 percent oxygen using a mask. RN #10 stated that only brought her oxygen up to the 80's. RN #10 stated RN #8 informed him (RN #10) that Resident #103 had foam and food coming from her mouth, and RN #8 had saved a food substance in a cup and showed it to him (RN #10). RN #10 stated he decided that Resident #103 had aspirated on something and needed to go to the hospital quick, and RN #8 agreed, so they called the ambulance and Resident #103 went to the hospital. RN #10 stated the food substance in the cup looked like meat or something. In an interview on 10/17/13 at 10:35 am, CNA (certified nurse aide) #12 stated during the evening of 9/20/13 Resident #103 was spitting out a frothy, mucous like substance from her mouth. CNA #12 stated she did report this to the nurse in charge. CNA #12 stated Resident #103 had just moved to this unit from another unit in the facility, so the nurse called the previous unit to see if the frothing was something new or old and the other unit stated this was something new. CNA #12 stated around 8:00 pm, Resident #103 was still sitting in the common area and the frothing around her mouth was getting worse. CNA #12 stated Resident #103 was having a hard time controlling it, the frothy substance was all around her mouth and on Resident #103's lower face, so CNA #12 stated she reported this to the nurse. CNA #12 stated RN #8 walked over and looked at Resident #103 and gave her (CNA #12) the "go ahead" to put Resident #103 to bed. CNA #12 stated RN #8 did not obtain any vital signs on Resident #103 or do a physical assessment of Resident #103 before she (CNA #12) put Resident #103 to bed for the night. CNA #12 stated Resident #103 still had the frothing coming from her mouth. Review of hospital physician discharge summary for Resident #103 dated 9/24/13, revealed primary [DIAGNOSES REDACTED]. #

This citation pertains to intake MI 965. Based on observation, interview and record review, the facility failed to provide services that meet professional standard of quality for 1 (#103) of 4 sampled residents who were reviewed for respiratory care, of a total sample of 4 residents, resulting in Resident #103, having extreme difficulty in breathing and being transferred to the hospital requiring admission and treatment. Findings include: The professional standard of quality for performing complete respiratory assessments is to assess respiration rate, rhythm, and depth, increased, decreased, or irregular respirations, lung sounds, oxygen saturation level, hypoxemia (low oxygen saturation level), labored or painful breathing, using accessory/chest muscles to breathe, the color of skin, nail beds, lips or mouth, restlessness, irritability, confusion, reduced level of consciousness, color and consistency of sputum, and the assessment of labs. (Mosby Sixth Edition Medical-Surgical Nursing Concepts and Clinical Practice, Phipps, Sands, Marek) The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). In "Legal and Ethical Issues in Nursing" by G. Guido (2001), it documents that "Documentation must show continuity of care, interventions that were used, and patient responses to the therapies implemented. Nurse's notes are to be concise, clear, timely, and complete." (pg. 171) It states that "A jury can infer that no observation of the patient was conducted if there is no mention of a change in condition of the patient." (pg. 171) Resident #103: Review of Resident #103's record revealed an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated she was severely impaired with cognitive skills, required limited physical assistance of one person for eating and extensive physical assistance of two persons for transfers and dressing. Review of speech therapy discharge note dated 9/5/13 revealed Resident #103 had ongoing cognitive, linguistic deficits requiring 24 hour supervision and also continued to have signs and symptoms of aspiration, however lung sounds remained clear. Review of Resident #103's activity of daily living plan of care revealed she had a mechanical soft diet with thin liquids and was to have no straws. Review of the physician progress notes [REDACTED]. Review of nurse's note for Resident #103 dated 9/20/13 at 11:10 am indicated Resident #103 was without fever, blood oxygen level was normal at 96 percent on room air and was pleasant and cooperative while participating in activities and therapy. Review of nurse's note for Resident #103 dated 9/21/13 at 7:30 am, signed by Registered Nurse (RN) #8, indicated Resident #103 was found in her room when RN #8 went in to give 6:00 am medication, breathing with great difficulty with a blood oxygen level of 71 percent on room air. The note indicated after oxygen was applied to Resident #103 at 5 liters per minute via nasal cannula Resident #103 continued to be uncomfortable with rapid breaths, stomach breathing, admitted to fatigue and requested RN #8 to "do something". The note indicated Resident #103 emitted a "food like substance" from her mouth along with a "frothy liquid like substance". The note indicated facility Nurse Practitioner was notified and an order was obtained to send Resident #103 to the hospital. The note then indicated family was notified. Then the nurse's note went on to indicate that on 9/20/13 Resident #103 had been emitting the "frothy substance" from her mouth. The note indicated Resident #103 had no evidence of discomfort, shortness of breath, anxiety or pain and denied pain or discomfort. The note indicated at 5:00 am Resident #103's breath sounds were audible without a stethoscope. The nurse's note indicated Resident #103 went to the hospital by ambulance around 5:45 am. In an interview on 10/11/13 at 10:10 am, RN #8 stated around 7:00 pm on 9/20/13, he observed Resident #103 with a white foaming substance coming out of her mouth. RN #8 stated he checked her "pulse ox" (oxygen level) and she was fine. The surveyor asked RN #8 if he documented the pulse oximetry he checked at 7:00 pm and RN #8 stated after Resident #103 was sent to the hospital on [DATE], he thought he did. RN #8 stated he thought the white foaming substance coming from Resident #103's mouth was regurgitation, so he gave her a cup to spit into and she went to bed as normal. RN #8 stated when he went in to do morning pills for Resident #103 around 5:00 am, she had really labored breathing, was gasping, fatigued, had oxygen level in the 70's (normal 95 to 100) and there was more foaming. RN #8 stated there was a food substance in her mouth that came out, which was fleshy colored, circular and Resident #103 spit the food substance out. RN #8 stated he attempted to use oxygen by nasal cannula to bring Resident #103's oxygen level up, but her level stayed down, so he (RN #8) called for a nurse on another unit to help him. RN #8 stated RN #10 came and they put an oxygen mask on Resident #103. RN #8 stated Resident #103 was still gasping for air and "doing the foaming stuff" even though her oxygen level was up to the 90's. RN #8 stated he could hear Resident #103's lungs without a stethoscope and they just sounded "wet". RN #8 stated he could tell from the strained look on Resident #103's face she was struggling to breathe. RN #8 stated he did not get a set of vital signs on Resident #103, did not listen to Resident #103's lungs, or notify anyone, including Resident #103's family or physician when he observed her foaming from the mouth at 7:00 pm on 9/20/13. RN #8 stated he did call and get an order on 9/21/13 to have Resident #103 sent to the hospital and Resident #103 went to the hospital by ambulance on the morning of 9/21/13. In an interview on 10/11/13 at 10:45 am, NP #9 stated she received a call from RN #8 very early in the morning regarding Resident #103. NP #9 stated RN #8 reported Resident #103 had been eating and started foaming at the mouth, and he (RN #8) wanted to send Resident #103 to the hospital. NP #9 stated code status doesn't matter when it's a possible aspiration, because choking isn't a normal way to die. NP #9 stated if it was an aspiration it gets checked out, and with Resident #103 it was an aspiration. In an interview on 10/11/13 at 12:30 pm, RN #10 stated he was working on East wing, during the night shift when around 2:00 in the morning RN #8 called him and said Resident #103 seemed short of breath with lung sounds congested. RN #10 stated when he got to Resident #103's room, she was short of breath, her oxygen level was low, so he told RN #8 to put her on 100 percent oxygen using a mask. RN #10 stated that only brought her oxygen up to the 80's. RN #10 stated RN #8 informed him (RN #10) that Resident #103 had foam and food coming from her mouth, and RN #8 had saved a food substance in a cup and showed it to him (RN #10). RN #10 stated he decided that Resident #103 had aspirated on something and needed to go to the hospital quick, and RN #8 agreed, so they called the ambulance and Resident #103 went to the hospital. RN #10 stated the food substance in the cup looked like meat or something. In an interview on 10/17/13 at 10:35 am, CNA (certified nurse aide) #12 stated during the evening of 9/20/13 Resident #103 was spitting out a frothy, mucous like substance from her mouth. CNA #12 stated she did report this to the nurse in charge. CNA #12 stated Resident #103 had just moved to this unit from another unit in the facility, so the nurse called the previous unit to see if the frothing was something new or old and the other unit stated this was something new. CNA #12 stated around 8:00 pm, Resident #103 was still sitting in the common area and the frothing around her mouth was getting worse. CNA #12 stated Resident #103 was having a hard time controlling it, the frothy substance was all around her mouth and on Resident #103's lower face, so CNA #12 stated she reported this to the nurse. CNA #12 stated RN #8 walked over and looked at Resident #103 and gave her (CNA #12) the "go ahead" to put Resident #103 to bed. CNA #12 stated RN #8 did not obtain any vital signs on Resident #103 or do a physical assessment of Resident #103 before she (CNA #12) put Resident #103 to bed for the night. CNA #12 stated Resident #103 still had the frothing coming from her mouth. Review of hospital physician discharge summary for Resident #103 dated 9/24/13, revealed primary [DIAGNOSES REDACTED]. Hospital emergency room physician note dated 9/21/13 indicated Resident #103 presents with complaint of respiratory distress. The physician note indicated the nursing home had checked on Resident #103 at 3:00 am and she was found with foam and sausage like material in her mouth. The note indicated Resident #103 was rechecked by nursing home staff at 5:30 am and her condition had exacerbated to the point of audible difficulty breathing. The note indicated Resident #103's chest x-ray done in the emergency roiagnom on [DATE] showed [MEDICAL CONDITION] vascular congestion (excessive fluid in the lungs). #

This citation pertains to intake number MI 233. Based on interview and record review, the Facility failed to provide adequate supervision (every 15 minute checks or 1 to 1 monitoring), and assistive devices (sensor pad alarms), to prevent falls for 1 of 3 sampled residents (#101) reviewed for falls, from a total of 3 sampled residents, resulting in a Fractured left hip as a result of a fall. Findings include: Review of the closed, medical record face sheet, revealed Resident #101 was an [AGE] year old woman, admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was severely Cognitively Impaired and was totally dependant for most Activities of Daily Living, including transfers. Review of the plan of care titled;"prevention of falls related to deficits, debility and impaired safety awareness due to Dementia" was not initiated until 8/7/13. The fall assessment score was 20 dated 7/18/13, 20 on 7/24/13 and 24 on 8/14/13. According to the Facility Fall Risk Evaluation form under instructions was written."..a total score of 10 or greater, the resident should be considered at HIGH RISK for potential falls." Review of the Facility Incident Report dated 7/18/13 (day of admission), at 9:45 AM, revealed Resident #101 had an unwitnessed fall and was found on the floor of her room. She had fallen out of bed, according to the report. Under the section titled, "Describe the Event (Facts only do not assume), was written, "Staff notified by roommate that she needed assistance, resident observed on floor paralled with bed, lying on right side, trembling. Hoyered to chair following vital signs being taken," There were no apparati injuries noted. The Corrective measures were to place a winged mattress on her bed and bed side mat, according to the report Review of the Facility Incident Report dated 7/24/13 at 4:10 PM, revealed Resident #101 had an unwitnessed fall and was found on the floor of. the living room area. Resident #101 sustained an abrasion on her hand and above her right eye. The corrective measures were to "not park her wheelchair near the water feature" because she thought it was raining and to place a wedge cushion in her wheelchair. Review of the Facility's Fall Prevention Policy/Procedure dated as revised on 7/25/13, under the section titled, "Procedure/Guidelines was written under #2. Each new admission will be considered a risk for falls for a minimum of 72 hours, ... A pressure sensitive pad will be placed on the mattress that will alert staff thru the nurse call system, ...for the first 72 hours if patient history suggests a cognitive/ambulation issue."Under #6 was written, "...b. anyone with a score of 10", will be put on the fall prevention program.. Under #7 was written, "care plan will be reviewed after any fall." Under the Fall Program Protocol #2 was written, "All bed/chair person/positional alarms will be responded to as it is an emergency alarm. .... Review of the Physical Therapy evaluation dated 8/3/13 at (no time), revealed Resident #101 "still requires extensive assistance, cues for weight shifting assistance and is not consistent." Review of the Orthopedic Physician's progress note dated 8/8/13 at (no time), revealed the instructions for Resident #101 to continue the brace on her left knee with limited weight bearing to left leg due to her fractured knee. Review of the Facility Incident Report dated 8/14/13 at 2:45 AM, revealed Resident #101 had a third unwitnessed fall and was found on the floor of.her room, complaining of left hip pain, refused a complete assessment of her hip and was transferred from the floor to a wheelchair with 2 staff .The Medical Staff were notified and ordered an X-Ray of her left hip. Review of the nurses dated 8/14/13 at 9:30 AM, revealed it was reported that Resident #101 had made suicidal comments earlier in the morning, however did not recall at 9:30 AM. Review of the Radiology Report dated 8/14/13 at 12:11 PM, revealed Resident #101 was diagnosed with [REDACTED]. 2) Moderate degree of osteoporosis 3) Moderate Osteoarthritis Review of the Physician order [REDACTED].#101 to the emergency room of a hospital for evaluation. During an interview on 10/7/13 at 2:30 PM, the Director of Nursing (RN#2), said Resident #101 was not on 1:1 close supervision or every 15 minute checks. When asked why Resident #101 was not provided any alarms such as a pressure sensor alarm pad which would have alerted staff when Resident #101 attempted to transfer herself, RN#2 said, " the alarms for the beds are connected to the nurses station." When asked why one wasn't used for Resident #101 after her first or second fall RN#3 said, 'we may not of had them yet." RN#2 left to obtain the date the alarms which were connected to the nurse's station were purchased. A second interview on 10/7/13 at 3:50 PM, when RN#2 returned with the date the Facility purchased sensor pad alarms, said the alarms were purchased on 7/23/13, (1 day before Resident #101's second fall and 2 weeks before Resident #101's third fall, which resulted in a fractured hip). In an interview at 11:30 AM on 10/7/13, the Assistant Director of Nursing, who was not aware of the Facility's Policy/Protocol for falls, and who was next in charge because the Administrator was on vacation and the DON was not in the Facility yet said, "we do not use alarms. We stopped altogether in May 2013." #

THERE ARE TWO (2) DEFICIENT PRACTICE STATEMENTS FOR THIS REQUIREMENT. 1. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROMOTE A SAFE ENVIRONMENT RELATED TO A WET FLOOR FOR 1 OF 8 RESIDENTS REVIEWED FOR FALLS (#13) FROM A TOTAL SAMPLE OF 22 RESIDENTS RESULTING IN A FALL AND FRACTURE OF THE LEFT WRIST WITH ACCOMPANYING PAIN AND DECLINE OF ACTIVITIES OF DAILY LIVING (ADL) SKILLS. FINDINGS INCLUDE: ON 10/1/12 AT APPROXIMATELY 9 PM IN THE CONFERENCE ROOM, A DESK AUDIT WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON). THE DON IDENTIFIED RESIDENT #13 AS A FALL WITH A FRACTURE WHICH HAD OCCURRED IN-HOUSE. ACCORDING TO THE 3/7/12 FACE SHEET, RESIDENT #13 WAS AN [AGE] year OLD FEMALE admitted TO THE FACILITY 1/10/12 WITH [DIAGNOSES REDACTED]. ACCORDING TO THE QUARTERLY MDS (MINIMUM DATA SET- AN ASSESSMENT TOOL) SIGNED AND DATED 10/1/12 RESIDENT #13 HAD A BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF 3 OF A POSSIBLE 15 FOR MENTAL COGNITION. THE MDS ALSO REFLECTED RESIDENT #13 WAS USUALLY ABLE TO EXPRESS IDEAS AND WANTS AND USUALLY ABLE TO COMPREHEND WHAT OTHERS WERE COMMUNICATING TO HER. WITH A SCORE OF A "1". A ZERO (-0-) INDICATING NO DIFFICULTIES. A COMPARATIVE QUARTERLY MDS SIGNED AND DATED 7/11/12 REFLECTED RESIDENT RESIDENT #13 WAS ALSO A "1" FOR EXPRESSION AND COMPREHENSION. A STAFF ASSESSMENT FOR MENTAL STATUS WAS CONDUCTED AND REFLECTED RESIDENT #13 HAD SHORT AND LONG TERM MEMORY PROBLEMS AND WAS MODERATELY IMPAIRED FOR DAILY DECISION MAKING WITH A SCORE OF "2". A ZERO INDICATING INDEPENDENT IN MAKING DECISIONS. ACCORDING TO SECTION G OF THE MDS, dated [DATE], FUNCTIONAL STATUS, REGARDING ACTIVITIES OF DAILY LIVING (ADLs) OF THE 7/11/12 QUARTERLY MDS, RESIDENT #13 WAS INDEPENDENT IN TRANSFERS AND AMBULATING ABOUT IN HER ROOM. RESIDENT #13 NEEDED SUPERVISION (OVERSIGHT, ENCOURAGEMENT OR CUEING) WITH AMBULATION IN THE CORRIDOR, AND LOCOMOTION ON AND OFF THE UNIT BUT NO PHYSICAL HELP FROM STAFF WAS NEEDED. SECTION J, OF THE SAME MDS, REFLECTED RESIDENT #13 HAD NO PAIN PRESENT DURING THE 5 DAYS PRIOR, THE LOOK BACK PERIOD AND HAD EXPERIENCED NO FALLS BEFORE OR SINCE ADMISSION. THE ACCIDENT/INCIDENT REPORT DATED 9/6/12 AT 10 AM REFLECTED UNDER, DESCRIPTION OF THE EVENT: HOUSEKEEPER (STAFF "R") OBSERVED RESIDENT #13 ON THE FLOOR IN FRONT OF HER BED ON HER BACK. UNDER "CORRECTIVE MEASURES TO PREVENT RE-OCCURRENCE: "HOUSEKEEPING NOT TO MOP WHEN RESIDENT IN ROOM." THE "INCIDENT INVESTIGATION" REPORT REFLECTED IN RESPONSE TO QUESTION NUMBER 1 "PRIOR TO THE INCIDENT RESIDENT WAS IN": BED (WAS CHECKED) AS THE RESPONSE. QUESTION NUMBER 7 REFLECTED RESIDENT WAS SLEEPING PRIOR TO THE INCIDENT. QUESTION NUMBER 8 ASKED FOR A DESCRIPTION OF THE SCENE AROUND THE FALL. THE RESPONSE DOCUMENTED WAS THE FLOOR WAS WET FROM MOPPING -WITH COVERS OF THE BED PULLED BACK. QUESTION 9 ASKED, "WHAT DID THE RESIDENT SAY THEY WERE TRYING TO DO WHEN THEY fell ?" THE RESPONSE WRITTEN: "GETTING OOB (OUT OF BED) & (AND) SLIPPED." THE "MINI-ROOT CAUSE ANALYSIS" COMPLETED ALONG WITH THE ACCIDENT/INCIDENT REPORT AND "INVESTIGATION REPORT", ON PAGE 2 UNDER "CONCLUSIONS AND HUMAN CAUSE", REFLECTED HOUSEKEEPING HAD MOPPED AN OCCUPIED ROOM AND LEFT THE WET FLOOR, RESIDENT (#13) WAS INDEPENDENT WITH TRANSFERS AND ADLs. THE "WET FLOOR" SIGN WAS PLACED AT THE ENTRY TO RESIDENT #13'S ROOM AND THEREFORE WAS UNABLE TO WARN RESIDENT #13 IN THE ROOM. IT WAS OBSERVED, RESIDENT #13'S HEAD OF THE BED FACED AWAY FROM THE DOOR TOWARDS THE WINDOW. THE NURSE'S INTERDISCIPLINARY NOTE DATED 9/6/12 AT 2:30 PM REFLECTED STAFF "R" HEARD A NOISE FROM RESIDENT #13'S ROOM. RESIDENT #13 WAS OBSERVED ON HER BACK, ON THE FLOOR, IN HER ROOM, BY HER BED. HOUSEKEEPING HAD JUST MOPPED HER FLOOR AND IT WAS WET. ON 10/2/12 AT APPROXIMATELY 4:20 PM RESIDENT #13 WHEELED HERSELF FROM AN ACTIVITY TO HER ROOM. RESIDENT #13 WAS ASKED HOW SHE HURT HER WRIST, HOW IT HAD FRACTURED. RESIDENT #13 STATED "A CAR ACCIDENT." WHEN ASKED IF THE FRACTURE HAD HAPPENED IN HER ROOM WHEN SHE (#13) HAD GOTTEN UP OUT OF BED? RESIDENT #13 STATED, "NO." WHEN RESIDENT #13 WAS ASKED HOW SHE GOT ALONG WITH HER ROOM-MATE, RESIDENT #13 STATED THAT SHE GOT ALONG FINE WITH "HER BROTHER". RESIDENT #13 HAD NO RECOLLECTION OF HOW SHE HAD FRACTURED HER WRIST. ON 10/5/12 AT APPROXIMATELY 11:05 AM, IN THE GENERAL LIVING AREA OF THE MEMORY UNIT, STAFF "R" WAS INTERVIEWED ABOUT RESIDENT #13'S INCIDENT IN WHICH SHE SUSTAINED A FRACTURED WRIST. STAFF "R" STATED SHE ASKED RESIDENT #13 "WHAT HAPPENED?" RESIDENT #13 STATED, IN RESPONSE, "I SLIPPED". STAFF "R" THEN ASKED RESIDENT #13, IF SHE, "HIT HER HEAD." RESIDENT #13'S RESPONSE TO THAT QUESTION WAS, "NO". STAFF "R" STATED RESIDENT #13 REPEATEDLY COMPLAINED THAT HER "ARM HURT". A REVIEW OF THE 10/1/12 QUARTERLY MDS REFLECTED CHANGES IN THESE SAME AREAS AS FOLLOWS: SECTION G RECORDED A CHANGE IN TRANSFERS REQUIRING LIMITED ASSISTANCE (STAFF PROVIDE GUIDED MANEUVERING ASSISTANCE OF LIMBS) OF 1 PERSON. RESIDENT #13 REQUIRED THE SAME AMOUNT OF ASSISTANCE, LIMITED OF 1 PERSON, FOR AMBULATION BOTH IN AND OUTSIDE OF HER ROOM. SECTION J RECORDED RESIDENT #13 HAD RECEIVED SCHEDULED AND PRN (AS NEEDED) PAIN RELIEF MEDICATION WITHIN THE PREVIOUS 5 DAY LOOK BACK PERIOD. STAFF ASSESSMENT OF PAIN REFLECTED FREQUENCY OF PAIN INDICATORS PRESENT OVER THE PREVIOUS 3-4 DAYS OF THE 5 DAY LOOK BACK PERIOD (NEARLY DAILY) VIA NON-VERBAL SOUNDS,VOCAL COMPLAINTS AND FACIAL EXPRESSIONS. ADDITIONALLY, SECTION J ALSO REFLECTED RESIDENT #13 HAD EXPERIENCED A FALL WITH A MAJOR INJURY. THE MDS CODED A DECLINE IN SEVERAL AREAS AND SHOWED AN INCREASED PAIN RELATED TO THE FRACTURE/MAJOR INJURY. ( ) 2. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO SAFELY STORE CHEMICALS IN THE CAFE' FOR APPROXIMATELY 5 RESIDENTS WHO EAT IN THE CAFE OF A TOTAL OF 28 RESIDENTS ON THE WEST UNIT AND FOR 18 OF 19 RESIDENTS ON THE MEMORY UNIT; FAILED TO PROPERLY DISPOSE OF 5 USED RAZORS ON THE EAST UNIT AND FAILED TO SECURE AN ELECTRIC STOVE IN THE EVENING IN THE THERAPY ROOM RESULTING IN THE POTENTIAL FOR INJURIES FROM ENVIRONMENTAL HAZARDS TO RESIDENT #24. FINDINGS INCLUDE: DURING THE INITIAL TOUR OF THE FACILITY ON OCTOBER 1, 2012 AT 6:37 P.M., THE TWO ENTRANCE DOORWAYS TO THE THERAPY ROOM AND ADJOINING ACTIVITY ROOM WERE OBSERVED OPEN. THERE WERE NO STAFF PERSONS INSIDE BOTH ROOMS OR IN THE HALLWAY CLOSE BY. UPON ENTERING THE ACTIVITY ROOM ADJOINING THE THERAPY ROOM, A GENERAL ELECTRIC STOVE WAS AGAINST THE HALLWAY WALL. THE FOUR BURNERS WERE OBSERVED COVERED WITH A CIRCULAR TIN COVER. UPON TURNING THE STOVE ON, ALL BURNERS BECOME HOT WITHIN 8 SECONDS, AND THE TIN COVERS WERE TOO HOT TO TOUCH. IN ADDITION, THE STOVE WAS TURNED ON. AGAIN, THE STOVE BECAME WARM WITHIN 30 SECONDS. A REVIEW OF RESIDENTS IN THIS THERAPY ROOM AREA WAS NOTED TO HAVE RESIDENT #24 SITTING ON THE SOFA OUTSIDE THE MAIN DINNING ROOM IN A HALLWAY LEADING TO THE THERAPY ROOM. DURING AN INTERVIEW WITH RESIDENT #24 ON OCTOBER 1, 2012 FROM 7:15 P.M. TO 7:30 P.M. ON THE SOFA, SHE DID STATE THAT SHE WAS A FORMER DIETICIAN. IN ADDITION, RESIDENT #24 WAS OBSERVED WITH A WALKER AT HER SIDE DURING THIS INTERVIEW. AT 7:30 P.M. ON OCTOBER 1, 2012, THE TWO ENTRANCE DOORWAYS WERE OBSERVED STILL OPEN TO THE THERAPY ROOMS. AGAIN, NO FACILITY STAFF WERE INSIDE THESE TWO THERAPY ROOMS. AT 8:00 P.M. ON OCTOBER 1, 2012, BOTH ENTRANCE DOORS TO THE THERAPY ROOMS WERE OBSERVED CLOSED AND LOCKED. DURING AN INTERVIEW WITH THE THERAPY DEPARTMENT MANAGER (P) ON OCTOBER 4, 2012 AT 8:10 A.M., HE STATED THAT IT WAS FACILITY POLICY TO KEEP THE TWO THERAPY ENTRANCE DOORS LOCKED WHEN STAFF HAD LEFT THE THERAPY ROOMS. ( ) DURING AN INDEPENDENT INITIAL TOUR OF THE FACILITY ON 10/1/2012 BEGINNING AT 7:00 PM, THE DOOR TO THE SHOWER ROOM ON THE EAST HALL WAS OBSERVED OPEN WITH DIRECT ACCESS FOR ANY OF THE APPROXIMATELY 45 AMBULATORY RESIDENTS OR RESIDENTS IN A WHEELCHAIR ON THE EAST UNIT. THE SUPPLY CABINET IN THE SHOWER ROOM WAS OBSERVED TO BE OPEN WITH THE KEY TO THE CABINET LOCK SITTING ON TOP OF THE CABINET. IN THE CABINET WAS A 32 OUNCE SPRAY BOTTLE OF "SPRING CLEAN" DISINFECTING SOLUTION. ACCORDING TO THE MATERIAL SAFETY DATA SHEET (MSDS) #BT315 (NOT DATED) PROVIDED BY THE FACILITY, SPRING CLEAN DISINFECTING SOLUTION SHOULD BE KEPT OUT OF REACH OF CHILDREN. ALSO, IF INGESTION SHOULD OCCUR, "DRINK PROMPTLY, LARGE QUANTIES OF WATER. DO NOT INDUCE VOMITING. AVOID ALCOHOL. SEEK MEDICAL ATTENTION." IN THE SAME SHOWER ROOM ON THE EAST UNIT, 5 USED, UNCOVERED, DISPOSABLE RAZORS WERE OBSERVED SITTING ON TOP OF THE SHARPS CONTAINER ATTACHED TO THE WALL. ALTHOUGH THE SHARPS CONTAINER WAS NOT FULL, THE RAZORS WERE SITTING ON THE TOP. THE SHARPS CONTAINER WAS ATTACHED APPROXIMATELY FOUR AND A HALF FEET ABOVE THE FLOOR AND WITHIN EASY REACH. AN ENVIRONMENTAL TOUR OF THE FACILITY TOOK PLACE ON 10/3/2012 BEGINNING AT 10:45 AM WITH THE ADMINISTRATOR, A MAINTENANCE EMPLOYEE, STAFF "M" AND THE MAINTENANCE SUPERVISOR, STAFF "N". WHILE TOURING THE AREA ON THE WEST UNIT, IDENTIFIED AS "THE CAFE" , A 32 OUNCE SPRAY BOTTLE OF "CLOROX CLEAN-UP" DISINFECTING SOLUTION WAS OBSERVED UNDER THE SINK CABINET UNSECURED. THE BOTTLE WAS LABELED, "KEEP OUT OF REACH OF CHILDREN." ACCORDING TO THE MSDS SHEET PROVIDED BY THE FACILITY TITLED, "COMMERCIAL SOLUTIONS, CLOROX CLEAN-UP DISINFECTANT WITH BLEACH" DATED 4/02, IF SWALLOWED, "DRINK A GLASS OF WATER. CALL A PHYSICIAN." WHILE TOURING THE "MEMORY CARE UNIT" DURING THE SAME ENVIRONMENTAL TOUR, THE JANITOR CLOSET IN THE MAIN RESIDENT CARE HALLWAY WAS OBSERVED TO BE UNLOCKED. THE HOUSEKEEPING CART WAS INSIDE THE CLOSET AND THREE BOTTLES OF CLEANING SOLUTIONS WERE OBSERVED HANGING ON THE SIDE OF THE CART DIRECTLY IN FRONT OF THE OPEN DOOR. THE CHEMICALS AND THEIR MSDS INFORMATION PROVIDED BY THE FACILITY WERE AS FOLLOWS; 1 - ? FULL, 32 OUNCE SPRAY BOTTLE OF "GREEN WORKS, "GENERAL PURPOSE SPRAY." THE BOTTLE WAS LABELED, "KEEP OUT OF REACH OF CHILDREN." ACCORDING TO THE MSDS SHEET TITLED "CLOROX COMMERCIAL SOLUTIONS GREEN WORKS NATURAL GENERAL PURPOSE CLEANER (CONCENTRATE)" DATED 10/09, IF INGESTED, "DRINK A GLASSFUL OF WATER. CALL A DOCTOR OR POISON CONTROL CENTER." 1 - ? FULL, 32 OUNCE SPRAY BOTTLE OF "GREEN WORKS," GLASS CLEANER." THE BOTTLE WAS LABELED, "KEEP OUT OF REACH OF CHILDREN." ACCORDING TO THE MSDS SHEET TITLED "CLOROX COMMERCIAL SOLUTIONS GREEN WORKS NATURAL GLASS AND SURFACE CLEANER", DATED 5/09, IF INGESTED, "DRINK A GLASSFUL OF WATER. DO NOT INDUCE VOMITING. CALL A DOCTOR OR POISON CONTROL CENTER." 1 - 2/3 FULL, 32 OUNCE SPRAY BOTTLE HAND LABELED AS "BLEACH AND WATER." THE BOTTLE WAS LABELED, "KEEP OUT OF REACH OF CHILDREN." ACCORDING TO THE MSDS SHEET TITLED "BLEACHES" EFFECTIVE DATE 6/17/94, "GIVE WATER IMMEDIATELY. DO NOT INDUCE VOMITING. GET MEDICAL ATTENTION." ( )

This citation pertains to intake number MI 003. Based on observation, interview, and record review the facility failed to prevent falls for 3 of 5 samples residents (Residents #501, #502, and #503) resulting in: 1) resident #501 attempting to stand up while sitting in her wheelchair and fell , which required her to be transferred to the hospital for sutures of a laceration to her forehead, 2) resident #502 being found lying on the floor in her room after a fall, with her fall alarm not on, resulting in a hematoma (blood accumulation under the skin that results in a bump) to the back of her head, and 3) resident #503 who was found on the floor in his room, with his fall alarm was not sounding, resulting in pain after hitting his head. Findings include: Resident #501: Per the facility face sheet Resident #501 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the facility incident report dated 5/28/2010 revealed that at 5:00 PM Resident #501 was observed lying on the floor in front of her chair, face down in her room. The report revealed that Resident #501 sustained a laceration on the left side of her forehead that was bleeding, and a skin tear on her left elbow. The incident report revealed that Resident #501 was transferred to the hospital for stitches of the laceration above her left eye on her forehead. Review of the incident report revealed that the interventions put into place after Resident #501's fall was, to put into place a tab alarm, and staff was told to keep an eye on Resident #501 while she was in a wheelchair. No other interventions were implemented. Staff Member #1, a Registered Nurse (RN) who cared for Resident #501, was interviewed on 3\28\2011. He said that on 5/28/2010 when Resident #501 fell , he heard a "boom" and then found Resident #501 on the floor, in her room. RN #1 said that he transferred Resident #501 to the hospital for stitches of the laceration above her left eye. He said that she returned to the facility the same night. RN #1 said that he could not remember if Resident #501 had an alarm on, or if it had sounded prior to her fall. RN#1 said that if he had written a corrective measure\intervention on the incident report to apply a pressure\tab alarm to Resident #501's wheelchair, then more than likely, no alarm was on Resident #501 prior to her fall. RN #1 said he would not have added an alarm to Resident #501 as a corrective measure if she had already had an alarm on prior to her fall. Record review of a "Fall risk Assessment" dated 4/6/2010 revealed that Resident #501 scored a sixteen (high risk) on her fall risk assessment. Another "Fall Risk Assessment" dated 5/28/2010 revealed that Resident #501 scored an eighteen (high risk) on her fall risk assessment. Record review of a Minimum Data Set ((MDS) dated [DATE] revealed that Resident #501 did not ambulate and had moderately impaired cognitive skills. Record review of a care plan dated 1/27/2010 revealed that Resident #501 was at risk for injuries from falls related to a history of falls without injury. Review of the care plan revealed an intervention for Resident #501 that included to have a tab alarm on while in bed. Record review of "Nursing Notes" dated 1/24/2010 revealed that Resident #501 was found sitting on the blue pad (bedside mat) on the floor that was at the side of her bed. The notes revealed that Resident #501's alarm had not sounded because, "the alarm was still attached, and the magnet had not disconnected causing the alarm to sound". The notes revealed that the string on the alarm needed to be shortened. Review of the nurses' notes dated 1/24/2010 revealed that Resident #501 was noted to attempt to get up out of her wheelchair three more times. The notes revealed that Resident #501 stated that she was trying to get up so she could walk. Record review of "Nursing Notes" dated 5/28/2010 revealed that at 5:00 PM Resident #501 was observed lying on the floor face down in front of her chair in her room. The notes revealed that Resident #501 had a 1 inch laceration above her left eye that was bleeding. The "Nurses' Notes" also revealed that Resident #501 began to choke on her saliva and was unable to lay flat. The notes revealed that Resident #501 was transferred to the hospital. Record review of the hospital "emergency room Notes" dated 5/28/2010 revealed that Resident #501 had a laceration to her forehead, elbow, forearm, and wrist. Record review the hospital emergency room notes revealed that Resident #501 received sutures to the laceration on her forehead. Record review of Resident #501's "Hospice Care Visit" record date 5/18/2010 revealed that upon the hospice nurse visiting Resident #501, Resident #501 was found slid down in her wheelchair. The hospice notes revealed that Resident #501's fall alarm had not activated as a result of her sliding down in her wheelchair. The note also revealed that the hospice nurse repositioned Resident #501 in her wheelchair so Resident #501 would not slide out. In an interview on 3/28/2011 at 12:00 PM the hospice nurse said that Resident #501's alarm was attached to Resident #501, but had not activated because the alarm had not disconnected when Resident #501 slid down in her wheelchair. She said that Residents #501 was supposed to be reclined back in her wheelchair. She said that staff at the facility would not always recline the wheelchair back far enough to prevent Resident #501 from sliding down. The hospice nurse also said that Resident #501 had declined in her health, but that had occurred prior to her fall on 5/28/2010. She said that the fall had nothing to do with Residents #501's decline in her medical condition. Record review of Resident #501's "Activities of Daily Living Flow Sheets" for the months of February, March, April, May, and June 2010 revealed an intervention to verify that Resident #501's fall alarm was on while she was in bed. The flow sheet revealed that the Certified Nurse Aid (CNA), who cared for Resident #501, was to initial daily, on every shift that the alarm was in place. The February flow record revealed twelve (12) shifts where initials were absent; therefore not verifying that Resident #501 fall alarm was in place. The March flow record revealed thirteen (13) shifts where initials were absent; therefore not verifying that Resident #501's fall alarm was in place. The April flow sheet record revealed six (6) shifts where initials were absent; therefore not verifying that Resident #501's fall alarm was in place. The May flow record revealed twelve (12) shifts where initials were absent; therefore not verifying that Resident #501's fall alarm was in place. The June flow record revealed thirteen (13) shifts where initials were absent; therefore not verifying that Resident #501's fall alarm was in place. Resident #502: Per the facility face sheet Resident #502 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the facility incident report dated 1/1/11 revealed that at 7:10 AM Resident #502 was observed on the floor flat on her back beside her bed. The incident report revealed that Resident #502 did not know what she was doing or how she had fallen. The incident report revealed that Resident #502's fall alarm was not on. The incident report also revealed that Resident #502 had a hematoma to the back of her head; with a quarter size lump. The incident report revealed that the corrective measures taken to prevent recurrence of a fall were, to put Resident #502's bed up against the wall. Resident #502 did not require a transfer to the hospital for treatment. Record review of nurses notes dated 1/1/2011 revealed that at 7:10 AM Resident #502 had put her call light on, and when the Certified Nurse Aide (CNA) went into Resident #502's room she found Resident #502 lying on the floor beside her bed. The notes revealed that Resident #502 did not know what happened or why she was out of bed. The notes also revealed that Resident #502's fall arm was off. The nurses' notes revealed that after Resident #502's fall, she had a hematoma to the back of her head. Record review of the MDS dated [DATE] revealed that Resident #502 was easily distracted. The MDS revealed that Resident #502 required limited assistance with ambulation. Record review of a "Fall Risk" assessment for Resident #502 dated 10/27/2010 revealed that Resident #502 scored a 15, dated two2/8/2011 Resident #502 scored 15, and dated 3/10/2011 revealed Resident #502 scored a 17 on the fall risk assessment. Review of the fall risk assessment revealed that a score of 10 or above represented a higher risk for falls. Record review of a care plan dated 11/24/2010 for Resident #502 revealed that she was at a risk for falls. The care plan revealed an intervention dated 11/24/2010 that Resident #502 was to use a tab alarm (an alarm that clips to the residents clothes and alarms when pulled apart from the main box) while in bed and in her wheelchair. The care plan also revealed that after her fall on 1/1/2011 an additional intervention was added to place a Resident #502 bed up against the wall. No other interventions were added to the care plan. Observation of Resident #502 was conducted on 3/25/2011 at 10:50 AM. Resident #502 was observed to be in bed with a pressure alarm on (a pad that lies underneath the resident and alarms when the resident gets off the pad). Record review of the care card that was in Resident #502's room revealed that Resident #502 was to have a pull tab alarm on while in her wheelchair and while in her bed. Staff Member #3, a CNA, and Staff Member #4, a CNA, were interviewed on 3/25/2011 at 11:00 AM. Resident #502's care card was shown to CNA #3 and she verified, per the care card, that Resident #502 was to have an alarm while in bed and while in her wheelchair. CNA #3 was told that upon observation of Resident #502, Resident #502 had a pressure alarm on her bed. CNA #3 verified that the care card was what the nurses used to identify the care required for a resident. CNA #3 stated, "This (the care card) is what we go by." Upon observation of the care card, the tab alarm section on the care card was highlighted yellow. CNA #3 stated that because the tab alarms section was highlighted in yellow that meant that the tab alarm was to be discontinued. CNA #3 stated that the CNA's used the "Activities of Daily Living" sheets to verify what type of alarm a resident required. CNA #4, who had been employed at the facility for ten years, stated that the yellow highlighting, on the care card meant that the tab alarm was not an active intervention for Resident #502. CNA #3 then stated that she must have been was incorrect about what the yellow highlighting meant. CNA #3 also stated that the Director of Nursing (DON) had told her that what the yellow highlighting meant. CNA#4 then stated, "No that's wrong, we never look at those (Care Cards) we go by the Activities of Daily Living sheets." CNA #3 stated that the care card revealed that Resident #502 was to have a tab of alarm and that the Activities of Daily Living sheets revealed that Resident #502 had a pressure alarm. CNA #4 stated that the care card had not been updated. Upon review of the Activities of Daily Living sheet, it was revealed that the Activities of Daily Living sheet that CNA #3 was addressing was the incorrect Activities of Daily Living sheet and in fact, did not belong to Resident #502. Record review Resident #502's Activities of Daily Living flow sheets for the month of January, February, and March 2011 revealed that Resident #502 was to have a tab alarm on while in bed and in her wheelchair. Review of the February Activities of Daily Living flow sheet revealed an intervention where the CAN, who cared for Resident #502, was to initial every shift that they had checked Resident #502's tab alarm to verify its placement and\or functioning. Review of the February Activities of Daily Living flow sheet revealed 19 initials were absent; therefore not verifying that Resident #502's alarmed was in place or functioning. Review of the March Activities of Daily Living flow sheet revealed 16 shifts where the CNA's signatures were absent; therefore not verifying that Resident #502's alarm was in place and\or functioning. Staff Member #5, a CNA employed at the facility for fourteen years, was interviewed on 3/25/2011 at 2:45 PM. She said that the CNA's check the fall alarms on all residents at the beginning of their shift, and periodically during their shift. CNA #5 said that there was no documentation where the CNA's verified the functioning of the resident alarms. CNA #5 stated that there should be a place to document the alarms had been checked, because the CNA's would do rounds together at the beginning and end of their shifts. CNA #5 stated that she always checked alarms, but did not document to prove it has been done. Staff Member #6, a CNA who cared for Resident #502, was interviewed on 3/28/2011 at 9:35 AM. CNA #6 said that she did not use the care cards that were in the resident rooms. She said that she used the Activities of Daily Living book to verify what type of alarms resident was supposed to have. CNA #6 stated that Resident #502 had a pressure alarm, and that Resident #502 used to have a tab alarm. CNA #6 stated that she could not remember when Resident #502 had a tab alarm. CNA #6 said that Resident #502 would take her tab alarm off, or would take her clothes off to remove the tab alarm. CNA #6 said that after Resident #502's to fall on 1/1/2011 a pressure alarm was placed on Resident #502. CNA #6 said that Resident #502 was a known fall risk, and would sound her alarms quite frequently. CNA #6 stated that staff could not get to Resident #502 fast enough when her alarm sounded; when she was attempting to ambulate without assistance. CNA#6 said that no other interventions that she knew of had been implemented other than to check on Resident #502 frequently. CNA #6 said that Resident #502 would go to the bathroom very frequently, and when Resident #502's alarms would sound, staff would find Resident #502 already in the bathroom. CNA #6 said that Resident #502 would tell her that she did not need to use the bathroom, but after CNA #6 six would leave the room, Resident #502 would get up out of bed without assistance. CNA#6 said that Resident #502 would still attempt to get up on her own without assistance very frequently. CNA #6 said that they did not document how often Resident #502 used the bathroom. CNA #6 verified again that Resident #502 had a pressure alarm on her person at the time of the investigation. CNA #6 was shown the January, February and March Activities of Daily Living sheets which revealed that Resident #502 was to have a tab alarm on her person. CNA #6 stated that every one (the CNA's) just charted Resident #502 had a tab alarm on, but in actuality Resident #502 and a pressure alarm on. Staff Member #7, a Licensed Practical Nurse (LPN) who cared for Resident #502, was interviewed on 3/28/2011 at 10:00 AM. LPN#7 said that she could not remember what type of alarm Resident #502 had prior to her fall. LPN #7 said that Resident #502 would take her tab alarm off by taking her clothes off. LPN #7 said that she did not always know if a resident's type of alarm had changed. She said that she would know that a resident had an alarm, but usually did not know what type of alarm or if the type of alarm had changed. She said that she could not remember if Resident #502 would take off her alarm prior to her fall on 1/1/2011. LPN#7 said that on 1/1/2011 when Resident #502 had fallen, Resident #502 ' s alarm was not on; because either Resident #502 removed the alarm or possibly the alarm was not put back on Resident #502. LPN #7 could not be sure as to why the alarm was not on at the time of Resident #502's fall on 1/1/2011. LPN #7 said that Resident #502 at times would use her call light for assistance, but normally would not wait for an answer and would just get up on her own to go to the bathroom. LPN #7 said that staff would frequently be in Resident #502's room, although, she did not think that there was an increase in how often Resident #502 was being toileted. LPN #7 said that she did not remember any changes that were made to Resident #502's scare plan after Resident #502's fall on 1/1/2011. She said that someone must have forgotten to update the Activities of Daily Living record to verify what type of alarm Resident #502 was to have. LPN #7 said that the Activities of Daily Living record should be correct. Resident #503: Per the facility face sheet Resident #503 was a [AGE] year old mail admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the facility incident report dated 2/28/2010 at 12:00 PM revealed that Resident #503 was found on the floor in his room, lying next to his bed, between his bed and his wheelchair. The incident report revealed that Resident #503 was yelling for help. The incident report revealed that Resident #503 was complaining of pain to his head. The incident report revealed that the corrective measures to prevent recurrence of Resident #503 falling was to add non-skid socks for Resident #503 when he did not wear his slippers. Record review of an additional incident report dated 12/11/2010 at11:50 AM, revealed that Resident #503 was trying to get out of bed by himself and rolled onto the floor. The corrective measures to prevent recurrence were to add a pressure alarm to Resident #503's bed and wheelchair. Another incident report dated 12/11/2010 at 4:05 PM revealed that Resident #503 was found in his room lying on the floor next to his bed. There were no changes in the corrective measures to prevent recurrence of Resident #503 falling again from the incident report dated 12/11/2010. Record review of Resident #503 fall risk assessment dated [DATE] revealed that Resident 3503 scored an eight (8), dated 8/25/2010 reveal the Resident #503 scored a ten (10) on his fall risk assessment, dated 11/24/2010 revealed that Resident #503 scored a nine (9) on his fall risk assessment, dated 2/28/2011 revealed that Resident #503 scored twelve (12) on his fall risk assessment. Review of the fall risk assessment revealed that a total score of ten (10) or above represented a high risk for balls. Record review of the nurses' notes dated February 28, 2011 revealed that Resident #503 was found on his floor lying supplying next to his bed in front of his wheelchair. The nurses' notes revealed that Resident #503's alarm was not on. The notes revealed that Resident #503 had stated that he did not know what happened. The notes revealed that Resident #503 had complained of pain, and had a slightly render the area at the crown of his head without swelling or bruising. Record review of Resident #503's care plan dated 9/10/2010 revealed that on 9/10/2010 Resident #503 had a pressure alarm on his bed. Dated 9/20/2010 the pressure alarm was changed to a tab alarm. Dated 11/24/2010 the tab alarm was discontinued, per the care plan. No interventions were noted on the care plan until 12/11/2010 which revealed to place a pressure alarm on Resident #503's wheelchair and bed. Dated 2/28/2011 an intervention was added to place non-skid socks on Resident #503. Staff Member #8, an RN and unit manager, was interviewed on 3/25/2011 at 1:50 PM. She said that she may had taken Resident #503's alarms off for a "trial" to see if not having an alarm would decrease Resident #503's agitation. RN #8 said that was her intervention that she did, because the alarms would agitate Resident #503. She said that she would have had staff increase supervision of Resident #503, but did not have supervision documented anywhere as an intervention. RN #8 said that she did not know of any documentation of the CNA's checking resident alarms to verify placement and/or functioning, other than what was documented on the Activities of Daily Living sheets. RN#8 said that she could not be sure that the CNA's checked resident alarms every shift or daily from any type of documentation. She said that after Resident #503's fall on 2/28/2011 she did not have staff increase supervision for Resident #503. She said that some medication changes were made and non-skid socks were added. RN #8 was asked how she knew that the CNA's were checking resident alarms; she said that she did not know until a CNA reported that an alarm was not functioning correctly. Staff Member #9, an RN who had cared for Resident #503, was interviewed on 3/25/2011 at 1:07 PM. She said that on 2/2/8/2011 Resident #503 was in his wheelchair and must have wheeled himself back into his room, which was were he was found after his fall on 2/28/2011. RN #9 said that when she went into Resident #503's room she found that his wheelchair brakes were not locked and his pressure alarm was not sounding. She said that she checked the connection of the alarm and after lifting Resident #503 up from the floor, placed him back in his wheelchair, stood him up again and the pressure alarm sounded. She said that she did not change the pressure alarm that did not alarm to another pressure alarm. She said that non-skid socks were put on Resident #503 after the fall. She said that she did not know who was responsible to check the fall alarms, who actually checked the alarms, or where it was documented that the alarms had been checked for placement and/or functioning. RN #9 said that when she found Resident #503, his head was up against the wall and he had a reddened area to the back of his head, no other injury was noted. Staff Member #10, an RN, was interviewed on 3/25/2011 at 1:30 PM. She said that on 12/11/2010 when Resident #503 had fallen; Resident #503 was attempting to get up out of his wheelchair on his own. She said that after the fall she placed Resident #503 in the dayroom so he would be in view of staff. She said that she thought Resident #503 always had a fall alarm on, but could not remember for sure. RN #10 said that she could not remember putting an alarm on Resident #503 after the fall. She said that the CNA ' s document on the Activities of Daily Living sheet when they checked resident alarms for placement and/or functioning. Record review of the Activities of Daily Living sheets for Resident #503 for the months of December 2010, January, February, and March 2011 revealed no documentation related to Resident #503's fall alarms for any of the months listed above. ( )