Every finding on record at Healthsource Saginaw, Inc

Based on observation, interview, and record review, the facility failed to safely store food and maintain safe food temperatures during service, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include:On 08/03/2026 at approximately 9:40 AM during the initial kitchen tour, an empty hand soap dispenser was observed at the hand sink near the manager's office. On 08/03/2026 at 9:44 AM cooked chicken breast was observed with a prep date of 8/1/26 and a use by date of 8/8/26 in the walk-in cooler. During this observation, Director of Dining R was interviewed on how long the food is kept for and he stated it's normally kept for three days, and the prep date is counted as Day 1. On 08/03/2026 at 9:45 AM pepper pot soup was observed with a prep date of 8/2/26 and a use by date of 8/9/26 in the walk-in cooler. On 08/03/2026 at 9:54 AM a dented can of enchilada sauce was observed on the can storage rack instead of on the dedicated dented can rack. During this observation, Director of Dining R placed the dented can into the dented can rack. On 08/03/2026 at 9:56 AM a dented can of black olives was observed on the can rack, instead of on the dedicated dented can rack. During this observation, Director of Dining R was asked how they check for dented cans, and he stated they check for dents during stock on Mondays, Wednesdays, and Fridays. On 08/03/2026 at 10:07 AM a yellow green residue was observed on the blade of a knife that was stored in the knife rack. During this observation, Director of Dining R placed the dirty knife in the dirty dish area near the three-compartment sink. On 08/03/2026 at 10:17 AM the ice machine drain line was observed sitting inside the drain in the state lodge. On 08/03/2026 at 10:18 AM the ice machine drain line was observed sitting inside the drain in americana lodge. On 08/03/2026 at 10:21 AM the ice machine drain line was sitting inside the drain in the arbor cafe. On 08/03/2026 at 10:24 AM the ice machine drain line was sitting directly inside the drain in waterfront grill. On 08/03/2026 at 10:29 AM the ice machine drain line was sitting directly inside the drain in raceway inn. On 08/03/2026 at 11:47 AM during lunch observation, the burgers were temped at 131 F while hot holding on the steam table. During this observation, Director of Dining R was interviewed on what the temperature requirements were, and he stated he wants it held at 165 F. On 08/03/2026 at 11:50 AM the garden salad was temped at 63 F on the cart without being stored on ice, located in patriot kitchenette. On 08/03/2026 at 11:56 AM the chocolate milk was temped at 49 F on the cart without being stored on ice, located in arbor cafe. During this observation, Director of Dining R was interviewed on what the temperature requirement was for cold holding, and he stated 40 F or below. On 08/03/2026 at 11:58 AM a cut tomato was temped at 61 F in arbor cafe. On 08/03/2026 at 12:10 PM ranch dressing was temped at 66 F on the cart without being stored on ice, in waterfront cafe. According to the 2022 FDA Food Code, 6-301.11 Handwashing Cleanser, Availability, Each handwashing sink or group of 2 adjacent handwashing sinks shall be provided with a supply of hand cleaning liquid, powder, or bar soap.According to the 2022 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.According to the FDA 2022 Food Code, 3-101.11 Safe, Unadulterated, and Honestly Presented, Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented.Record review of the facility's policy on food storage, While receiving, some damaged products may not be identified right away to be sent back. Any items that are dented, leaking, or swollen must be stored in a designated and labeled area away from all other food until returned to the supplier. All damaged products will be returned to the supplier for credit. According to the FDA 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.According to the 2022 FDA Food Code, 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.According to the 2022 FDA Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control . time/temperature control for safety food shall be maintained .at 57 C (135 F) or above.According to the FDA 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5 C (41 F) or less.Record review of the facility's policy on hot holding, HOT PRODUCT HOLDING TEMPERATURES must be maintained at 140 F (60 C) or above while holding and serving.Record review of the facility's policy on cold holding, COLD PRODUCT HOLDING TEMPERATURES must be maintained at 40 F (4 C) or below while holding and serving.

Based on observation, interview and record review, the facility failed to implement a comprehensive infection control (IC) program including comprehensive and precise outcome surveillance, documentation, and data analysis, monitoring and tracking of potential infections, use and implementation of Enhanced Barrier Precautions (EBP) for three residents (#1, #84, and # 92) of three residents reviewed and Transmission Based Precautions (TBP) for one resident (#58) of one resident reviewed, resulting in the potential spread of microorganisms and illness to all 156 facility Residents. Findings include: Resident #58: On 8/4/26 at 11:25 AM, Resident #58 was not in their room. A sign indicating the Resident had Enhanced Barrier Precautions (EBP) in place was observed on the Resident's door. Directly inside the room door, above the hand sanitizer dispenser, a typed sign stating, Wash Hands with Soap and Water was observed. An interview was completed with Licensed Practical Nurse (LPN) BB on 8/4/26 at 11:27 AM. When queried why there was a sign above the hand sanitizer dispenser in Resident #58's room directing individuals to wash their hands with soap and water, LPN BB replied, I don't know, let me look. LPN BB reviewed Resident #58's Electronic Medical Record (EMR) and stated, Positive C-diff (Clostridioides difficile- contagious bacteria spread through spores which causes severe colon inflammation and watery diarhhea) in the report. LPN BB was asked why Resident #58 was not in Contact TBP if they were positive for C-diff and replied, They should be. I don't know why they don't have contact. With further inquiry, LPN BB stated, (Resident #58) is still getting IV (intravenous) Vanco (powerful antibiotic used to treat specific bacterial infections). They give that (Vanco) to (Resident #58) at dialysis. LPN BB was asked if the Resident remained symptomatic for c-diff and revealed she was unsure without reviewing the EMR. Note: IV Vanco is not used to treat c-diff infections. Record review revealed Resident #58 was most recently admitted to the facility on [DATE] with diagnoses which included infective endocarditis (infection of the inner heart lining and valve), Clostridium difficile (c-diff) infection (contagious bacteria which watery diarrhea and is spread by spores), diabetes mellitus, and end stage renal disease with dialysis dependance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required maximum to total assistance to complete Activities of Daily Living (ADLs) with the exceptions of eating and oral hygiene. Review of Resident #58's care plans in the EMR revealed the Resident did not have a care plan in place related to c-diff infection and/or alteration in bowel elimination. Review of Resident #58's hospital documentation in the EMR revealed the Resident tested positive for C-diff on 7/8/26. Further review of the Resident's hospital medical records revealed the following: - 7/13/26: Infectious Disease Consultation Report. patient as C diff infection.9. Old medical records reviewed. which showed that the patient had previous aortic valve endocarditis back in May of 2026 and has been placed on lifelong IV vancomycin. Plan. PO (oral) Dificid (fidaxomicin - specific antibiotic used to treat c-diff) . Review of Resident #58's Health Care Provider (HCP) orders revealed Resident #58 had an order for Contact precautions r/t (related to) ? (sic) C diff. with a start and end date of 7/7/26. Review of progress note documentation in Resident #58's EMR revealed a Nurses note dated 8/1/26 at 3:29 PM which detailed, Dx (diagnosis) C. Diff. Contact isolation discontinued r/t colonization. On 8/6/26 at 8:35 AM, Resident #58 was observed in their room in bed. An interview was completed at this time. When queried if they had been diagnosed with c-diff in the hospital, Resident #58 responded, Yes. Resident #58 was then asked if they were still having diarhhea and replied, Yes. Resident #58 then grabbed an emesis container that was on their bed and held it to their face. When queried, Resident #58 confirmed they were feeling nauseous. At 8:39 AM on 8/6/26, Registered Nurse (RN) QQ was notified of Resident #58's nausea. When queried if Resident #58 was still having diarhhea, RN QQ revealed they did not think so as the Resident was on Imodium and Metamucil TID (three times a day). When queried where bowel movement (BM) consistency is documented, RN QQ revealed the EMR and stated, Still having large loose liquid BMs. RN QQ was asked when the Resident's last loose stool was and replied, This AM. Review of Resident #58's Bowel Movement report documentation from 7/6/26 to 8/6/26 revealed the Resident was incontinent and their BMs were consistently loose/liquid with occasional mucous. There were two exceptions where Soft/Formed was documented. On 7/26/26, Bowel Movement documentation specified, Consistency: Soft/Formed and on 8/5/26, Bowel Movement documentation specified, Consistency: Soft/Formed; Consistency: Loose; Consistency: Liquid; Color: Brown; Characteristics: Mucous. An interview was completed on 8/6/26 at 9:05 AM with Infection Control (IC) Registered Nurse (RN) B. When queried regarding Resident #58 having c-diff and not being on contact TBP, IC RN B revealed Resident #58 was originally admitted on [DATE] and was having loose stools. IC RN B stated the Resident was tested for c-diff on 7/7/26 and I placed them in contact (TBP). (Resident #58) ended up going to the hospital that night for lethargy and came back on 7/22. Stools were semi formed when they returned. IC RN B stated, (Resident #58) came back on contact (TBP) and then changed to EBP on 7/28/26 because they started having formed stools. When asked to clarify if Resident #58 began was having formed stools on 7/22/26 or 7/28/26, IC RN B did not provide a response. Resident #58's BM documentation was reviewed with IC RN B at this time. When queried regarding the documentation indicating the Resident was having ongoing diarhhea and not formed stools, IC RN B stated, The staff are telling me it can be contained so I put (Resident #58) on EBP. IC RN B was asked if the Resident was incontinent of bowel and confirmed they were. When queried what they meant when they said contained, IC RN B responded that the loose liquid stool is contained in the Resident's brief. When asked how that applied to c-diff spores and transmission, IC RN B indicated they understood the concern. IC RN B then said the Resident and staff had told them it was improving. When queried if the reviewed the documentation, IC RN B revealed they did not. When asked why the Resident was not on contact TBP due to still having liquid stools and no documentation of reflex C. difficile toxin antigen assay results (diagnostic test used in conjunction with PCR diagnostic test and clinical systems to determine colonization vs. active infection), IC RN B was unable to provide an explanation but verbalized they would speak to the Infectious Disease Physician. Review of facility policy/procedure entitled, Infection Prevention/Control Service Clostridioides Difficile Management (No Date) revealed, Assessment. When c-diff is systematic. can cause some or all of the following symptoms: Watery diarrhea; Strong foul odor of stool with or without the presence of blood or pus; Abdominal cramps/nausea/vomiting. Steps to follow for suspected case of C-diff infection. Transmission-based Precautions: Place the patient/resident in contact precautions. Discontinue Isolation: Isolation may be discontinued when the below is met: Antibiotic has been in use for at least 3 days and stool consistency is formed/semi formed for 48 hours and stool can be contained and discontinuation approved with IC Nurse. A review of the facility IC Program was completed with IC RN B at this time. When queried if they had identified any trends in infections, IC RN B stated, Last month I had an increase in my UTIs (Urinary Tract Infections). The facility IC surveillance documentation from July 2026 was requested and reviewed with IC RN B at this time. Initial review of the line listing and mapping tools revealed less infections indicated on the mapping tool than on the line listing. When queried regarding the obvious discrepancy in numbers between the line listing and the mapping tool, IC RN B replied, Only HAI (Healthcare Acquired Infections are) on mapping. Detailed review of the number of infections listed revealed there were 80 total antimicrobial treatments for infections listed. The list did not include 80 separate residents as some individuals received more than one treatment for their infection. Nineteen of the infections listed were identified as being HAI. The mapping tool had 16 infections identified. When queried regarding the discrepancy in the number of HAI infections, IC RN B confirmed the discrepancy and responded that they are still working on the data for July (2026). When qeried regarding summary and analysis of infections for July 2026, IC RN B revealed they had not completed the analysis and summary yet. When asked why they had not, IC RN B indicated the facility had not had their meeting yet. Due to lack of data and analysis, the facility IC data for June 2026 was requested for review. Review of the June 2026 IC data revealed there were 67 total antimicrobial treatments for 64 infections. There were 19 HAIs included on the line list. The mapping tool provided for June 2026 designated 16 infections When asked, IC RN B reiterated only HAI were included on the mapping tool. IC RN B also provided a separate, written Infection Log form for June 2026. This list included 16 resident infections which were also included on the line list. When asked what the Infection Log was, IC RN B responded that they also use it to track the HAIs on the line list. When queried regarding the discrepancy in the number of HAI infections between the line list, the mapping tool, and the Infection Log form, IC RN B review the two lists and revealed they missed infections. All residents included on the June 2026 line list received an antimicrobial treatment. There were no residents listed that had signs/symptoms of infection and/or potential infection who did not receive antimicrobial treatment. When queried how they were tracking potential infections, IC RN B stated, I review nurses' notes and do floor rounds to see if anyone is running a temperature, has new nausea, vomiting, diarhhea, cough, etc. When queried if there were any residents who had signs/symptoms of infection in June who did not receive treatment, IC RN B responded there was nothing. When queried if they were saying no residents during the entire month of June had a new onset cough, nausea, headache, and/or any other potential sign/symptom of infection, IC RN B revealed they do not maintain a list of residents with potential signs/symptoms of infection. When queried if it is possible for someone to have signs/symptoms of infection and/or even an active infection and not receive treatment, IC RN B confirmed it was. When queried if an infection, which may not require treatment in one individual, could be transmitted to another resident who would require treatment due to comorbidities and/or being immunocompromised, etc., IC RN B responded that it could. IC RN B was asked if the line listing represented antibiotic stewardship or comprehensive outcome surveillance of infections, IC RN B did not respond. When queried how they were able to track and identify trends and origins of infection if they were not tracking all signs/symptoms of infection and/or potential infections, IC RN B verbalized understanding. When queried why they did not include the Community Acquired Infections (CAIs) on the mapping tool, IC RN B responded they were not aware they needed to. When asked what the purpose of the mapping tool was, IC RN B responded that it is a visual tool to track infections and identify spread and/or potential trends. IC RN B was then asked if a Resident who is admitted with an infection can transmit that infection to another resident at the facility and responded that they could. When queried how they were tracking and identifying spread and/or potential infection trends from residents with CAIs, IC RN B revealed they weren't. Review of the Infection Prevention and Control June 2026 Data summary form was completed. When asked, IC RN B revealed the summary was their monthly analysis. The summary included a list of 13 residents identified as having HAIs. When asked why the summary only had 13 residents which was less that that identified on the line list and mapping tool, IC RN B revealed the documentation and stated they missed residents. The summary specified, MDROs (Multi Drug Resistant Organisms) . 2 residents with MRSA in the urine, 1 resident with MRSA in the wound . A comparative review with the June 2026 line list revealed six residents had MDROs including two carry over wound CAI with MRSA from previous months who were still receiving treatment. The other four MDROs were all HAI and included two residents with MRSA in wounds, one resident with MRSA in their urine, one resident with pneumonia/UTI with a positive UA (urinalysis) for e-coli (bacteria commonly found in the gut), positive chest x-ray, positive MRSA., one resident with MRSA in their wound, and one resident with Extended-Spectrum Beta-Lactamase in their urine. When queried why the numbers did not match, IC RN B responded that they did not included HAIs. When asked why there were four residents with CAIs and the summary only included three, IC RN B indicated they must have missed a resident. Review of the MDROs for June revealed one resident with MRSA in their wound was on the same hall as the resident with MRSA in their urine. Per the line list, the Resident with MRSA in their wound and the resident with pneumonia/UTI with a positive UA (urinalysis) for e-coli (bacteria commonly found in the gut), positive chest x-ray, positive MRSA. resided in the same hall of the facility. The resident with MRSA in their wound began antibiotics on 6/20/26 and the resident with pneumonia/UTI with a positive UA (urinalysis) for e-coli (bacteria commonly found in the gut), positive chest x-ray, positive MRSA. began antibiotics on 6/26/26. The line list did not specify when the signs/symptoms of infection started for either resident. When queried if there were any potential trends/spread associated with the MRDOs, IC RN B reviewed the summary and indicated there was not. When queried regarding the two residents identified above with MRSA who resided on the same hall, IC RN B did not provide an explanation. Further review of the summary revealed, There were 16 HAIs that met reporting criteria. in June 2026. Findings: 3 Skin infections, 4 pneumonias, 10 UTIs (5 were CAUTIs [catheter associated UTI]) . Three was an increase in CAUTIs this mouth. Isolations for June. 2 residents were placed in contact precautions related to c-diff and then changed to Enhanced Barrier Precautions. The line list did not include any residents with c-diff infection. When asked why there were no residents with c-diff infection listed on the line list, IC RN B responded that they weren't on antibiotics. When queried who the resident were that were placed in precautions related to C-diff were, IC RN B responded, I don't know and indicated they did not track residents who were not receiving antimicrobial treatment. When queried regarding the increase in UTIs, IC RN B revealed they had identified the increase and began educating staff regarding catheter care in July 2026. When asked why they did not begin educating staff in June as the UTIs were diagnosed at the beginning of the month, a response was not provided. When asked why the summary/analysis did not include the specific causative microorganisms for the UTIs including spread/trends in the facility, such as two residents developing UTIs caused by proteus (gram negative bacteria), an explanation was not provided. The summary did not include any detailed information and/or analysis pertaining to CAIs. Review of facility provided policy/procedure entitled, Infection Prevention Control Program (dated 2025) revealed, Purpose. maintains a comprehensive Infection Control program. identifying and reducing infection risk. program allows for the systematic, coordinated, and continuous surveillance for infection whether HAI or CAI. Responsibility. The Infection Preventionist (IP) has day to day overall responsibility for the operation of the Infection Prevention Program. responsible for coordinating data collection and evaluating data. Review of facility policy/procedure entitled, Infection Prevention Service Infection Surveillance Program (no date) revealed, The Infection Surveillance Program shall include. Residents/patients requiring surveillance include but are not limited to: Residents/patients on isolation precautions. with a fever. receiving special treatments or invasive procedures that may be associated with infections. with signs and symptoms of jaundice, rashes, diarrhea, draining wounds, cough or respiratory congestion, etc. indicating a suspicion of infection. R84: A review of R84's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included Urinary tract infection (UTI) from Pseudomonas (aeruginosa mallei pseudomallei- microorganism) and VRE (vancomycin resistant enterococcus - microorganism) that required intravenous (IV) antibiotics through a peripherally inserted central catheter (PICC/ for long term IV antibiotic use), metastatic prostate cancer, need for assistance with personal care and dementia. A review of the resident's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) 05/15 and indicated severely impaired cognition. According to a review of R84's orders: Resident on enhanced barrier precautions D/T (due to) VRE in urine On 08/03/2026 at 11:21 AM, during an observation of R84 resting in bed there were six 10ml saline IV syringe flushes on the windowsill in direct sun and notably warm to touch. R84 had an IV pole with an empty IV hung that was labelled piperacillin/tazobactum 4.5 GM (antibiotic) Q8 hours. According to a record review of R84's Orders revealed: Monoject (one time use) Prefill Saline Flush (sodium chloride 0.9 %) syringe; amt: 1syringe; injection Every 8 Hours (at) 06:00, 14:00, 22:00.; and Piperacillin-tazobactam recon soln (reconstituted solution); 4.5 gram; amt: 4.5gm; intravenous Special Instructions: flow rate of 100mL/hour diagnosis UTI positive for VRE and Pseudomonas. Every 6 Hours (x 24) 18:00, 00:00, 06:00, 12:00. On 08/03/2026 at 12:36 AM, during an observation of IV PICC antibiotic medication administration with Nurse OO she was unable to find the saline flush available in the medication cart and needed to retrieve them from the medication supply room, she said they were normally kept in the medication cart. Upon entering the room Nurse OO was asked to observe the syringes stored in the windowsill, Nurse OO retrieved the six IV saline flush prefilled syringes from the windowsill and said she would need to discard them as they should not be stored on the windowsill nor in the direct sunlight. During the observation of Nurse OO administered medication access via the PICC line only wearing gloves and at no time did she wear additional personal protective equipment (PPE). Nurse OO was asked if the resident was in any precautions and she replied No, (that R84) was in contact (precautions) but has been out for about a week. She was asked what the contact precautions had been for and she said R84 had a C-Diff (clostridium difficille - microorganism) history and it was prophylactic (precautionary). Nurse OO was asked if PICC line access required any precautions and was referred to the enhanced barrier precaution sign on R84's door. Nurse OO had a surprised look and then stated Yes, I guess and acknowledged that a gown should have also been worn. According to R84's care plan record review revealed: Potential for cross contamination of infectious disease. Contact precautions. With intervention: Gloves and gowns to be worn for the following high contact residents care activities: Dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care (central line, urinary catheter, feeding tube, tracheostomy, chronic wound); Staff/Visitors to follow standard precautions and follow sign on door. The care plan did not note any update to reflect a downgraded Enhanced Barrier Precautions as stated by Nurse OO, as was posted on R84's door and found in R84's orders. According to a record review of the facilities policy titled PICC line nursing management revealed no direction on following EBP or wearing PPE other than non-sterile gloves when administering medication, flushes or accessing site. No additional policy on enhanced barrier precautions was received from facility as was requested by team lead on 08/05/2026 via email to the facilities DON at 3:26PM. R92: A review of R92's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, aphasia (cognitive communication deficient with speech and understanding), dysphasia (impaired ability to eat and drink), percutaneous endoscopic gastrostomy tubes (PEG / delivers nutrition and medications directly into the stomach). A review of the resident's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) was unable to be assessed and indicated severely impaired cognition and non-interviewable; the resident was dependent on staff for activities of daily living (ADL's). On 08/05/2026 9:57 AM, during observation of tube feeding administration Nurse LL had worn only gloves and no other personal protective equipment (PPE) when she accessed R92's PEG tube site and change the formula and tube set. Nurse LL was asked if R92 was in any precautions related to her PEG tube and she replied Yes, (R92) has swallowing precautions because she does not take anything by mouth. Nurse LL was asked about PPE needed to access R92's PEG tube and she said she always wears gloves and then asked, Am I supposed to wear a gown? Nurse LL was asked to observe the sign on R92s door and decide for herself. Nurse LL stated Oh, yes, it is a direct line into her body; I forgot. According to a record review of 92's care plan revealed: Focus: Potential for complications related to history of atypical adenomatous hyperplasia .: with intervention: Diet: NPO (nothing by mouth) with nutrition administered by tube feed.; And Focus: I have alteration in Gastrointestinal Status R/T (related to). PEG. with Intervention: Enhanced barrier precautions in place related to PEG; Administer. medications as ordered by PCP via peg tube.; And Focus: I require tube feeding R/T CVA; dysphagia; NPO status. With Intervention: Administer tube feed solution as ordered via peg tube. According to a record review of R92's orders revealed: Enhanced Barrier Precautions Twice A Day 07:00 - 19:00,19:00 - 07:00 According to the facilities policy titled enteral tube feeding revealed no direction on following EBP or wearing PPE during accessing PEG or other enteral feeding tubes. No additional policy on enhanced barrier precautions was received from facility as requested by team lead on 08/05/2026 via email to the facilities DON at 3:26PM. General observation infection control: On 08/04/2026 at 10:03AM, observed on the floor in the hall outside the resident rooms was an ~ (approximate) 4x4 inch folded gauze with bright red substance on it, CNA PP was asked to observe it. CNA PP picked it up and stated, oh it must be Ketchup. When CNA PP was asked to observe the item together she then acknowledged it was a piece of gauze and the red substance appeared to be blood. CNA PP disposed of the gauze in the trash. CNA PP did not alert other staff nor tried to clean or disinfect the area the blood soiled dressing was found. On 08/06/2026 at 9:35 AM, During an interview with DON and ADON A the observations were reviewed and both agreed that the expectation for standards of care for precautions are followed per the facilities policies and that the observations made on 08/03/2026 at 11:21 AM or 08/03/2026 at 12:36 AM for R84; the observation made on 08/05/2026 9:57 AM for R92; And the observation made on 08/04/2026 at 10:03AM of the environment, that none of those were acceptable practices for infection control nor followed the facilities policies. In regard to the soiled dressing found in the hallway, the DON further said in addition to CNA PP discarding the blood soiled gauze that the expectation was that CNA PP should have also called housekeeping to disinfect the hall. A record review of the facilities posted center of disease control (CDC) sign posted on the doors of R84 and R92's revealed: Enhanced barrier precautions everyone must: clean their hands, including before entering and when leaving the room. And Providers and staff must also: wear gloves and a gown for the following high contact resident care activities. Device care or use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing. Resident #1: Observation and interview on 08/06/2026 at 8:45 AM revealed observation of bright yellow over the door caddy of personal protective equipment (PPE) over Resident #1's room door. Observation of Registered Nurse (RN) V and Certified Nurse Assistant (CNA) W were observed to setup dressing supplies with barrier and supplies for dressing changes to left heel. Maxasorb dressing with silver AG- 4x4s, Gauze wrap, saline to clean, ABD, skin prep to peri wound. Neither nurse nor CNA wore a gown as required for enhanced barrier precautions. Observation of left heel wound old dressing dated 8/5/26 was removed. RN V washed and changed gloves. Observation of Resident #1's left heel noted baseball size indented wound with large (75%) of wound bed with black eschar to upper and right side of wound area, open lower left of wound with open pink granular wound bed with drainage noted on dressing. Wound cleansed with normal saline, Maxasorb dressing applied and covered with a 4x4 gauze and covered with an ABD dressing and wrapped gauze wrap. At the end of the dressing change the surveyor asked if enhanced barrier protections should have been taken. Nurse V and CNA W looked at the posted sign on the resident's room door and stated that yes, we should have applied gowns and a mask. Resident was observed to have a urinary catheter and left upper arm PICC line in place.

This citation pertains to Intake Number 3094671. Based on observation, interview and record review, the facility failed to ensure residents' dignity in regard to call light placement and response times, and, also, during dining services for five residents (Resident #6, Resident #32, Resident #92, Resident #147 and Resident #171) of five residents reviewed for dignity and from the confidential Resident Council group meeting, resulting in verbalizations of anger, being ignored by staff, having incontinent episodes due to not being toileted, humiliation and embarrassment. Findings Include: Resident #92 (R92): A review of R92's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, aphasia (cognitive communication deficient with speech and understanding), dysphasia (impaired ability to eat and drink), percutaneous endoscopic gastrostomy tubes (PEG / delivers nutrition and medications directly into the stomach). A review of the resident's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) was unable to be assessed and indicated severely impaired cognition and non-interviewable. The resident was dependent on staff for activities of daily living (ADL). On 08/03/2026 at 10:38AM, during an observation of resident resting in bed her call light was clipped to the wall cord and out of reach. CNA GG entered R92's room and was asked to locate the resident's call light, after she located the call light, she unclipped it and placed it on the bed. When she was asked if the resident would have been able to reach it, she replied, I guess not; I would expect it to be on her bed and not where it was located, clipped to the wall cord. On 08/06/2026 at 09:58AM, observed resident resting in bed. The call light was clipped the cord on the wall and not in resident's reach. Requested UM D to observe the call light and was asked how the resident would call for help if needed. UM D replied well she couldn't; and I don't know why it was placed there. Reviewed that R92 was nonverbal and unable to call out for help as well as a history of falls with UM D and he stated, I absolutely agree that is a problem. According to a record review of 92's care plan revealed: Focus: I have limitations in ability to perform ADL's/hygiene/transfers related to. CVA (stroke) with right hemiparesis. frequent falls. With interventions: Call light within reach. The facility's policy entitled Call Lights revealed: Policy: every patient/resident/shall have their call light answered promptly; Purpose: to receive patients/residents requests for help and act on them. Resident #6 (R6): A review of R6's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included dementia, moderate protein-calorie malnourishment, Muscle atrophy (wasting), difficulty walking, repeated falls and incontinence. A review of the resident's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 4/15 that indicated severely impaired cognition and non-interviewable; the resident was dependent on staff for activities of daily living (ADL's). According to a record review of R6's care plan revealed: Focus: ADLs Functional Status.I have limitations in ability to perform activities of daily living (ADL's)/hygiene/transfers related to: Dementia; .reduced mobility. with Interventions: I eat meals in my room; encourage to come out to dining room for meals. Requires set up for meals with encouragement due to poor appetite .; And Focus: Resident at risk for nutritional deficiencies (due to) therapeutic diet, underweight status, muscle wasting and subcutaneous fat loss. with Interventions: Total assistance (with) feeding at all meals & snacks. Resident #32 (R32): A review of R32's medical record revealed an admission into the facility on [DATE] with diagnoses that included stroke, hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, dementia, Parkinson disease and diabetes mellitus. A review of the resident's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 04/15 that indicated severely impaired cognition and non-interviewable; the resident was reliant on staff for assistance of activities of daily living (ADL's). A record review of R32's care plan revealed: Focus: I demonstrate Hearing Loss. With intervention: Be face to face when speaking to (resident); And Focus: I have limitations in ability to perform ADL's/hygiene/transfers related to: CVA with left side hemiplegia; debility; Alzheimer's. with intervention: I eat meals in my room or cafe. Requires set up and supervision assistance for meals.; And Focus: I am at nutritional risk d/t advanced age, need for modified textures for safety, early satiety with meals. with Intervention: I require total assistance with eating at meals. Resident #147 (R147): A review of R147's medical record revealed an admission into the facility on [DATE] with diagnoses that included Pneumonia related to aspiration of food, hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, muscle weakness, dementia, dysphasia (impaired ability to eat and drink) and diabetes mellitis. A review of the resident's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 04/15 that indicated severely impaired cognition and non-interviewable; the resident was reliant on staff for assistance of activities of daily living (ADL's). A record review of R147's care plan revealed: Focus: I have limitations in ability to perform ADL's/hygiene/transfers related to dementia; Debility; Contracture of right knee and left hand; Radiculopathy of lumbar region, right foot drop, right sided hemiplegia and hemiparesis with Interventions: Staff will encourage me to sit in dining room for supervision with meals. I require set up assistance for meals. May utilize meal tray for meals per my request.; And Focus: I am hard of hearing with Intervention: Look at me when speaking, adjust tone to assist with hearing, use a white board if needed to communicate.; And I am at nutritional risk for altered nutrition related to. dementia, Parkinson's disease. with interventions: Total assistance at all meals & snacks. Up right at meals. On 08/03/2026 at 12:19 AM, an observation was made during dining task in the assisted dining room of the long-term care unit of CNA II standing over R32 and feeding her while holding conversation with CNA HH who was observed standing over R6 and R147 and walking around the table between the two residents and feeding them at the same time. No hand hygiene was observed between feeding the two residents. On 08/03/2026 at 12:25 AM, observed staff nurse who provided chairs for the 2 CNA's and advised them to sit with residents while feeding them. When she was asked she said she knew the state agency (SA) observed them already but that did not mean they couldn't do better for the residents. On 08/04/2026 at 12:19 PM, during an interview with Nurse JJ she was asked about the assisted dining room residents and if it was standard or acceptable to be standing over residents while feeding them, and she said no it is not and said she had noticed with the newer CNA's it happens more often. On 08/05/2026 at 10:40AM, during an interview with feeding assistant NN she was about her training and she explained. When asked if she sat with the residents when she assisted with feeding residents or remained standing when she was feeding residents, she said she sat next to the resident when she assisted with feeding. According to a review of the facilities policy titled Guidelines for feeding the dependent patient/resident; try to seat yourself next to the patient resident so that I contact can be made talk to the patient residence and set the mood for a pleasant social experience; take time, allow the patient / resident time to taste chew and swallow. Do not rush the patient / resident as it does not make mealtime a pleasant experience. Resident #171 (R171): On 8/4/26 at 1:02 PM, Resident #171 was observed in their room, sitting in bed. The Resident was noted to have a Right Below the Knee Amputation (BKA) and an ACE wrap was in place over the BKA. When queried, Resident #171 revealed they are at the facility for therapy and intravenous (IV) antibiotic therapy. When queried if the staff at the facility treat them with dignity and respect and if they answer the call light timely when they need assistance, Resident #171 responded, They are never here when you need them. Resident #171 was asked what they require assistance with and stated, Going to the bathroom. Resident #171 then stated, It took them 45 minutes to an hour to come when my bed broke. With further inquiry, Resident #171 revealed the head controller had broken and fallen off their bed and they could not reach it. When asked, Resident #171 verbalized they wanted to raise their head because they were in pain and uncomfortable. When asked if they had any accidents due to the length of time it took the staff to respond to their call light, Resident #171 replied, I haven't sh*t my pants yet, but I could. I have the urinal or else I would be in trouble. With further inquiry, Resident #171 revealed the call light wait times are frequently long and verbalized feelings of frustration and irritation. An interview was completed with the Director of Nursing (DON) on 8/5/26 at 1:54 PM. When queried regarding the acceptable length of time for staff to respond to a resident call light, the DON did not provide a direct response. When queried if 45 minutes was acceptable, the DON responded that it was not. A report of Resident #171's call light times were requested at this time and provided by the Assistant Director of Nursing (ADON). Review of Resident #171's call light response times from 8/1/26 to 8/4/26 revealed the Resident's call light was utilized 22 times. Six of the call light response times were greater than 20 minutes and ranged from 21 to 52 minutes. The DON was queried regarding the call light response time report and confirmed the extended call light response times were not acceptable. Record review revealed Resident #171 was admitted to the facility on [DATE] with diagnoses which included right BKA, diabetes mellitus, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required setup to maximum assistance to complete Activities of Daily Living (ADLs). Review of facility policy/procedure entitled, Call Lights (no date) revealed, Every patient/resident/shall have their call light answered promptly. During interviews done on 8/3/26 at 2:00 p.m., during the confidential Resident Council Meeting (12 resident's in attendance) the following was verbalized as dignity concerns. Resident Rights Review at Council Meetings: 8 of 12 resident's stated Activity G did not go over Resident Rights per facility policy at every council meeting. During an interview done on 8/3/26 at 3pm with Activities G stated, Ya, I have missed a couple, I just forgot to go over them (Resident Rights). Facility Food and Dietary Concerns: 8 of 12 confidential resident's stated the facility food was cold (when served in rooms), did not taste good (burnt hamburgers), served late sometimes, and resident's were not allowed to change their mind and order off the alternative menu foods. During an interview done on 8/5/26 at 1:20 p.m., Director of Dietary Services R stated, We don't use the individual plate warmers (to keep food warm) because we don't have the heating element on the units; we can, but we don't have them now, we could put them on the units. Confidential resident stated Maybe management should eat what we eat and they would see what it's like. 5 of 12 confidential resident's said they have to spend their own money in the facility gift store to buy food because they don't like what was served, and they were told that is the only food they are getting. Confidential resident stated I keep extra food in my room because I get hungry. Resident Activities of Daily Living/toileting not done during Meal Serving Time: 8 of 12 confidential resident's had concerns regarding being toileted and said The CNA's are passing trays so there is no one to toilet us, we are told that they can't toilet us, they are passing trays (food trays during meals). 4 of 12 confidential resident's voiced they had accidents (incontinent episodes) because no one took them to the bathroom during meal serving time; they said they were very up set and embarrassed. 2 of 12 confidential resident's said They (staff) can't change my oxygen tank because they are serving food. 2 resident's said staff refused to change their oxygen tank (ran out of oxygen) due to passing trays at the time. Call Light Response Times: 12 of 12 confidential resident's said staff come in and shut off our lights and do not give us care, take up to an hour to answer lights; third shift is the worst. Management Interviews: During an interview done on 8/6/26 at 9:00 a.m., the Director of Nursing stated There are opportunities for improvement, we know there are complaint's; they (staff) are expected to answer (call lights) within 15 minutes, we expect them to do care when they answer the light and don't shut off the light until the care is given. During an interview done on 8/6/26 at 9:10 a., Assistant Director of Nursing A stated We do have resident's who do not like the food, we are constantly working on it. During an interview done on 8/6/26 at 11:00 a.m., Operations Executive P stated First we serve the hot foods then if they want something not on their ticket they can get it. Review of the facility Call Lights policy dated June, 2021, stated Purpose: To receive patient/resident requests for help and act upon them, in requests of an emergency nature, the patient's/resident's request shall take priority over all other activities (difficulty breathing (including needing oxygen tank changed), need for bathroom), call lights will be answered promptly. Review of the facility Prohibition of Abuse, Neglect, mistreatment, involuntary Seclusion, and Misappropriation of Property policy #P-039 (un-dated), stated Purpose: To protect the rights of patients/residents of HSS (facility). To be free from all forms of abuse as well as neglect; Neglect: is failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure care and storage of respiratory care equipment, per professional standards of practice, for four residents (Resident #58, Resident #85, Resident #146, and Resident #166) of four residents reviewed. Findings include: Resident #58: An observation on 8/4/26 at 11:25 AM revealed that Resident #58 was not in their room. A nebulizer machine with connected medication administration set was present on the bedside dresser. The nebulizer administration set was connected with visible clear colored fluid present in the medication administration chamber. An interview was completed with Licensed Practical Nurse (LPN) BB on 8/4/26 at 11:27 AM. When queried where Resident #58 was, LPN BB revealed the Resident was currently out of the building at dialysis. Record review revealed Resident #58 was most recently admitted to the facility on [DATE] with diagnoses which included infective endocarditis (infection of the inner heart lining and valve), Clostridium difficile (c-diff) infection (contagious bacteria which watery diarrhea and is spread by spores), heart failure, diabetes mellitus, and end stage renal disease with dialysis dependance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required maximum to total assistance to complete Activities of Daily Living (ADLs) with the exceptions of eating and oral hygiene. Review of Resident #58's Health Care Provider (HCP) orders revealed the Resident received Ipratropium-albuterol solution (prescription medication used to treat chronic and acute respiratory illness) nebulization; 0.5 mg (milligram)-3 mg. every 6 Hours. via nebulizer. Resident #146: On 8/4/26 at 10:28 AM, Resident #146 was observed in their room in bed and an interview was completed. When queried regarding the reason they came to the facility, Resident #146 replied, Came because of my breathing and I need therapy. A nebulizer machine was present on the dresser beside the Resident's bed. The nebulizer administration set was connected and in a gallon size plastic Ziplock style bag. Upon inspection, the connected nebulizer administration chamber was observed to have visible, clear colored, fluid in the chamber. When queried if the facility staff rinse the nebulizer administration set out after they receive a breathing treatment, Resident #146 stated, No and added, They just put it in the plastic bag which I don't think they should do because it hold germs. With further inquiry, Resident #146 revealed they were concerned about how the staff put the nebulizer in the plastic bag with fluid in it because they got pneumonia at the facility twice already. Record review revealed Resident #146 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), pneumonia, pain, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required set-up to total assistance to complete ADLs. Review of Resident #146's HCP orders revealed the Resident received Ipratropium-albuterol solution. for nebulization . every 8 Hours. via nebulizer. On 8/5/26 at 10:03 AM, Resident #146 was observed in their room in their bed. The nebulizer machine remained in the same place on the dresser beside the bed. The nebulizer administration set was connected and sitting on top of the dresser, not in a bag. A moderate amount of clear colored fluid was present in the medication chamber of the administration set. When asked if they had a breathing treatment today, Resident #146 replied, No, not yet. When queried how long the nebulizer administration set had been sitting on top of their dresser, Resident #146 stated, I didn't put it in the bag when I was done, and they (facility nurse) didn't come back in. Resident #146 explained they set the nebulizer administration set there when they were finished with their treatment but did not do anything else with it since the nurse did not return. When queried if the nurse who administers their breathing (nebulizer) treatment usually stays in the room with them when they are completing the treatment, Resident #146 responded they do not. Resident #166: On 8/4/26 at 1:14 PM, Resident #166 was not in their room. A nebulizer machine with connected administration set was sitting on the dresser next to the bed. The nebulizer administration set was connected, and clear colored fluid was visible in the medication chamber. The administration set was sitting in an open gallon size, plastic Ziploc style bag. The tubing on the nebulizer set appeared to be dated 7/24/26 but was unclear due to ink smearing. An interview was completed with Licensed Practical Nurse (LPN) CC on 8/4/26 at 1:15 PM. When asked where Resident #166 was, LPN CC responded that the Resident was sent out on the 2nd to the hospital and was expected to return to the facility soon. When queried why the Resident was sent to the hospital, LPN CC revealed they were unsure. Record review revealed Resident #166 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, COPD, supplemental oxygen dependance, and right lower radius fracture (larger bone in arm). Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required supervision to moderate assistance to complete ADLs. Review of Resident #166's HCP orders revealed the Resident had orders for the following medications to be administered via nebulizer: - albuterol sulfate 2.5mg/3 milliliter (mL) solution for nebulization. every 4 hours PRN (as needed) . Last administered on 8/2/26 at 4:45 PM - Ipratropium-albuterol solution. for nebulization . every 6 Hours. Last administered on 8/2/26 at 6:13 PM. Review of documentation in Resident #166's Electronic Medical Record (EMR) revealed the Resident was transferred to the hospital due to respiratory distress including decreased SPO2 levels (percentage of oxygen in the blood) and elevated respiratory rate. On 8/5/26 at 9:52 AM, Resident #166 was not in their room. The nebulizer remained in the same place on the dresser beside the Resident's bed with visible fluid in the medication chamber of the nebulizer administration set. An interview was completed with the facility Director of Nursing (DON) on 8/5/26 at 10:31 AM. When queried what the facility process/procedure related to nebulizer care after use and storage, the DON stated, Supposed to rinse out, let air dry, and put in bag for protection. The DON was informed of observations of nebulizers with visible fluid in the medication chambers as well as Resident statements that staff did not rinse the nebulizer out and let them dry. The DON did not provide further explanation but indicated staff would be educated. Review of facility policy/procedure entitled, Nebulizer (No Date) revealed, To provide a method of delivering aerosol medications, improve ventilation and/or loosen secretions. This procedure is performed by a nurse. Patient/resident will be monitored during the course of the treatment to ensure they are receiving medication and optimal benefit of treatment and for any problems related to the treatment. Cleaning: 1. Between treatments on the same patient/resident; rinse nebulizer and mouthpiece with sterile saline or sterile water. 2. Remove excess sterile saline or sterile water from parts by shaking and allow to air dry. 3. After parts have air dried, place them inside the holding compartment of machine or a clean, dry, covered, water proof container until next use. 5. Store tubing and mask in open plastic bag when not in use. Resident #85: Review of the Face Sheet, Physician's orders and nursing progress notes dated 1/2025 through 8/3/26, revealed Resident #85 was [AGE] years old, alert with confusion, admitted to the facility on [DATE], and required assistance with all Activities of Daily Living. The residents diagnoses included, chronic heart failure, diabetic, depression, anxiety, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia (low oxygen) and dependence on supplemental oxygen. Review of physician orders dated 1/25, revealed Resident #85 was receiving 4L of supplemental oxygen due to lung disease and respiratory failure. Observation was made on 8/5/26 at 8:15 a.m., of Resident #85's room; the nasal cannula was hanging half off the bed partly touching the floor, and was not in a bag. The resident was not in her room at the time. During an interview done on 8/6/26 at 12:50 p.m., the Director of Nursing/DON stated the NC when not in use should be put in a plastic bag. Review of the facility Respiratory Equipment/Tube Changing policy #111.11 (un-dated) stated Purpose: To limit the number of respiratory infections.

Based on interview and record review the facility, with a census of 136 residents, failed to ensure adequate staffing to meeting the care needs of residents. Findings Include: During the survey staff and the residents who requested to remain anonymous stated the following: Weekends are the worst and at times there are only two aides scheduled for the unit when it should be four. Today there are only two aides assigned to the unit which gives them about 20 residents to care for. The weekend Staffing Coordinator is horrible and not helpful in filling shifts. Staff from other units refuse to work on 300 units due to the low work ethic of the aides. The aidess on some units will not answer call lights and nurses will refuse to assist with non-nursing tasks. The facility is understaffed on the weekends, it is difficult to get help or have the call light answered timely. Residents throughout the survey shared the following: Call light wait times are extended and by the time a staff answers I have forgotten what I needed. It took them 45 minutes to an hour to come last night when my bed broke. I waited over an hour and a half for staff to answer the call light. Due to the call light wait times I had an accident (urinated on self) due to the delay. On 8/5/2026 at 1:40 PM, Nurse LL stated she is responsible for about 22-23 residents today and her hall partner left at approximately 1:05 PM. They counted off the narcotics together (as there was no plan in place for someone else to take over the assignment) but she did not sign the narcotic log or take the keys to the medication cart. Nurse LL informed Nurse Manager D there was no current coverage as Nurse LL was scheduled to work a partial shift and she was not comfortable being responsible for about 45 residents. Manager D stated he was occupied with a State Surveyor at that time. On 8/5/2026 at approximately 1:55 PM, Nurse Manager D stated he was not aware Nurse MM was not working the entire 12-hour shift today, as that was not communicated to him from the staffing department. He was not aware that he needed coverage from 1:00 PM to 7:30 PM. Review was conducted of unit assignment sheets, and it revealed there were at times only two aides assigned to work the unit: 500 Unit Assignment Sheets: 2/8/2026 3rd shift: 2 nurses and two aides with approximately 42 residents 2/15/2026 3rd shift: 2 nurses and 2 aides with approximately 42 residents 2/20/2026 3rd shift: 2 nurses and 2 aides with approximately 42 residents 3/8/2026 3rd shift: 2 nurses and 2 aides with approximately 42 residents 7/6/2026 2nd shift: 1 nurse and 3 aides with approximately 30 residents 300 Unit Assignment Sheets: 8/2/2026 3rd shift: 2 nurses and 2 aides with approximately 44 residents 7/11/2026 3rd shift: 2 nurses and 3 aides with approximately 42 residents 6/27/2026 1st shift: 2 nurses and 3 aides with approximately 42 residents 6/21/2026 1st shift: 2 nurses and 3 aides with approximately 42 residents 6/20/2026 1st shift: 2 nurses and 3 aides with approximately 42 residents 6/13/2026 2nd shift: 2 nurses and 3 aides with approximately 42 residents 6/11/2026 2nd shift: 2 nurses and 3 aides with approximately 42 residents 6/18/2026 2nd shift: 2 nurses and 3 aides with approximately 42 residents On 8/6/2026 at 11:20 AM, an interview was conducted with People Operations Director VV regarding staffing. She explained she has a staffing department of five and they staff the entire facility. There are two of her staff that specifically work with staffing the long-term care units. They send out staffing reports (via email) to nursing management three times a day and if there are any changes they do contact the unit to alert them. Director VV shared the weekends have proved more difficult to staff and they do receive a fair amount of call-ins. From 8/3/26 to today they have received 14 call-ins from aides and 6 call-ins from nurses. Director VV was asked what the staffing numbers by unit are and she provided the following ( nurses work 12 hours shifts and CNA (Certified Nurse Assistants) work 8 hour shifts): 500 Unit Nurses: Day Shift: 2 Night Shift: 2 CNA's: Morning: 5 Afternoons: 5 Nights: 4 400 Unit: Nurses: Day Shift: 2 Night Shift: 2 CNA's: Morning: 5 Afternoons: 5 Nights: 4 300 Unit: Nurses: Day Shift: 2 Night Shift: 2 CNA's: Morning: 5 Afternoons: 5 Nights: 4 200 Unit: Nurses: Day Shift: 3 Night Shift: 3 CNA's: Morning: 5 Afternoons: 5 Nights: 4 08/06/2026 11:41 AM, Staffing Coordinator RR stated the staffing report is emailed to Nursing Management at 7:00 AM and 2:00 PM. If there are any updates to the schedule once it is sent out, they contact the unit directly to alert them to the change(s). During their shifts they will work on securing coverage for open shifts but if they exhaust their options, it would be up to the managers to mandate staff. Review was conducted of call-ins from July 31, 2026, to June 1, 2026, and there were 232 call-ins. On 8/6/2026 at 1:15 PM, Human Resource Manager WW stated there are the following open positions: Four full-time nursing positions One part-time nursing position 14- full-time aide positions 15 part-time aide positions During the confidential Resident Group meeting held on 8/3/26 at 2:00 p.m., 8 of 12 resident's voiced concerns regarding not having enough staff to toilet them and attend to their needs during meal times. The resident's said staff are all busy passing trays and they say they can not toilet them because they are serving the trays. 4 of 12 confidential resident's voiced they had accidents (incontinent episodes) because no one took them to the bathroom during meal serving time; they said they were very up set and embarrassed. 2 of 12 confidential resident's said They (staff) can't change my oxygen tank because they are serving food. 2 resident's said staff refused to change their oxygen tank (ran out of oxygen) due to passing trays at the time. During an interview done on 8/6/26 at approximately 10:30 a.m., the Director of Nursing and Assistant Director of Nursing A both said Nursing Assistant's should be toileting residents as they request at all times. The Director of Nursing stated There is room for improvement.

Based on observation, interview and record review, the facility failed to operationalize procedures to ensure accurate narcotic medication reconciliation for one resident (Resident #168) of one resident reviewed and in one of one medication cart with change of responsibility. Findings include: Resident #168: On 8/4/26 at 10:53 AM, Resident #168 was observed in their room. The Resident was in bed with the lights off and the blinds closed on the window. The Resident responded when spoke to but displayed facial grimacing with movement. When asked how they were, Resident #168 stated, I had surgery on my stomach and my thighs and legs hurt. When asked what their pain level was on a scale of 0 to 10 with 10 being the worst possible pain imaginable, Resident #168 responded, Ten, it's horrible. A medication cup containing pills was observed sitting on the Resident's overbed table with more than 10 pills in the cup next to an uneaten breakfast tray. When queried regarding the pills in the medication cup, Resident #168 responded that the nurse had left them there for them to take when they felt up to it. On 8/4/26 at 10:57 AM, Licensed Practical Nurse (LPN) BB was observed standing at the medication cart in the hallway near Resident #168's room. LPN BB was asked to come to Resident #168's room. The medication cup containing pills was pointed out to LPN BB. When asked what the medications were, LPN BB indicated they did not know and took the cup from the Resident's bedside table. LPN BB stated, They (medications) were on the table when I went in. LPN BB was asked if they are supposed to leave medications on a resident's bedside table and responded that they were not. The medications were reviewed and identified with LPN BB at the medication cart. There were 12 tablets in the medication cup including a 5/325 milligram (mg) tablet of oxycodone/acetophemin (narcotic medication/controlled substance commonly called Percocet and used to treat severe pain). A review of the narcotic medication reconciliation book revealed Resident #168's last oxycodone/ acetaminophen tablet was signed out for administration to the Resident at 6:30 AM on 8/4/26. The nurse signature of who signed the medication out was difficult to read. When queried who signed out the medication for administration, LPN BB stated it was not them and provided a nurse's name. An interview was completed with the Director of Nursing (DON) on 8/4/26 at 11:40 AM. When queried regarding Resident #168's medications being found on their bedside table, including a narcotic medication, the DON stated, I don't know what to say. That is not okay. 300 Unit: On 8/5/2026 at 1:40 PM, Nurse LL stated she is responsible for about 22-23 residents today and her hall partner left at approximately 1:05 PM. They counted off the narcotics together (as there was no plan in place for someone else to take over the assignment) but she did not sign the narcotic log or take the keys to the medication cart. Nurse LL informed Nurse Manager D there was no current coverage as Nurse LL was scheduled to work a partial shift and she was not comfortable being responsible for about 45 residents. Manager D stated he was occupied with a State Surveyor at that time. On 8/5/2026 at approximately 1:55 PM, Nurse Manager D stated he was not aware Nurse MM was not working the entire 12-hour shift today, as that was not communicated to him from the staffing department. He was not aware that he needed coverage from 1:00 PM to 7:30 PM. On 8/5/2026 at 2:15 PM, a review was conducted of the August 2026 Controlled Substance Log for Cart #2 (300 Unit). On 8/5/2026 the 7:00 AM off-going and on-coming nurses (Nurse MM and a 2nd nurse) signed the narcotic log. There were no other entries for 8/5/2026 during this review. On 8/5/2026 at approximately 2:50 PM, a review was conducted of the August 2026 Controlled Substance Log for Cart #2 (300 Unit). On 8/5/2026 under 7 AM on-coming was Nurse MM and Nurse Manager D signatures. The bottom of form stated, All nurses need to sign the book after doing count, this is a must with the D.E.A. when you take the keys, you are saying the count is on and correct. On 8/06/2026 at 10:15 AM, Nurse MM stated she was a pickup shift and when she agreed to the shift she informed them, she could only work until 1 PM as she had an appointment. She completed a narcotic count with Nurse LL and left. On 8/6/2026 at 10:50 AM, Nurse Manager D was queried regarding scheduling on his unit. He explained the staffing department staffs the unit unless it's a critical situation or request for time off. They receive the schedule about three days in advance and have a meeting twice a week regarding scheduling. Once they receive the schedule if there are updates, they are not made aware of this those changes by the staffing department. Yesterday, he assumed Nurse MM picked up the entire shift and was not aware she agreed to work until about 1:00 PM. He did contact staffing and they informed him this was agreed upon between Nurse MM and the staffing department. Manager D contends he was never made aware he would need coverage after 1 PM. Manager D was queried regarding the narcotic count of that Cart #2 given that there was no coverage initially. He stated the following: Nurse MM counted off with Nurse LL when she left around 1:00 PM Nurse LL counted off with Manager D when he took the cart over about 2:30 PM. Nurse LL again counted off with Manager D around 5:30 PM when he left for the evening. Nurse Manager D was informed that Nurse LL did not sign off on the narcotic log with Nurse MM. He then shared he did not realize it was Nurse MM's was the signature he signed next too on the narcotic log but asserted it was Nurse LL he completed the narcotic count with at about 2:30 PM. Manager D continued both nurses completed the narcotic count prior to Nurse MM ending their shift. He expressed just because a narcotic count is completed is not indicative of that nurse (oncoming) being responsible that assignment. Nurse LL completed the count with Nurse MM but was not responsible for that assignment. From approximately 1:00 PM to 2:30 PM there was no nurse assigned to provide care to the residents assigned to Medication Cart #2. On 8/6/2026 at 11:21 AM, Nurse LL clarified she did complete a narcotic count and sign the log with Nurse Manager DD when he was taking the cart. But only completed the count with Nurse MM and did not sign the log as she was not taking the keys to the cart. She explained they complete narcotic count with the nurse they are passing the keys and assignment too. Review was completed of the staffing forms provided to 300 Unit for 8/5/2026. The schedule indicated Nurse MM was scheduled from 7:00 AM-1:00 PM. 08/06/2026 11:41 AM Staffing Coordinator RR stated the staffing report emailed to the Nurse Managers each morning indicated Nurse MM was working a partial shift.

Based on observation, interview and record review, the facility failed to 1) Maintain 3 clean and sanitary medication carts of 8 medication carts reviewed for cleanliness, and 2) Ensure that medications were not left at 1 resident's (Resident # 168) bedside unattended by a nurse, of 34 sampled residents, resulting in an unsafe medication pass (a wandering resident could take medications left at bedside), and cross contamination of residents' medications of 3 medication carts sampled. Findings Include: Resident #168: On 8/4/26 at 10:53 AM, Resident #168 was observed in their room. The Resident was in bed with the lights off and the blinds closed on the window. A medication cup containing pills was observed sitting on the Resident's overbed table with more than 10 pills in the cup next to an uneaten breakfast tray. When queried regarding the pills in the medication cup, Resident #168 responded that the nurse had left them there for them to take when they felt up to it. On 8/4/26 at 10:57 AM, Licensed Practical Nurse (LPN) BB was observed standing at the medication cart in the hallway near Resident #168's room. LPN BB was asked to come to Resident #168's room. The medication cup containing pills was pointed out to LPN BB. When asked what the medications were, LPN BB indicated they did not know and took the cup from the Resident's bedside table. LPN BB stated, They (medications) were on the table when I went in. LPN BB was asked if they are supposed to leave medications on a resident's bedside table and responded that they were not. The medications were reviewed and identified with LPN BB at the medication cart. There were 12 tablets in the medication cup. The medications included: - Gabapentin 400 milligram (mg) tablet (medication commonly used to treat nerve pain) - Omeprazole 20 mg (medication used to treat acid reflux) - Methocarbamol 500 mg (prescription muscle relaxer) - Effexor XR 75 mg (antidepressant medication) - Losartan 50 mg (medication used to treat high blood pressure) - Hydrochlorothiazide 25 mg (diuretic medication- water pill- used to treat high blood pressure and edema) - Naproxen 500 mg (Over the counter pain medication) - Lipitor 20 mg (medication used to treat high cholesterol) - Cetirizine 10 mg (over the counter medication used to treat seasonal allergies) - Cymbalta DR 60 mg (medication commonly used to treat depression) - Vitamin D3 25 microgram (mcg) supplement - Oxycodone/acetophemin (narcotic medication/controlled substance commonly called Percocet and used to treat severe pain) An interview was completed with the Director of Nursing (DON) on 8/4/26 at 11:40 AM. When queried regarding Resident #168's medications being found on their bedside table, including a narcotic medication, the DON stated, I don't know what to say. That is not okay. On 8/4/26 at 11:15 AM, the Medication Cart #1 (Labeled 260-262 &280-294) was observed to be unlocked and unattended in the hallway of the facility. Resident #103: On 8/3/2026 at approximately 11:40 AM, Resident #103 was observed resting with eyes closed in bed. In the corner of the right side of the room was an IV (intravenous) pole with an empty Sodium Chloride bag attached to the pole with a pharmacy label dated 7/18/26. On 8/3/2026 at 11:55 AM, Nurse SS observed the empty Sodium Chloride bag in Resident #103's room. He reported that the resident received fluids that was a one-time order. When asked why it was still in the room (two weeks after administration) it was explained they leave them in the resident rooms for just in case purposes. On 8/4/2026 at 1:00 PM, a review was conducted of Resident #103's electronic medical record and it revealed he was admitted to the facility on [DATE] with diagnoses that included Dementia, Hypertension, Heart Disease, Depression and Chronic Obstructive Pulmonary Disease. Further review of the chart yielded the following: Physician Orders: Sodium Chloride 0.9% parenteral solution: 1 L (Liter); intravenous. One time order was placed on 7/18/2026. Progress Notes: 7/18/2026 at 12:10: Lab results given to (physician), new order for 1 L (liter) NS (normal saline), and recheck labs Monday. On 8/4/2026 at 4:05 PM, Infection Preventionist B was informed of the empty Sodium Chloride Bag in Resident #103's room dated 7/18/2026. She stated upon completion of administration it should have been discarded of. Patriot Unit: Observation of Patriot Units Medication cart #1 was done on 8/3/26 at 9:00 a.m., accompanied by Nurse, RN J. -Drawer #3 had crushed pills, dust and papers on the bottom in the back. -In the 8th drawer was found a silver pair of earrings and dust on the bottom. During an interview done on 8/3/26 at 9:03 a.m., Nurse RN J stated I don't know who cleans the med cart. Wheels Unit Medication Cart #1: Observation was done on 8/3/26 at 9:10 a.m., accompanied by Nurse, LPN K. The following was found: -In the 3rd drawer was found crushed pills, dust and pieces of paper on the bottom. -In the 4th drawer was found dirt-like, dust and crushed pills loosely on the bottom back. -In the 7th drawer was found crushed pills, dust and pieces of paper. During an interview done on 8/3/26 at 9:15 a.m., Nurse, LPN K stated the night shift cleans the carts. Garden Unit Medication Cart #2 Observation was done on 8/3/26 at 9:10 a.m., accompanied by Nurse, LPN L The following was found: -In the 4th drawer was found crushed pills, dust and pieces of paper. During an interview done on 8/3/26 at 9:30 a.m., Nurse, LPN L stated Nights cleans it (the med cart). During an interview done on 8/5/26 at 8:15 a.m., the Director of Nursing stated The night nurse's clean the cart's. Review of the facility Medication Storage policy (un-dated), stated the medication carts will be kept clean. Unlocked Medication Carts: Observation on 08/04/2026 at 3:25 PM the state surveyor observed medication cart on Wheels care unit, 220's hallway, Cart #2 Room#240, 242, 220-223, 235. Surveyor was able to open the drawers of medication cart. Observed single dose medications in boxes by each resident. In an interview on 08/04/2026 at 3:26PM, Registered Nurse (RN) Z came out of a closed resident's room, and the surveyor asked why the medication cart was left unattended and unlocked? RN Z stated that the cart should lock itself over time with the auto lock mechanism. Nurse Z had no reason as to why the cart was left open and accessible to other residents and visitors. In an observation and interview on 08/06/2026 at 8:03 AM of the Patriot care unit Hallway rooms 320s, the state surveyor observed an unlocked medication cart #1 and was able to open drawers on the medication cart out of sight of the nursing station. There was no nurse in sight. Surveyor waited for Registered Nurse (RN) AA to come from the direction of the nursing station. The state surveyor asked the nurse why was the surveyor able to open medication cart drawers? RN AA stated that she thought the auto lock on the medication cart would lock it.

This citation pertains to Intake Number 3094671. Based on observation, interview and record review, the facility failed to ensure 1) Palatable and appealing food, 2). That food was served at correct temperatures, and 3). Offer alternative meal choices at all meals for 3 of 31 residents reviewed for dietary services and 12 of 12 Confidential Resident group members, resulting in resident's having to get alternative foods on their own, voiced anger, frustration, and residents not eating what was served and going hungry. Findings Include: R5: On 08/03/2026 at 10:17 AM, during an interview with R5 it was revealed that the food was so-so and often barely warm, R5 reported that it was better previously but had gotten much worse with the new kitchen guys. R5 complained about being served chicken 4-5 times a week and mash potatoes 3-4 times a week between the lunch and dinner meals served. R5 said they served a lot of broccoli and zucchini with no alternative vegetables. On 08/04/2026 at 1:57PM, during a follow up interview with R5 said his breakfast was just ok and stated, it's hard to screw up scrambled eggs and voice being upset over not getting the double portion of sausage as requested. R5 stated they don't always read the tickets or bring you what you ask for. On 08/05/2026 at 2:55PM, during a mutual interview conducted with Registered Dietitian (RD) Q stated They (staff or resident's) can call (to the kitchen) and ask for more food, we have to serve all the residents then first, then if there is more, they can get it. On 08/05/2026 at 3:00PM, during an Interview, dietary staff KK said if residents want more food they can call down to the kitchen or ask staff to. Dietary staff KK said they (dietary staff) meet with residents often especially if they are requesting extra portions on a regular basis and said they can be automatically ordered for double portions if it fits the resident diet needs. On 08/06/2026 at 10:03AM, during an interview with R5, he revealed he did not eat breakfast yesterday (08/05/2026) that he was nauseated and it did not look good to him. R5 said that dinner yesterday (08/05/2026) was supposed to be chicken of some sort he did not eat it because it looked like it had been through a meat grinder; no thanks. R5 was asked about how he ordered his meals and he said they (staff) come once a week and fill out the orders on a tablet, but like I said, I don't think they can read very well. R5 said that the food often sounded better than it appeared. R5 was asked if the facility offered alternate choices in those cases, he said you can ask for it, but they will often say they run out. R5 said that he loves hamburgers but not here and reported that they are served burnt up; so dry they make me cough. R80: On 08/03/2026 at 3:30 PM, during an interview with R80 stated the food here was not good and they serve a lot of chicken, and R80 said does not like the chicken. On 08/04/2026 at 10:08AM, during a follow up interview with R80 he said last night they served roast beef and his only comment about it was well, at least it's not chicken. On 08/05/2026 at 10:16AM, during an interview R80 said I only eat cereal for breakfast, I just don't like the way they cook. On 08/05/2026 at 3:00PM, during an Interview with dietary staff KK said if residents want more food or alternative food they can call down to the kitchen or ask staff to. On 08/06/2026 at 10:27AM, follow-up interview with R80 reported that he had a hot dog and a ham and cheese sandwich for dinner last night and said it was because they (the facility) served chicken. When asked how he ordered meals R80 said they (staff) come around with a tablet and ask what you want to order. R80 stated I tried to get an egg salad sandwich, but they won't make one; I love egg salad he said it is not on the anytime alternate menu. R80 said he ends up ordering hotdogs from the alternative menu if they have chicken or something else if he doesn't like the meal and that the menu was limited. According to a review of the facilities policy titled table ordering revealed responsibilities: assist residents with meal concerns; monitor for last minute changes; if the resident refuses their meal or wants something different 2. Discuss acceptable alternate using alternate menu 3. Immediately call kitchen 4. Request replacement meal. 5. Confirm with the kitchen. Residents Served per Facility Dining Program: Observation made on 8/5/26 at 7:15 a.m., in Great Lakes dining room revealed, 4 resident's sitting eating their breakfast and 2 resident's (Resident's #13 and #178) sitting at different tables and watching the others eat their food for 15 minutes (7:30 a.m. to 7:45 a.m.), until Nursing Assistant/CNA T came and asked Dietary Server U to give him their trays. During an interview done on 8/5/26 at 7:48 a.m., CNA T was asked if all the resident's in the dining room were to be served before trays were taken out to the floor and he stated Yes, they are supposed to be served first. During an interview done on 8/5/26 at 7:50 a.m., Dietary Server U was asked if trays should be served to resident's sitting in the dining room before sending trays out to the floor and she said she just goes slip to slip. Dietary Server U did not say there was any order to serving food trays. During an interview done on 8/5/26 at 1:20 p.m., Dietary Manager R stated, We take the tickets and give them to the nursing assistants at the desk and they organize them according to where they are sitting; any time we see it it's not an issue. Nursing was to sort the food tickets according to who sits in the dining rooms and put them on top, so all resident's who eat in the dining room are served table to table. In this way, no resident has to sit and watch other resident's eat. Dietary Manager R said they do dietary audits to ensure the meal process is going smoothly. Review of the facility Dietary Dining Operations Global Audits dated 6/4/26 through 8/4/26, revealed no documentation on the audit tool regarding serving all resident's table to table or serving all resident's in the dining room prior to serving the room trays. Alternative Food Requests: During the confidential Resident Group meeting held on 8/3/26 at 2:00 p.m., 8 of 12 resident's stated they were not allowed to get an alternative meal choice if they did not pre order it (prior to the meal the day prior). During an interview done on 8/5/26 at 1:20 p.m., Dietary Manager R stated They (resident's) should not being told they can't have the alternative, they should not be doing that at all. During an interview done on 8/5/26 at 2:55 p.m., Registered Dietitian Q stated They (staff or resident's) can call and ask for more food, we have to serve all the residents then first, then if there is more they can get it. During an interview done on 8/5/26 at 11:00 a.m., Operations Executive P stated The Dietary Server needs to assemble the tickets (put them in the right order to be served table to table). Review of the facility Meal Service policy (un-dated) stated Pass food trays table by table. Confidential resident attending the group meeting held on 8/3/26, stated I keep extra food in my room because I get hungry. Review of the dietary procedure for tablet ordering and serving dated 3/1/26, revealed the next day meal requests were to be completed from 1:30 p.m. to 2:00 p.m., each day. The procedure stated Responsibilities: Assist resident's with meal concerns, monitor for last minute changes, discuss acceptable alternative using alternate menu, immediately call the kitchen, request replacement meal that complies with resident diet and texture orders. Food Served Late: During the confidential Resident Group meeting held on 8/3/26 at 2:00 p.m., 8 of 12 resident's said the food is served late. Review of the dietary Dining Operations Global Audit Sheet's dated 6/4/26 through 8/4/26, revealed a total of 6 times food was served late on the units (on 6/4/26, 6/9/26, 7/8/26, 7/14/26, 7/28/26 and 8/4/26). Cold Food: During the confidential resident Group meeting held on 8/3/26 at 2:00 p.m., 5 of 12 resident's said their food was served cold. Observation of the facility resident units done on 8/3/26 and 8/5/26, revealed no resident microwaves were on units. The only microwaves were the staff's in the staff break rooms (away from resident halls). During an interview done on 8/5/26 at 1:20 p.m., Director of Dietary Services R stated, We don't use the individual plate warmers (to keep food warm) because we don't have the heating element on the units; we can, but we don't have them now, we could put them on the units. Confidential resident stated, Maybe management should eat what we eat, and they would see what it's like. Resident #22: In an interview on 08/03/2026 at 10:17 AM with Resident #22 it was revealed that the food has always been bad. Resident #22 had resided at the facility for 4 years and used to be able to order a chief salad, but the facility stopped that option. Resident #22 stated that the kitchen has all the supplies for a chef salad, but that they will not put it together. Resident #22 stated that she has tried to order all the ingredients separately and put it together herself. Resident #22 stated that she orders snacks instead of meals, because she does not like the meal/food options on the menu and will have the aides go and get pudding and cookies. Observation and interview on 08/05/2026 at 9:38 AM with Resident #22 were seated up in edge of bed, with a breakfast of French toast, 2 yogurts and a banana. Resident #22 stated that the French toast was warm, but the butter did not melt on the toast. Resident #22 stated that she has been ordering a full breakfast and limiting her other meal food choices because the food is usually bad. Observation on 08/05/2026 at 10:09 AM Observation of the Garden unit steam table not in use, noted posted information on therapeutic diet tray guidelines for servers and Long-Term Care alternate Menu items included limited items, with no chef salad option.

Based on observation, interview and record review the facility failed to provide meaningful activities to meet the needs of 4 of 4 residents (#10, #18, #124, #129) and also residents reviewed on the 500-Unit for activities. Findings Include: On 8/4/2026 at approximately 1:00 PM, multiple 500 Unit residents (on the secured unit) were observed just sitting in the dining room at the table. There was a back table full of sensory activities, but they were not being utilized. On 8/4/2026 at approximately 2:45 PM, activities staff had still not visited the unit to complete activities with the residents. On 8/4/2026 at 1:45 PM, an interview was conducted with Activities Director G regarding programming on the 500 unit. There is typically one staff assigned to that unit and they realized today there were no activities completed on the unit. She stated she typically reminds her (Activity Aide TT) to go to the unit and will assist as well but she did not do that yesterday. Director G was asked if that is the Activity Aides' normal assignment why would she need to be reminded to complete her job duties. There was no answer provided. The director was informed the residents did not appear to be engaged in any activity that would meet their needs as they were in a room with the television on. She expressed understanding.A review was made of August 2026 activity calendar for the 500 unit, and it was pointed out that over 75% of the scheduled activities were either listening to music or watching television. The calendar was not geared towards the needs of the residents that occupy the unit. Many of the residents on the secured unit are pleasantly confused, have diagnose of dementia or Alzheimer's and exhibit behaviors. Many of the scheduled events would not hold their interest. Director G stated since it was pointed out the calendar is repetitive and not reflective of the residents in that unit. On 8/4/2026 at 2:26 PM, an interview was conducted with Activities Assistant TT regarding programming on the secured unit. She explained in the morning she does H20 on the go which is passing flavored water to the residents on the unit. At 10:00 AM they either exercise, listen to music or watch television; today they watched a concert performance on television to get them ready for the celebrity impersonator event later today. At 2:00 PM- she takes as many as she can off the unit for an event. Assistant TT' shared she did not make it down to the 500 unit yesterday as she was completing her online required education prior to scheduled vacation. She stated although she did not make it down there, she put on some music for them to listen to too. Assistant TT was asked if the programming she explained (music and television) would meet the residents needs and she stated she does not think that it would sustain their attention. Review was conducted of 500 Unit Activity Calendars from May 2026 to August 2026. It was found the residents routinely were scheduled for television, music and flavored water.August 2026:Television: 20 timesMusic: 18 timesFlavored water:20 timesJuly 2026:Television: 26 timesMusic: 13 timesFlavored water:23 times June 2026:Television: 19 timesMusic: 14 timesFlavored water:21 times May 2026Television: 25 timesMusic: 17 timesFlavored water:19 times On 8/6/2026 at 9:05 AM, review was completed with Activities Director G of residents' individual activity attendance sheets, and it was found of the four residents reviewed there was a lack of dementia related meaningful activities provided to the residents. Director G reported she understood the concern. The review yielded the following: Resident #10:Resident #10 was assessed as not being cognitively intact with diagnoses that included Dementia, Anxiety and Hypertension. Over the last month the following activities were completed with her:Talked to Resident #10: 16 timesRoom visit: 5 times Resident #18:Resident #18 was assessed as not being cognitively intact with diagnoses that include, Dementia, Alzheimer's, Anxiety and Hallucinations. Over the last month the following activities were completed with her:Talking to Resident #18: 11 timesRoom visits: 4 timesTV/Exercise: 5 timesResident #124:Resident #124 was assessed as not being cognitively intact with diagnoses the include Dementia, Atrial Fibrillation and Arthritis. Over the last month the following activities were completed with her:Room Visits: 3 timesFlavored water: 21 times Resident #129:Resident #129 was assessed as not being cognitively intact with diagnoses that include Alzheimer's, Dementia, Hypertension, and Anorexia. Over the last month the following activities were completed with her:Talked to Resident #129: 18 timesRoom Visits: 4 timesTelevision: 2 times Staff that requested to remain anonymous explained activities staff are typically in their hall for a 10:00 AM and 2:00 PM activity, but they only take certain residents to events off the unit. But most of the time the residents are sitting in the dining room watching television. They stated they do not engage their residents that much with activities that actually may interest them. Review was conducted of Activity Assistant job description. It stated the following: .assists in conducting scheduled activities to promote the physical, social, and mental wellbeing of residents.

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure intravenous (IV) and PICC (Peripherally Inserted Central Catheter) line maintenance, monitoring, and care for two residents (Resident #122 and Resident #171) of two residents reviewed.Findings include: Resident #122: On 8/4/26 at 1:37 PM, Resident #122 was observed in their room in bed. The Resident was pleasantly confused. An IV pump was present in the room with an IV bag of D (Dextrose) 50.45 NS (Normal Saline) hanging on the pump. The tubing was fed through the pump and the IV bag was empty. The IV bad was labeled, Infuse one time on 7/20. Resident #122 had a PICC line in the upper arm. The PICC line dressing was dated 8/3/26. Review of Resident #122's Electronic Medical Record (EMR) revealed that the Resident was admitted to the facility on [DATE] with diagnoses which included dementia, repeated falls, fifth metacarpal bone fracture (bone in hand which connects pinky finger to wrist) in their right hand, and pain. Review of the Minimum Data Set (MDS) assessment, dated 7/16/26, revealed the Resident was severely cognitively impaired and required moderate to total assistance to complete Activities of Daily Living (ADLs). Review of Resident #122's EMR revealed that the Resident was not currently receiving any IV medications. Further review revealed the Resident did not have an active PICC line dressing change order and did not have an order to flush the PICC line when not in use. An interview was completed with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on 8/5/26 at 3:43 PM. When queried why Resident #122 still has a PICC line, the ADON and DON reviewed the Resident's EMR and both responded they did not know and would need to find out. When asked if the Resident had an order for a PICC line dressing change, the ADON stated, No. When queried if PICC lines that are not being used should be flushed, both the ADON and DON verbalized they should. When asked if Resident #122 had an order for their PICC line to be flushed, the ADON stated, No, there should be. Resident #171: On 8/5/26 at 9:56 AM an observation and interview were completed with Resident #171. The Resident had a PICC line present in their Left Upper Extremity (LUE). The dressing on the PICC line was dated 8/5/26. Dark brown colored drainage was present under the dressing. An IV pump was present in the room with an empty bag of cefazolin (IV antibiotic) 2 grams (g) hanging on the pump but not infusing. The antibiotic bag was not dated when hung/administered and the IV tubing was not dated. Record review revealed Resident #171 was admitted to the facility on [DATE] with diagnoses which included right Below Knee Amputation (BKA), diabetes mellitus, and infection with IV antibiotic therapy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required setup to maximum assistance to complete Activities of Daily Living (ADL). Review of Resident #171's hospital medical record documentation revealed the PICC line was inserted on 7/29/26. An interview was completed with Infection Control Registered Nurse (RN) B on 8/5/26 at 9:49 AM. When queried regarding the facility policy/procedure related to what date staff write on PICC line dressings, RN B stated, It's the date you change it. Date and initials. When asked if IV tubing should be dated, RN B responded that it should. On 8/5/26 at 2:09 PM, Resident #171 was observed in their room. The Resident was receiving their IV antibiotic through the PICC line in their RUE. The PICC line dressing was dated 8/5/26 with visible dark colored drainage present under the dressing. The IV tubing was undated. An interview was completed with RN QQ on 8/5/26 at 2:20 PM. When queried if IV tubing is supposed to be dated per facility policy/procedure, RN QQ stated, They should be. RN QQ was then asked how long IV tubing is able to be used for and responded, Three days. When asked if all IV tubing is good for three days, RN QQ stated, Yeah. An interview was completed with the ADON on 8/5/26 at 2:53 PM. When queried if IV tubing should be dated, the ADON responded, Yes. When queried how long IV tubing is able to be used, the ADON responded, Any primary is 72 hours. When queried if that included intermittent antibiotic therapy, the ADON reviewed the policy and indicated that primary tubing is able to be utilized for 72 hours per the policy. A follow up interview was completed with the ADON and the Director of Nursing (DON) on 8/5/26 at 3:43 PM. When queried regarding Resident #171's receiving intermittent antibiotic therapy through primary IV tubing, the ADON responded that they were incorrect during prior interview and that tubing used for intermittent IV medication therapy is only good for 24 hours. Review of facility policy/procedure entitled, Intravenous Infusions, Administration of (no date) revealed, Nursing Implications. 6. All primary tubings must be changed every 72 hours and labeled with completed IV tubing label. Piggyback IV tubings are to be changed every 24 hours and labeled appropriately. Review of facility policy/procedure entitled, Intravenous, Secondary Antibiotic Administration (no date) revealed, The piggy-back method of intravenous administration is to be used for infusing IV antibiotic medications. D. Documentation and labeling: 1. Label piggy back tubing with date and time, change every 24 hours. Review of facility policy/procedure entitled, PICC Line Management (no date) revealed, Procedure. 10. Maintaining the PICC line when medications are not being given. D. Use two (2) pre-filled needless syringes to flush each lumen with 10 mL (milliliters) of sterile normal saline every eight (8) hours to keep the line open. F. Evaluate the need for the PICC. Unless the physician determines otherwise, obtain and order to remove the PICC when it is not being used for the delivery of IV medications or hydration therapy. 12. PICC line dressing change: A Complete weekly and B. PRN (as needed) whenever the dressing becomes loose. or accumulation of moisture or fluid under dressing.L. Label and date the dressing change.

Based on interview and record review, the facility failed to ensure that an appropriate legal representative signed Advance Directive documentation for one resident (Resident #122) of three residents reviewed. Findings include:Resident #122:Review of Resident #122's Electronic Medical Record (EMR) revealed an Advance Directive form specifying the Resident wanted Hospitalization, Cardiopulmonary Resuscitation/Mechanical Ventilation, and IV (intravenous) Hydration but did not want Tube Feeding. The Advance Directive form was signed on 7/7/26 by an unknown individual, who was not the Resident. Review of Resident #122's face sheet revealed the Resident had two friends listed as their Emergency Contact. Neither of the listed emergency contact names matched the signature on the Advance Directive form. Review of Resident #122's EMR revealed the Resident was admitted to the facility on [DATE] with diagnoses which included dementia, repeated falls, right hand fifth metacarpal bone fracture (bone in hand which connects pinky finger to wrist), and pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required moderate to total assistance to complete Activities of Daily Living (ADLs). Additional documentation in Resident #122's EMR revealed the Resident had been deemed incompetent to make medical decisions. Review of the Resident's EMR revealed Durable Power of Attorney (DPOA) for finance designation documentation. A review of the document titled, A Durable Power of Attorney for My Finances designed Resident #122's friend, Witness EE as Resident #122's agent to to make any decisions regarding the Resident's financial affairs. The document did not address anything pertaining to medical decision making and/or did not designate a DPOA for medical decision making. An interview and review of Resident #122's EMR was completed with the Director of Nursing (DON) on 8/5/26 at 1:11 PM. When queried regarding the signature of Resident #122's Advance Directive form, the DON confirmed the signature was not the Resident's. When queried if the Resident had a DPOA for medical decision making, the DON provided the document titled A Durable Power of Attorney for My Finances located in the EMR. The DON revealed the individual designated as the Resident's DPOA for Finances was Witness EE who was also the Resident's listed Emergency Contact. When queried regarding the discrepancy in the names on the Financial DPOA document, the Emergency Contact on the face sheet, and the signature on the Advance Directive form, the DON clarified that Witness EE often went by their middle name and confirmed that Witness EE had signed the Advance Directive form. When asked why Witness EE signed the Advance Directive form when they were not the Resident's DPOA for medical decision making, the DON was unable to provide an explanation and indicated Social Services Staff FF would be able to provide an explanation. An interview was completed with Social Services Staff FF and the DON on 8/5/26 at 1:24 PM. When queried regarding the signature on Resident #122's Advance Directive form, Staff FF confirmed the signature belonged to Witness EE. When queried if Resident #122 had a POA for medical decision making, Staff FF responded that it was Witness EE. Staff FF was asked where the documentation was that stated Witness EE was the Resident's medical POA and indicated it was included in the A Durable Power of Attorney for My Finances document. Staff FF was asked to review Resident #122's , A Durable Power of Attorney for My Finances document and show where it specified in the document that Witness EE was the Resident's designated medical DPOA. Staff FF reviewed the document and pointed out a section that stated, 11. What if I need a conservator or guardian? If the court needs to appoint someone as conservator or guardian or my estate or as guardian of my person, this is who I nominate: (Witness EE) . When queried if the court had appointed a guardian for the Resident, due to incapacity, Staff FF responded they had not. With further inquiry, Staff FF revealed they called the lawyer and they told me that (Witness EE) should go to the court to get guardianship. Staff FF verbalized they informed Witness EE that they should contact the court to obtain guardianship but, as far as they were aware, they had not done that. When asked if Witness EE should have signed the Advance Directive form when they were not the Resident's designated legal representative for medical decision making, both Staff FF and the DON verbalized they should not have signed the form. A policy/procedure related to Advance Directives was requested at this time but not received by the conclusion of the survey.

Based on interview and record review, the facility failed to prevent the development of a facility-acquired Urinary Tract Infection (UTI) for one resident (Resident #52) of two residents reviewed, resulting in verbalized discomfort by Resident #52, antibiotic therapy and prolonged illness. Findings include: Resident #52:In an interview on 08/03/2026 at 10:47 AM, Resident #52's family member revealed that the resident she developed a Urinary Tract Infection (UTI) the prior week while residing in the facility. The facility staff started Resident #52 on intravenous (IV) antibiotics and got a urine culture. The family member stated that the resident could not self-ambulate and needed staff assistance to get to the restroom. The family member thought that the call lights took too long and that's how the resident got the infection. Inj an observation on 08/05/2026 at 9:48 AM, Resident #52 was observed to be up to restroom with two staff members Certified Nurse Assistants X and DD getting a shower. Shower was given and personal care attended to. An interview and record review on 08/05/2026 at 10:32 AM with the Infection Control Preventionist (ICP) B of Resident #52's urinary tract infection revealed that on 7/28/2026 Resident #52 developed Signs & Symptoms of confusion and was started on antibiotic Macrobid 100mg oral every 12 hours on 7/31/2026. Resident #52's antibiotic was changed on 8/3/2026 to Cipro 250mg BID x10days, and then on 8/4/2026 the dose was changed to Cipro 500mg QD x 6 days. Record review of Resident #52's urinary culture dated 8/1/2026 noted organism of Escherichia coli (E. coli). ICP B agreed that the Urinary Tract Infection (UTI) was facility acquired and that Confusion was not a reason for antibiotics. Other interventions could have been increasing fluids and monitoring. ICP B agreed the facility had an uptick in UTI's and that she did perform peri care education with Certified Nursing Assistances (CNAs) in June 2026, The UTI rate for the month of July 2026 was a 1.2% increase. The ICP B stated that the Starting of antibiotic prior to culture results is a physician thing because they do not want the resident to go septic so they start antibiotics on the resident and then we can change the antibiotic if needed when the culture comes back. Record review of the facility 'Urinary Tract Infection: Nursing Assessment Algorithm', date 5/22/2022, revealed signs: shaking chills, new onset urinary incontinence, frequency, blood in urine. Symptoms: New onset burning on urination (dysuria), flank pain, supra-pubic pain, fever of unknown origin greater than 100.5 degrees. A urinalysis supportive of UTI with no indwelling catheter would include WBC count of greater than 10/mm leukocytes/ml, positive nitrates, positive leukocyte esterase, absence/few epithelial cells, greater than 100,00 CFU/ml bacteria present. Record review of the facility 'Antibiotic Stewardship', undated, revealed that the antibiotic stewardship program will serve to promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and patient/resident safety, and reducing treatment-related cost .

Based on observation, interview and record review the facility failed to ensure that an enteral feeding formula maintained its best nutrient value and was protected from possible contamination or degradation by being administered beyond 24 hours from initiation for one resident (Resident #92) of two residents reviewed for enteral feeding. Findings include: Resident #92 (R92):A review of R92's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, aphasia (cognitive communication deficient with speech and understanding), dysphasia (impaired ability to eat and drink), percutaneous endoscopic gastrostomy tubes (PEG / delivers nutrition and medications directly into the stomach). A review of the resident's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) was unable to be assessed and indicated severely impaired cognition and non-interviewable; the resident was dependent on staff for activities of daily living (ADL's).On 08/04/2026 at 10:38AM, observation of tube feeding formula running at 45/ml (milliliters) an hour, dated 08/03/2026 at 0700 (7AM) and initialed.On 08/05/2026 at 09:37 AM, observation of observation of tube feeding formula running at 45/ml (milliliters) an hour, dated 08/03/2026 at 0700 (7AM) and initialed.On 08/05/2026 at 09:42 AM, during an interview with Nurse JJ, she was asked how long tube feeding formula was safe to use once it is opened and hung. She replied that it was good for 24 hours. Nurse JJ was asked to observe the date and time on R92's running tube feeding formula. Nurse JJ stated she was hooked up when I got here, that's my bad. Observed Nurse JJ changed the formula at 9:44AM.On 08/06/2026 at 09:22 AM, During an observation of R92 there was tube feeding formula running at 45/ml (milliliters) an hour, dated 08/04/2026 at 0950 (9:50AM) and initialed. The machine was beeping and screen indicated a caution flush error warning.On 08/05/2026 9:38 AM, during the medication administration task, Nurse LL was asked how long the supplement drinks were good upon opening. She said 24 hours and then added that was also the same for tube feeding formulas.On 08/05/2026 9:57 AM, during continued medication administration task, Nurse LL was asked who cleared the TF pump for the caution flush error warning to observe the tube feeding formula running at 45/ml (milliliters) an hour, dated 08/04/2026 at 0950 (9:50AM). Nurse LL acknowledged that formula was over 24 hours and that she would replace it.A record review of 92's care plan revealed: Focus: Potential for complications related to history of atypical adenomatous hyperplasia .: with intervention: Diet: NPO (nothing by mouth) with nutrition administered by tube feed.; And Focus: I have alteration in Gastrointestinal Status R/T (related to). PEG. with Intervention: Enhanced barrier precautions in place related to PEG; Administer. medications as ordered by PCP via peg tube.; And Focus: I require tube feeding R/T CVA; dysphagia; NPO status. With Intervention: Administer tube feed solution as ordered via peg tube.A record review of R92's orders revealed: Start: (tube feeding formula) at 45 ml/hr X 18hours (6pm-12pm) (810mL Total) Once A Day18:00; and Stop: (tube feeding formula) at 45 ml/hr X 18hours (6pm-12pm) (810mL Total) Once A Day 12:00; and TF (tube feed) Flushes: 300mL H2O (water) flushes q 4hrs (1800mL Total) Every 4 Hours 02:00, 06:00,10:00, 14:00,18:00, 22:00.The facility's, titled enteral tube feeding revealed: Procedure: 6. Follow manufacturer's directions for hanging closed feeding formula and flush. other than that there was no guideline on timeframe for degradation noted in the policy.According to the safe use of ready to use tube feeding formula after 24 hours of hanging it should be discarded to avoid contamination and nutrient degradation.

Based on observation, interview and record review, the facility failed to prevent the development of facility-acquired skin injury of the left heel for one resident (Resident #1) of three residents reviewed, resulting in Resident #1 developing a deep tissue injury to the left heel that opened into an ulcer with verbalization of pain and discomfort. Findings include: Resident #1:Observation and interview on 08/03/2026 at 9:50 AM with Resident #1 revealed that he had a left heel sore and bottom/butt sore; he stated that he did come in with the butt wound. Observed mechanical transfer performed by Certified Nurse Assistants X and Y. Soft protectant boots were noted bilaterally to the feet. Observation of Peripheral Inserted Central Catheter (PICC) line to the right upper arm with occlusive dressing dated 7/29/2026. Observation on 08/03/2026 at 9:56 AM of Resident #1 while lying in bed revealed left heel dressing dated 8/3/26. In an interview and record review on 08/05/2026 at 11:10 PM, Registered Nurse (RN) V stated that Resident #1's left heel wound started/developed at the facility and was acquired/started a month ago. Record review of July antibiotic log revealed [NAME] 1gm IV q8 hours and Zosyn 3.375mg Q 6 hours for osteomyelitis of the coccyx wound Stage 4 and then the development of the left heel wound in June 2026. Record review of Resident 1's Minimum Data Set (MDS) quarterly 5/16/2026 section M; Skin conditions noted 1 stage 4 (coccyx) pressure ulcer. Record review of Resident #1's nursing progress notes revealed that on 6/15/26 at 3:55PM that the resident returned from wound clinic with soft boots after complaints of bilateral heel pain. Record review of wound clinic note dated 6/15/2026 noted other order: Patient states his heels are painful, no open areas noted. Please obtain bunny (soft) boots for patient to use while in bed. Record review of wound clinic notes, dated 6/22/2026, revealed new wound to left heel .Record review of wound clinic note dated 7/20/2026 noted, left heel worsened, IV antibiotic therapy needed. Record review of 'Infection Control Antibiotic Log' line listing from July 1, 2026, through July 31, 2026, noted Resident #1 started Intravenous antibiotic therapy of [NAME] and Zosyn for left heel wound which was facility acquired. Observation was made on 08/06/2026 at 8:14 AM of Resident #1's antibiotic intravenous therapy of piperacillin/tazobactam (Zosyn) 4.5gm/100ml NS, left upper arm PICC line. In an interview on 08/06/2026 at 8:20 AM with Resident #1 prior to his left heel dressing change observation, the resident complained of pain and requested pain medication given to resident per his request. Resident #1 stated that the pain was awful and it hurt to get moved. Observation and interview on 08/06/2026 at 8:45 AM revealed a bright yellow over the door caddy of personal protective equipment (PPE) over Resident #1's room door. In an observation Registered Nurse (RN) V and Certified Nurse Assistant (CNA) W were observed to setup dressing supplies with barrier and supplies for dressing changes to left heel. Maxasorb dressing with silver AG- 4x4s, Gauze wrap, saline to clean, ABD, skin prep to peri wound. Neither nurse nor CNA wore a gown as required for enhanced barrier precautions. Observation of left heel wound old dressing dated 8/5/26 was removed. RN V washed and changed gloves. Observation of Resident #1's left heel noted baseball size indented wound with large (75%) of wound bed with black eschar to upper and right side of wound area, open lower left of wound with open pink granular wound bed with drainage noted on dressing. Wound cleansed with normal saline, Maxasorb dressing applied and covered with a 4x4 gauze and covered with an ABD dressing and wrapped gauze wrap. At the end of the dressing change the surveyor asked if enhanced barrier protections should have been taken. Nurse V and CNA W looked at the posted sign on the resident's room door and stated that yes, we should have applied gowns and a mask. Resident was observed to have a urinary catheter and left upper arm PICC line in place. Record review of facility 'Infection Prevention/Control Service Wound Care' policy, dated 2/2017, revealed that Personal Protective Equipment (PPE) as indicated for the procedure should be applied. Record review of the facility 'Pressure Injury Prevention and Management Program' policy undated revealed Pressure Ulcer/Injury' refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%, when two medication errors were observed for one resident (Resident #41) with a total of 25 observations, resulting in a medication error rate of 8%.Findings include:On 08/05/2026 at 2:09 PM, during medication pass observation UM D was asked what the red boarder around the medication on the resident's medication administration screen meant and he said because it was late, clarified as past the window for the scheduled administration time. The medications of midodrine hydrochloride salt 10 mg and acetazolamide 250mg both due at 1PM were administered (outlined in red). UM D admitted that Nurse MM that was scheduled on the hall left at 1 PM and that there was no additional nurse coverage on the schedule for her 20+ residents, he did not have a report sheet and that he had just taken over as the UM to cover the residents.On 08/06/2026 at 10:15AM, during an interview with Nurse MM she was asked what time she left the floor on 08/05/2026, she said she had picked up a partial shift to help them out and that she was only scheduled to work from 7AM to 1PM due to other commitments. Nurse MM said no one was on the schedule to cover her but they (the unit manager and staffing) were aware I was leaving and said that she completed a narcotic count with the other floor staff Nurse LL before she left. Nurse MM she had no idea when UM D took over the cart and resident assignment.Resident #41 (R41):A record review of R41's orders revealed: acetazolamide tablet; 250 mg; amt: 1 tablet; oral. Three Times A Day (at) 09:00, 13:00, 18:00.; and (midodrine hydrochloride salt); 10 mg; amt: 1TABLET; oral Special Instructions: Hold for systolic BP (blood pressure) greater than 100. Three Times A Day (at) 09:00, 13:00, 18:00. According to a record review of the facilities policy and procedure titled: medication administration general guidelines revealed: Policy: pharmacy will provide medication administration instructions as required to assure medications are administered as prescribed, in accordance with good nursing principles and practices and only by legally authorized personnel.; Purpose: To assure safe medication administration.; Procedure: 2. Medication is administered according to the prescriber's order. 13. Medications are administered within 60 minutes of scheduled time.

Based on observation, interview and record review, the facility failed to ensure a comprehensive nursing assessment of a surgical wound for one resident (Resident #171) of three residents reviewed for skin conditions. Findings include:Resident #171:On 8/4/26 at 1:02 PM, Resident #171 was observed in their room, sitting in bed. The Resident had a Right Below the Knee Amputation (BKA). An ACE wrap was in place over the surgical end of the amputation. When queried, Resident #171 revealed they fell at home following their BKA surgery and developed an infection. They returned to the hospital and had to have another surgery on the amputation due to the infection and then came to the facility because they needed intravenous (IV) antibiotic therapy as well as Physical Therapy (PT). Resident #171 was asked how the wound on the BKA was healing and revealed they did not know. Resident #171 stated, They haven't touched the dressing here. With further inquiry, Resident #171 revealed the wound dressing had not been changed since surgery. Resident #171 stated, I'm supposed to go see (Surgeon) but I don't know what day it is. Resident #171 verbalized they are worried about the surgical wound getting worse since no one is looking at it at the facility. When asked, Resident #171 revealed the dressing had been being changed when they were in the hospital. Record review revealed Resident #171 was admitted to the facility on [DATE] with diagnoses which included right BKA, diabetes mellitus, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required setup to maximum assistance to complete Activities of Daily Living (ADLs). Review of Resident #171's Health Care Provider (HCP) orders revealed the following:- Dressing to remain in place to right BKA until ortho follow up x 2 weeks. Notify. of any s/s (signs/symptoms) of infection. Twice A Day (Ordered: 7/30/26) Review of Resident #171's Hospital documentation revealed the following:- Discharge summary dated [DATE]: Discharge Diagnoses: Right BKA stump wound dehiscence with possible deep tissue injury secondary to recent fall status post revision 7/26/26 - Intraoperative cultures growing MSSA (Methicillin-Susceptible Staphylococcus Aureus- type of bacteria). Discharge Instructions. Orthopedic Surgery Follow up on 8/12/26- For Wound Reevaluation. continued on IV Unasyn (antibiotic) for MSSA wound infection with plans for PICC (Peripherally Inserted Central Catheter - catheter inserted in a vein in the upper arm and fed to a large vein at the top of the heart for long term IV therapy) line placement and outpatient antibiotic therapy. transfer to a skilled nursing facility for ongoing wound care and rehabilitation.- 7/30/26 Orthopedic Progress Notes: Pt (patient) seen resting in bed. Dressing changed. Incision: healing well, no redness or drainage- new dressing applied. Plan. Dressing change every 3 days- Xeroform gauze along incision, 1 layer of 4 x 4s over the gauze, wrapped with 4 in synthetic Webril (soft, cotton roll dressing used to cushion and protect), and apply amputation wrap Ace wrap for uniform compression. placement pending. On 8/5/26 at 9:58 AM, Resident #171 was observed in their room in bed. The ACE wrap remained in place on their right BKA. When queried if the facility nursing staff looked at their right leg and/or if they removed the ACE wrap, Resident #171 stated, No one looks at the ace wrap expect PT. When asked, Resident #171 revealed PT staff look at the ACE wrap to ensure it is in place but do not remove it or access the surrounding area. An interview was completed with the Director of Nursing (DON) on 8/5/26 at 1:54 PM. When queried regarding Resident #171 not receiving wound care at the facility, the DON responded that some surgeons do not want the dressing removed post operatively until the Resident is seen in the office for their follow up visit. The DON was then asked how the facility nursing staff are assessing the surgical wound for signs/symptoms of infection if they are not looking at the Resident's leg, the DON did not provide a response. When queried if the ACE wrap in place on the Resident's BKA is considered part of the wound dressing, the DON responded, No. The DON was then queried how nursing staff are assessing the surgical wound when they are not removing the ACE wrap and responded, Can't assess. When asked why staff are documenting there are no signs/symptoms of infection when they are not removing the ACE wrap and/or looking at the Resident's lower extremity, the DON was unable to provide an explanation. At 2:09 PM on 8/5/26 an interview and observation of Resident #171 was completed with the DON. When queried, Resident #171 informed the DON that the facility nursing staff had not looked at their right BKA nor had they removed the ACE wrap and/or changed the dressing. Resident #171 proceeded to express their frustration and concern to the DON. The DON removed the ace wrap on the Resident's right BKA at this time. An area of dried, brown colored drainage, slightly larger than a half dollar was present of the dressing and the ACE wrap. No active drainage was observed. The DON verbalized they would obtain a new ACE wrap for compression and rewrap the Resident's BKA. An interview was completed with the DON after exiting the Resident's room. When queried, the DON stated they understood the Resident's frustration and indicated nursing staff should have been removing the ACE wrap and thoroughly assessing the BKA.

Based on observation, interview and record review, the facility failed to ensure an environment free from accident hazards for one resident (Resident #146) of one resident reviewed resulting in a lack of appropriate and secure storage of a supplemental metal compressed gas oxygen tank.Findings include:Resident #146:On 8/4/26 at 10:28 AM, Resident #146 was observed in their room in bed. The Resident had a nasal cannula in place and was receiving supplemental oxygen at 4 Liters (L)/minute via an oxygen concentrator. A metal cylinder of portable compressed oxygen was observed laying on the visitor chair in the room. The portable oxygen tank had oxygen in it and was not contained in a holder. A wheeled oxygen tank holder was sitting next to the chair when the oxygen tank was laying. When queried regarding the oxygen tank, Resident #146 responded that a home health care company had delivered it for them to go home with it. Resident #146 was unsure of the date the portable oxygen container had been delivered when asked. Resident #146 further revealed they were supposed to go home previously but had respiratory issues and had to stay at the facility longer. Record review revealed Resident #146 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), pneumonia, pain, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required set-up to total assistance to complete ADLs. Review of Resident #146's Electronic Medical Record (EMR) revealed Resident #146 was dependent upon supplemental oxygen and planned to be discharged home. Review of progress note documentation revealed a Social Services note, dated 7/14/26 at 8:42 AM which specified, (Transport) will be picking (Resident #146) up to transport home at 4:15PM today. Portable oxygen concentrator was delivered on Friday and is in (Resident #146's) room. On 8/5/26 at 10:03 AM, Resident #146 was observed in their room in their bed. The nebulizer machine remained in the same place on the dresser beside the bed. The nebulizer administration set was connected and sitting on top of the dresser, not in a bag. A moderate amount of clear colored fluid was present in the medication chamber of the administration set. When asked if they had a breathing treatment today, Resident #146 replied, No, not yet. When queried how long the nebulizer administration set had been sitting on top of their dresser, Resident #146 stated, I didn't put it in the bag when I was done, and they (facility nurse) didn't come back in. Resident #146 explained they set the nebulizer administration set there when they were finished with their treatment but did not do anything else with it since the nurse did not return. When queried if the nurse who administers their breathing (nebulizer) treatment usually stays in the room with them when they are completing the treatment, Resident #146 responded they do not. An interview was completed with the Director of Nursing (DON) and Unit Manager Registered Nurse (RN) C on 8/5/26 at 10:27 AM. When queried regarding the portable oxygen tank observed sitting on the chair and not being in a holder in Resident #146's room on 8/4/26, RN C stated they, Saw it yesterday and about had a stroke. When queried what time they observed the oxygen tank sitting on the chair, RN C stated, About 4:00 PM. RN C verbalized they put the tank in the holder sitting next to the chair at that time. When asked, both the DON and RN C verified the tank not being in a holder was a safety concern. When queried why the oxygen tank was sitting on the chair and not in the holder, both the DON and RN C indicated the tank had been delivered by a company to the Resident for use at home. When asked why staff entering and exiting the room had not identified and addressed the concern previously, neither the DON nor RN C were able to provide an explanation. Review of facility policy/procedure entitled, Oxygen Administration/Oxygen Concentrator (no date) revealed, C. Employees responsible for transporting oxygen tanks to and from storage area must transport tanks in carriers at all times.

Based on interview and record review, the facility failed to provide Notice of Medicare Non-Coverage (NOMNC) and/or Advanced Beneficiary Notice (ABN) for eligible residents in writing of the terms and services which are/are not covered under Medicaid or by the facility's per diem rate issued for two residents (Resident #1, Resident #6) of three residents reviewed, resulting in the likelihood for financial hardship, In an interview on 08/04/2026 at 10:52 AM, Registered Nurse S MDS coordinator- stated that the Notice of Medicare Non-coverage (NOMNC) and Advanced Beneficiary Notification (ABN) are located in the residents' financial records, which the state surveyors do not have access too. Observation of the Matrix program state surveyors do not have access to the financial tab. The state surveyor requested copies of NOMNC/ABN for residents R1, R6, R147. In an interview and electronic record review on 08/04/2026 at 11:24 AM, Registered Nurse (RN) S stated that she made a mistake and did not issue NOMNC for Resident #6 on 5/21/2026. Resident #6 had been a long-term care resident and went out to the hospital and came back as skilled services. Resident #6 had no NOMNC issued when she became skilled in-patient services due to intravenous therapy for infection. Resident #6 returned from the hospital on 4/14/2026 as skilled care, No NOMNC was issued on 5/21/2026 her last day of skilled care. Resident #1 admitted on [DATE] and on 5/16/26 he was supposed to discharge back to an Adult [NAME] Care (AFC) facility, and then the Community Mental Health (CMH) nurse and family decided against discharge the resident #1 back to the AFC related to wound care. There was no NOMNC and no ABN issued because the resident requested a discharge, but he stayed here in the facility. Record review of facility 'Skilled Nursing Facility Non-Coverage Procedures' policy, undated, revealed that non-coverage Medicare skilled nursing facility letters will be issued to those patients/residents who do not meet admission or continued stay criteria. The purpose was to provide consistent notification of patients/residents and responsible parties of non-coverage. Record review of the facility 'Advance Beneficiary Notification (ABN) Procedure', undated, revealed the facility will provide written notification to a beneficiary prior to providing services or items that may not be covered benefit by their payer source. The purpose was to allow the beneficiary time to make an informed decision about whether to proceed with the service(s) or item(s) that may not be covered, and to accept financial responsibility if their insurance denies payment.

This citation pertains to Intake Numbers 2999184 and 3006165. Based on interview and record review, the facility failed to prevent the opening of one resident's (Resident #104) postal mail of 3 sampled residents, resulting in Resident #104 receiving opened mail/letters while residing at the facility. Record review of the Health Care Association of Michigan (HCAM) 'Rights of Residents in Michigan Nursing Facilities' 2024, states that residents have the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility through a means other than a postal service, including the right to: Privacy of such communications . An interview was conducted on 7/13/2026 at 11:55 AM with Resident #104 about his opened mail. Resident #104 stated they opened my mail, slit it with a knife and then they taped it up and brought it to me. Activities staff bring the mail. I talked to the manager. She tried to get me to blow it off. The manager investigated the mail thing and it happened in April or May, I believe. An interview on 7/14/2026 at 10:0 2 AM with Activities Director F on the mail process revealed that residents' mail comes in and the Activities Department delivers it. The finance office receives the mail and brings it to the activities office. We sort it by resident care unit, and we distribute it to the residents. In regard to a question about opening mail, the answer was Yes, I know that the finance department/office has opened mail. An interview on 7/14/2026 at 12:41 PM with Unit Manager B on opened mail revealed that Resident #104 stated that his mail was opened before he got it. He had a bank statement or mail from the bank and the front office lady in finance accidentally opened his letter. He uses the same bank as the facility does and it happened a couple of months ago. We did a concern form for it. Record review of Resident #104's 'Concern/Complaint Form', dated 4/29/2026, revealed: When the mail came today it was already opened. Asked the person delivering the mail why it was opened? She did not know stating maybe they thought it was their mail. The letter is from a bank and had resident name and facility address. Finance was asked why it was opened? Finance Stated they thought it was a bill for the facility. Resident does not believe this and was upset it was opened because it had its name on it. Investigation: Upon checking, finance stated they 'accidentally opened the resident's mail thinking it was a bill for the facility. Leadership response: Resident's mail was opened accidentally by employee in finance department; Employee was educated not to open resident's mail. Discussed this with the resident and informed him mail will not be opened again.

This citation pertains to intake Number 3073791. Based on observation, interview and record review, the facility failed to ensure quality of care for one resident (Resident #102) of 3 residents reviewed, resulting in Resident #102 receiving duplicate wound care treatments and a lack of a documented physician's notification of a change in condition. Resident #102:Observation and interview on 7/13/2026 at 12:17PM with Licensed Practical Nurse (LPN) I and Registered Nurse (RN) J of Resident #102's coccyx region wound vac dressing change. Observe Resident #102 lying in bed turned to the left side, observed coccyx wound of 4.5cm x 6.5cm, 2cm depth, no drainage at time of observation. RN J stated the wound has drainage with wound vac of serosanguinous. Observation of wound care the area was cleansed and no tunneling noted. Observation of wound bed was with pink tissue, RN J stated that the coccyx wound was acquired in the hospital, and that Resident #102 goes to the wound clinic once a week. Foley catheter observed, with yellow drainage, intact and off the floor. Observed the wound vac dressing change being performed by LPN I and RN J, Wound vac applied, sponge placed cut to wound size, bridge sponge placed, top barrier cover applied to wound site. Good suction to the dressing and dressing compressed to draw of drainage. An interview and record review on 7/13/2026 at 2:45 PM with Licensed Practical Nurse (LPN) wound care certified K about Resident #102's coccyx wound revealed that the resident had been in and out to the hospital and came back to the facility on 3/12/2026 with two little red spots, when she returned from the hospital and the nursing staff documented those on 3/12/2026. Record review of Resident #102's progress notes dated 3/13/2026 documented a red buttock with dark intact non-blanchable area on the right buttocks and a dark intact blanchable area to the coccyx. Resident #102 was sent back out to the hospital from [DATE] through 3/26/2026 and returned with no open (wound) area to the coccyx region. On 4/20/2026 Resident #102 was documented to have unstageable sacral pressure injury measuring approximately 3.0cm x 2.9cm with slough and drainage. LPN K stated that April 20th is when the wound began. An interview and records review on 7/14/2026 at 9:08 AM with Licensed Practical Nurse (LPN) wound care certified K revealed that Resident #102's coccyx wound began on 4/20/2026 when LPN K was notified of an open area on the coccyx region. LPN K stated that she put in treatment orders of calcium alginate which was a chemical Debride treatment because the wound was on the coccyx and measured 3.0x 2.9cm. LPN K stated and reviewed nursing documentation that the Resident #102 came back from the hospital on 3/26/206 with no skin issues. On 4/9/2026 nursing progress note revealed coccyx with pink area at risk for opening. On 4/20/2026 that's when LPN K was notified that the coccyx was opened. LPN K stated that the facility We waited for the physician to come and assess the wound for a wound clinic order. The physician came on 4/29/2026 and the unit manager talked with physician. There was no physician notification progress note, or documentation by the physician on the 4/29/26 visit. There was no wound culture done because there was no sign & symptoms of infection. Record review of physician progress notes were dated 4/2/2026 was noted to be a History & Physical (H&P) document with no mention of skin issues, and a physician 6/12/2026 progress note with no mention of coccyx wound. In an interview and record review on 7/14/2025 at 10:25 AM with Registered Nurse (RN) Unit Manager D revealed that Resident #102's coccyx wound opened on 4/20/2026 measuring 3.0cm x 2.9cm. Record review of Resident #102's electronic medical record revealed No notification of physician documentation found. RN D stated that staff were treating the wound in the facility with the wound care nurse. RN D stated that she wrote a note but did could not find any documentation of physician notification of change in condition dated 4/20/2026. Record review of physician notes in the electronic medical record were dated 4/2/2026 H&P and on 6/12/2026 progress note. Record review of the wound care treatment orders dated 6/9/2026 noted Hysept solution 0.25% to open coccyx wound and on 6/20/2026 Santyl 250 units/gram to wound. Record review of the Treatment Administration Record (TAR) noted that both treatments to the coccyx had been signed out on 6/20/26, 6/21/26 and 6/22/26 as administered. The unit manager referred the surveyor back to the wound care nurse for clarification. In an interview and records review on 7/14/2026 at 12:00 PM, LPN K stated that the Dakins or Santyl orders are usually from the hospital, Santyl is not what she would use. Record review of physician's orders revealed that on 6/9/2026 Hysept order was in place then on 6/20/2026 a Santyl 250 units/gram topical to wound was ordered. Record review of the Treatment Administration Record (TAR) noted that both treatments to the coccyx had been signed out on 6/20/26, 6/21/26 and 6/22/26 as administered. LPN K stated that according to the documentation both treatments were administered on those dates. The Hysept should have been discontinued, and pharmacy should have caught that. Record review of computer orders put in on 6/20/2026 were from the pharmacy. There were double treatment orders and should have only been one treatment type order. Record review of the facility 'Resident Change of Condition' policy, dated December 2022, revealed to ensure each resident receives treatment at the time of a change of condition. (1.) The facility will contact the physician at the time of a resident's condition change that is unrelieved with nursing interventions or requires medical intervention that is not available by standing orders. Such contact shall be documented in the medical record. Condition change shall include: (b.) A change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications (e.g., development of a pressure ulcer or deterioration of a pressure ulcer .) In the event the physician does not respond to the situation effectively, the facility will follow a chain of command to ensure care is satisfactory for the resident. The nurse manager or Director of Nursing will contact the physician; if the issue is not satisfactory resolved they will then contact the medical director. Each episode will be documented in the resident's medical record. Record review of the facility 'Nursing Standards of care Long Term Care' document undated revealed the facility will use the standards of care to promote consistent quality and the provision of clear and concise direction. These standards of care are expected to be performed for every resident at HSS. The nursing policies and procedures are included with these standards and will be followed and carried out by all nursing staff.

This Citation pertains to Intake Number MI00149011. Based on observation, interview and record review, the facility failed to supervise and prevent a fall for one resident (Resident #1) with a history of anticoagulants and falls, of 3 sampled residents, resulting in the lack of meaningful interventions to prevent repeated falls and the lack of ongoing supervision of a resident, who was a known fall risk, resulting in Resident #1 sustaining a fall from wheelchair and suffering a subdural hematoma with hospitalization and death. Findings include: Record review of the facility Assessment: Nursing' policy, dated 6/2021, revealed all residents will receive nursing care based on a documented assessment of individual needs/problems. The purpose is to identify residents' needs at time of admission and throughout hospitalization , to provide individualized care, a written plan of care, implement interventions and positive outcomes, provide monitoring and evaluation of care, and begin the process of discharge planning. Resident #1: Record review of Resident #1's hospital discharge documents, dated 11/18/2024 through 12/3/2024, revealed that Resident #1 presented to the hospital with an ecchymosis (bruising) to the left side of the face from a fall. Review of Resident #1's medications included Plavix (clopidogrel) 75 mg oral daily and Aspirin 81 mg oral daily (both have blood thinning effects). Hospital documents noted that the current condition would worsen with another fall resulting in significant head trauma, coma, end organ damage and death may occur. Record review of Resident #1's hospital CT of the head due to head injury and being on anticoagulation therapy dated 11/18/2024 revealed no evidence of acute intracranial hemorrhage. On 12/3/2024 in the late afternoon Resident #1 was discharged to a long term care facility. Resident #1 no longer resided at the facility. Observation on 1/14/2025 at 8:00 AM revealed that room [ROOM NUMBER] was located on the Wheels rehab unit. room [ROOM NUMBER] was a private room with a restroom located a short walk from the nursing station. Record review of Resident #1's long-term care facility Admission nursing progress note, dated 12/3/2024 at 6:10 PM, noted: A/O (Alert & Oriented) 2-3, denies pain, daughter present. All consents signed, full code, transported by (ambulance). Recently fell while living in assisted living. No major skin issues some mild bruising. Lots of confusion. Will continue to assess. A record review of Resident #1's 'Admission Fall Assessment', dated 12/3/2024, revealed a history of one or more falls within the previous 6 months. Elimination pattern of incontinence, 2 or more high fall risk, drugs (Plavix and aspirin), requires assistance or supervision for mobility, transfer, or ambulation, lack of understanding of one's physical and cognitive limitations. Total fall risk score of 19 revealing high fall risk. In an interview on 1/14/2025 at 8:51 AM, admitting Licensed Practical Nurse (LPN) stated Resident #1 came from assisted living with a history of falls. Care plan is done by the charge nurse, which would have been Licensed Practical Nurse (LPN) F Charge nurse. I can't recall him, I read the notes but can't recall a face to the name. He was in the 280's hallway he had a daughter. They were very nice people. He seemed alert and oriented. They had conversations, and she was worried about him falling, he had a history of falls. I did come in the next day and was told he was sent out for falling. Resident #1's nursing progress note, dated 12/3/2024 at 9:03 PM, by Registered Nurse I stated 'resident observed laying on his back on the floor next to his bed, (Resident) reports that he was attempting to pick-up the candy/chips he had spilled on the floor and lost his balance. He was reported to be confused and impulsive upon admission. He is a fall risk (Resident) had on his own fuzzy thick socks on, that had grippy on the bottom. He denied hitting his head and other injury. No visible new injury noted'. Record review of Resident #1's 'Occurrence Reporting Worksheet', dated 12/3/2024 at 9:03 PM, revealed the resident was observed on his back on the floor next to bed, attempting to reach chips and lost his balance. No injury. Call light was in reach, new admit. Call light was on at time of fall. Did have on non-skid footwear. Last observed lying in bed at 8:30 PM. Staff to ensure all items are on overbed table next to resident before leaving room. During an interview on 1/15/2025 at 8:10 AM, Registered Nurse (RN) I stated I remember that night, the first fall he fell out of bed or was found on the floor. He was restless attempting to get out of bed. I was sitting at the nursing station and heard a loud smack noise. The Certified Nurse Assistant (CNA) (I don't know which one) got him up and brought him out to the day room. I looked up he was on the floor. I only had a couple of hours with him, he was a new admit. I saw his black glasses, because I had removed them from his pocket earlier. The CNA had told me that she put him in the dining/day room earlier because he was attempting to get out of bed. She didn't tell me why she put him there. I can't remember who the CNA was. I can't say for sure who it was. Yes, CNA J was assigned to him. I started neuro checks, (no Neuro checks were found in documentation) I don't know where they are. The second fall occurred in the Dining/day room. I didn't see his fall; I only heard the landing. I assessed him he had a large knot on his forehead with bleeding and laceration to forehead. The goose egg was the size of a baseball or an egg. I called the doctor and she said to just restart the neuro checks and to send him out if he falls again. He was still on the floor because he did not want to get up because he his head hurt. At the beginning of the shift, he was rational and could hold a conversation, but he was still confused. He was impulsive. I called the daughter and told her you should send him out and she agreed. Surveyor asked if Certified Nursing Assistant (CNA) was the CNA who placed the resident in the day room and RN I stated not sure. Record review of Resident #1's Nursing progress notes, dated 12/3/2024 at 9:41 PM, revealed 'Observed to have arrived with purple bruise to left check area, small, scattered scabbing to left top of forehead, some healing non-scabbed abraded areas to both knee and scattered bruising to bilateral upper extremities/lower extremities, right upper extremities dialysis fistula with blood shadowed pressure dressing left intact. Positive brill/thrill. Wearing brief that is dry at this time. Head circumference 22.25 inches. Bilateral top half rails. Bed in lowest position. Many empty bags of chips and candy wrappers observed in trash at bedside. Black rimmed eyeglasses observed on bedside table. Cell phone, charging box and charging cord observed at bedside. Medications entered, misc. care orders entered, observations and consents completed'. Record review of Resident #1's Nursing progress note, dated 12/3/2024 at 10:29 PM, revealed '(Resident #1) was placed in wheelchair with bilateral foot pedals on and placed into the Day Room due to being restless and making attempts to get out of bed. This nurse heard a loud smack and looked over and observed resident lying face down in the floor. with legs tangled up into the foot pedals. Left side of face made contact with the floor. Pool of blood visible on the floor under left side of face. Very large hematoma bleeding to left forehead and left upper cheek bone. Bleeding controlled with pressure to left forehead. Hematoma to right chest. Left hip had bulge with new onset bruising. Bilateral lower extremities symmetrical. Resident is moving all extremities without signs or symptoms of pain. (Resident #1) was rolled onto his back with neck stabilized by nursing as positioned onto back. He did not lose consciousness. He is reporting pain to head. Doctor notified. New orders to monitor with re-starting neuro checks, left hip X-ray and to send to ER (emergency room ) if he falls again. Daughter wants resident sent to hospital for evaluation'. Record review of Resident #1's 'Occurrence Reporting Worksheet', dated 12/3/2024 at 10:29 PM, revealed 'a fall in the dining room. Observed to have fallen in dining room lying on floor face down. Neuro checks started, X-ray of hip ordered. Resident was sent out to ER, will review fall and safety interventions with physical therapy'. An interview was conducted on 1/16/2025 at 11:22 AM with Certified Nursing Assistant (CNA) J, who called back. When asked about Resident #1 in room [ROOM NUMBER], she could not recall him. Surveyor described resident's fall from bed and WC. CNA J said that she could not remember that man and stated that was a month ago, I simply can't recall. When a resident is confused/restless it's my procedure to put the resident in the dining/day room, because the nurses sit at the nursing station. I put the residents in the dining/day room if confused/restless, so people can watch them. The dining/day room has TV and glass walls so people can watch the resident. The nurses can observe him in the dining/day room. I always report straight away to the nurse about things up with restless/confused resident. The Wheels Unit is short term rehab and gets lot of admissions. Afternoon CNA's have 8 residents each. I can't recall him. Record review of Resident #1's nursing progress note, dated 12/3/2024 at 11:14 PM, revealed 'Hematoma became larger, and blood pressure elevated to 157/102 prior to ambulance arrival. Resident would not allow nursing staff to attempt sitting him upright nor would he keep ice to his forehead. Complaint of pain to face/head. Ambulance arrived at approximately 10:05 PM for transport. Resident took his eyeglasses. Nurse order received for left hip X-ray not entered due to resident being transported out to hospital'. Hospital record review of Resident #1's Hospital re-admission post fall on 12/3/2024 at 11:46 PM revealed resident presented post fall out of wheelchair. Resident has had two falls since arriving at long term care facility around 5:00 PM (approximately 6.5 hours ago). The resident fell out of his wheelchair tonight and hit his head. He is on Plavix (anticoagulant). CT head due to anticoagulant left front-parieto-occipital acute subdural hematoma with maximum width 1.2 cm, no midline shift. admitted with intracranial hemorrhage to ICU under trauma services . Record review of Resident #1's death certificate, dated 12/18/2024, revealed 'due to complications of acute traumatic subdural hematoma with antiplatelet therapy, repetitive blunt force head trauma and delirium vs dementia'. Date of injury 12/3/2024 fall from wheelchair, recurrent falls.

Based on observation, interview and record review, the facility failed to prevent two residents (Resident's #415 and Resident #75) from developing pressure ulcers, resulting in discomfort/pain, the likelihood for infection, delayed healing, antibiotic usage, and weekly wound care. Findings Include: Resident #415: Review of the Face Sheet, Wound Documentation dated 6/6/24 through 8/6/24, and care plans dated 1/23, revealed Resident #415 was [AGE] years old, admitted to the facility on [DATE] and readmitted on [DATE], alert and his own person and required staff assistance with Activities of Daily Living/ADL's. The resident's diagnosis included, dementia, stroke, muscle weakness, anorexia, malnutrition, chronic pain, chronic kidney disease, and heart failure. The resident developed a pressure ulcer on the right heel while at the facility due to shearing of bedding. Observation was done on 8/6/24 at 6:15 a.m., of Resident #415's right heel pressure ulcer dressing change. The wound care and dressing change was done per orders; however, no pressure relieving devices were used at all to keep the heel off the bed prior to wound care and after it was completed. Wound Nurse RN P did not put any measures in place to keep his right heel off the bedding. During an interview done on 8/6/24 at 6:30 a.m., Nurse P said the resident's Stage II pressure ulcer was not there on admission and it was caused by friction from the bedding (the sheets had rubbed against the skin and caused a blister and it opened). Review of the resident's facility Wound Management Reports dated 6/6/24 and 8/6/24, revealed the heel pressure ulcer was first documented on 6/6/24 (2.5 cm by 1 cm in size) and last documented on 8/6/24 (2.5 cm by 1.5 cm in size). Review of the resident's facility Wound Management Report dated 6/6/24, stated Resident has an abrasion to Rt ankle r/t (related to) rubbing against bedding. Date/Time Observed Pressure Ulcer: 6/6/24 06:01. Review of the resident's facility Wound Management Report dated 8/6/24, stated Present on Admission/Re-entry? No. Review of the physician order dated 8/6/24, stated Cleanse Rt ankle with NS (normal saline), pat dry, apply Puracol (wound care) with Allevyn heel border dressing every Tues, Thurs, Sat and PRN (as needed. Review of the resident's facility Pressure Ulcer/Injury care plan dated 1/27/23, stated Keep bony prominence's from direct contact with one another, staff to utilize pillows, wedges or blankets as needed. Use a pillow under heels to relieve pressure on the heels while in bed. Review of the facility Pressure Ulcers: Standard Of Care For Prevention & Treatment policy dated June 2021, stated Remove unnecessary irritations such as wrinkled bed linen, damp linen, chafing of two skin surfaces, pressure from casts/splints/dressings, crumbs, moisture due to feces, urine or perspiration. Utilize protectors as indicated (per care plan). Consult therapies for appropriate pressure relieving devices. 49944 Resident #75 (R75): Resident #75 is [AGE] years old and admitted to the facility 07/12/24 with diagnoses that include sepsis, rheumatoid arthritis, hypertension and acute respiratory failure with hypoxia. On 08/07/24 at 12:47 PM, R75 was observed with a dressing on their right heel. R75 was asked about the dressing and why it was there. R75 stated that the dressing was there for a wound on their heel. When asked how they got the wound on their heel, R75 stated it is from their ankle-foot orthosis (AFO) brace and the AFO is rubbing up and down on their heel. R75 stated that they are going to see [NAME] and Filippis (company that makes orthotics) to check on getting a better fitting brace for their right leg. R75 was observed to have an air mattress on their bed. No other interventions noted. R75 stated that staff puts his feet up on pillows now while in bed to keep his heel from rubbing anymore. On 08/07/24 at 01:10 PM, record review revealed that R75 developed this pressure sore on his right heel on 08/05/24 and that R75 scored a 16 on the Braden Scale indicating that they are at high risk for pressure ulcer development. Record review revealed that there was no physicians order located to monitor the skin around the AFO. On 08/07/24 at 02:48 PM, an interview was conducted with Wound Care Nurse P. Wound care nurse P was asked how they believe the wound developed. Nurse P stated that the resident believes it's from his AFO brace. Nurse P stated that R75 refused heel boots that were offered on admission and that they placed a low air loss mattress on bed prior to wound developing. Nurse P was asked if an order was put in on admission to monitor the skin and circulation around the AFO. Nurse P stated, yes, an order is put in for that on admission. Nurse P was asked what stage the wound is currently in. NurseP stated the wound is a Stage II, indicating that the wound is open. This surveyor was unable to locate an order for monitoring skin around AFO in the health record. NurseP was asked if there should have been an order on admission to monitor the skin around the AFO. Nurse P stated yes there should have been an order. On 08/08/24 at 10:33 AM, record review revealed that the facility did not enter an order to monitor the skin around the AFO brace on the right foot or create a care plan for it until 08/07/24 when it was brought to the attention of the wound nurse. An order was entered on 08/07/24 at 15:56 PM (3:56 PM) and a care plan to monitor the skin around the AFO was created on 08/07/24. On 08/08/24 at 01:01 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked if there should be an order to monitor around AFO braces or splints if the resident admits with one. The DON replied yes there should be an order to monitor that. Record review of the policy titled, Pressure Ulcers: Standard of Care for Prevention and Treatment revised February 2017 revealed: Purpose: 3. To protect against the adverse effects of pressure, friction and shear. Essential Points: If a patient is at risk for developing a pressure ulcer, open a problem on the care plan indicating the at-risk status. Modify CENA or other designated staff assignment as needed. Record percentage of food consumed. Consult with the dietician if intake is not adequate. Consult therapies for appropriate pressure relieving devices.

This Citation pertains to Intake Numbers MI00143243 and MI00143245. Based on interview and record review the facility failed to complete a comprehensive fall investigation and notification to a physician of X-ray results for one resident (Resident #602), resulting in; 1. Resident #602 falling on 02/26/2024, X-rays being completed on 02/27/2024 with the resident sustaining a nasal bone fracture, left side of maxilla (bone that forms upper jaw) fracture with recommendation for CT (computed tomography) scan; 2. Facility's failure to notify physician of x-ray results and recommendations.; 3. Taking seven days for the facility's physician to review x-ray results and assessing Resident #602 seven days after the fall, after which Resident #602 was again sent to emergency room for evaluation with findings of subacute bilateral subdural hematomas and; 4. Lack of clear and consistent documentation surrounding Resident #602 subdural hematomas. Findings include: Resident #602: On 3/25/2024 at 5:00 PM, an interview was conducted with Nurse H regarding Resident #602's fall on 2/26/2024. Nurse H explained the CNA (Certified Nursing Assistant) assisted Resident #602 to the restroom and once he was situated on the toilet the CNA tuned around to change the position of the walker. In those moments the CNA's back was turned the resident attempted to readjust himself on the toilet, fell and hit his face on the floor. The CNA yelled out the door for assistance and the resident was observed laying on his left side on the bathroom floor, his nose was bleeding with bruising over this eyebrow and bridge of nose. A head-to-toe assessment was completed, ice compress provided for his forehead and pressure applied to his nose to stop the bleeding. Nurse H reported he was not sent to the hospital nor was imaging ordered. On 3/25/2024 at approximately 10:00 AM, a review was completed of Resident #602's medical records and it indicated he was admitted to the faciltiy on 2/21/2024 with diagnoses that included, Dehydration, Acute Metabolic Acidosis, Acute Kidney Failure, Heart Disease and Atrial Fibrillation. Resident #602 was assessed as being cognitively intact and able to make his needs known. Further review yielded the following: Care Plan: (Resident #602) has increased risk for bleeding related to anticoagulant therapy .Provide one assistance for bathing, hygiene, and toileting daily . On 3/26/2024 at 11:00 AM, an interview was conducted with Family Member P regarding Resident #602's fall. Family Member P stated facility staff informed their mother that Resident #602 had no fractures from the fall, yet he was sent to the hospital a week after. The emergency room staff informed them he had a brain bleed, nose fracture and his Eliquis would be discontinued until a CT scan was completed. Family Member P added Resident #602 shared with them, the CNA left the bathroom (prior to fall) as he requested privacy and once he readjusted on the toilet, that was when he fell and hit his head. On 3/26/2024 at 1:20 PM, an interview was conducted with Family Member Q regarding Resident #602's fall. Family Member Q stated Resident #602 stated his physician was rounding a week after his fall and observed that his nose was broken and wanted him sent to the emergency room for evaluation and CT scan. When facility staff initially called, they informed Family Member Q that nothing appeared to be broken but upon a family visit it appeared to them that Resident #602's nose was broken. On 3/26/2024 at approximately 3:45 PM, further review was completed of Resident #602 medical record. Fall Event Report: The event was created by Nurse L on 2/26/2024 at 12:15 PM and closed by ADON (Assistant Director of Nursing) on 2/27/2024 at 8:09 AM. The reported indicated the following: .fall in bathroom . Resident left alone in bathroom for less than 5 seconds while nursing assistant obtained wheelchair. fell off toilet onto L (left) side, hitting L arm and L temple. Developed nose bleed which resolved with pressure. Returned to bed and vital signs/neuros checks initiated. Bruising noted to L forehead and L cheek. Complaining of pain only on L cheek .IDT (interdisciplinary team) met and reviewed fall in which resident attempted to transfer self while in bathroom and lost balance and fell . Resident was times two assisted back onto the toilet. The aide turned around to get wheelchair and resident attempted to rise without assist .will care plan for resident not be left alone when in bathroom due to decline in mobility . It can be noted the report does not indicate the CNA involved in the incident identity or statement of events, Resident #602's statement, or the statement of the second nurse that assisted after the fall statement. Furthermore, the report failed to indicate that x-rays were ordered, fractures were reported from the x-ray with recommendations for a CT scan and there was no physician notification of the results. Lastly, the following sections within the fall event report were incomplete: - Event Details - Pain Observation - John Hopkins Observation - Body Observation - Neurological Check - Mental Status - Possible Contributing Factors - Interventions X-Ray Results: Reported on 2/27/2024 at 12:35 PM: .There is evidence of a nasal bone fracture. There is a possible fracture of the anterior maxillary spine as well .Consider CT scan for confirmation. emergency room Records: .Patient arrives with x-ray results from prior fall on 2/27/2024 .He reports 3 days ago he had 2 people assisting him off the commode when he fell to the ground and hit his face. He had several x-rays at that time which showed nasal fracture .Mild edema with ecchymosis along the nasal bridge with dependent ecchymosis below the eyes which appears in healing stage .According to his paperwork that he arrives with this fall was at least 1 week ago when he had x-rays. X-rays recommended CT scan for confirmation of nasal fracture .There is subacute bilateral subdural hematoma on CT head .Volume loss in brain. Interval development of low attenuated extra-axial fluid collections as described above without midline shift .fractures involving the bilateral nasal bones and the fracture involving the frontal process of the maxilla on the left side .Subdual hematomas were discussed with .neurosurgery .He reviewed CT images and recommends outpatient follow up for repeat CT scan. Recommends discontinuing Eliquis until repeat CT imaging and follow up in 1 week .Neurosurgeon progress note .Patient has a very small chronic possibly epidural hematoma in left frontal regional and possibly streaks of blood along the tentorium with no mass effect. Would suggest repeat CT in 1 week and follow up in office after .EMS (Emergency Medical Services) .Upon arrival to (facility) we received information from the nurse. She stated the patient had fallen 2 days ago but was not sent to the hospital. They stated the patient is on blood thinner and received an X-ray today and found he has facial fractures. The nurse stated their doctor said he is not able to stay at facility without going to ER with the fractures. She stated her doctor talked to (receiving hospital) and that he has to go for head CT .proceeded to the patient who was in the sun room in a wheelchair with bruises on left cheek, left chin and above left eyebrow. The patient stated he had fallen because the nurses didn't set him back far enough . Progress Notes: 2/26/2024 at 15:03: Resident left alone in bathroom for less than 5 seconds while nursing assistant obtained wheelchair. fell off toilet onto L side, hitting L arm and L temple. Developed nose bleed which resolved with pressure. Returned to bed and vital signs/neuro checks initiated. Bruising noted on L forehead and L cheek. 3/5/2024 at 13:32: PCP rounds gave or to send resident to ER for CT scan. For possible fracture of Maxillary. 3/5/2024 at 21:35: Patient return Back with Family transport from Hospital. Patient Eliquis to Be Dc until he see his neurologist .Hospital report indicated patient has some brain Bleed . Practitioner Notes: 3/5/2024: The patient had a fall with facial trauma. He had x-rays done, which came back positive for nasal fracture and fracture in his maxillary spine area. The patient is complaining of pain in his nasal area. He has bruising and some ecchymosis around his nose and periorbital area .nose is slightly curved to the left and he has bruising around his nose with tenderness in the nasal area and maxillary .I have discussed with nursing to send him to the ER for CAT scan to evaluate his fracture and involvement of his maxilla for possible treatment at this time . 3/7/2024: The patient was sent recently to the ER after he had a fall and developed periorbital hemorrhages and nasal fractures. X-ray of head came back positive for nasal fracture. He was sent to the ER for and he had a CAT scan, which came back positive for nasal bone fracture, small fracture of the maxilla with extra-axial bleeding noted on the CAT scan likely acute, small, subdural hemorrhage .He was seen by neurosurgery in ER. At this time, Neurosurgery recommended the patient to be discharged back to facility. He will repeat CT scan in 1 week to evaluate the bleeds. At this time his Eliquis has been discontinued. We will continue to monitor him closely. Patient will follow with neurosurgery and will obtain CT head in 1 week . 3/14/2024 at 9:00: .Patient reports left facial pain after falling last week and being found to have fractures. Son also reports possible brain bleed and will need to follow up with Neurosurgeon .X-ray nasal bones and x-ray orbits 2/27: There is evidence of a nasal bone fracture. There is a possible fracture of anterior maxillary spine . It can be noted there were no progress noted related to Resident #602's x-ray results that were received by the facility on 2/27/2024, subsequent nose fracture, CT recommendation nor physician notification until 3/5/2024 when Physician J completed facility rounding. Nursing notes indicated a brain bleed, but there was no further clarity or correction made regarding these notations. On 3/26/2024 at 2:10 PM, an interview was conducted with CNA M regarding Resident #602's fall on 2/26/2024. CNA M explained the resident was in the Day Room and his wife asked if she could assist him to restroom. CNA M wheeled Resident #602 back to his room and into the bathroom where she proceeded to assist Resident #602 to stand from the wheelchair, pull down his pants and sit on the toilet. Resident #602 requested privacy from CNA M stated she obliged and stepped right outside the door. About two minutes later she heard the thud and found the resident to the side of the vanity and his nose was bleeding. When CNA M asked Resident #602 what happened and he responded he tried to readjust himself on the toilet and fell in the process and his head on the floor. CNA M stated the nurse quickly responded and assessed the resident prior to placing him back in bed. On 2/26/2024 at 4:35 PM, an interview was conducted with ADON (Assistant Director of Nursing) Unit Manager C, regarding Resident #602's fall. They were asked the process when X-ray results are received and explained upon receipt of the results the nurse would be responsible to inform the physician of the results and then receive further instruction. They were informed there was no documentation from facility staff related to his X-ray results and notification to the physician of Resident #602's fractures and the recommendation for CT scan. Manager C and ADON stated they would follow up with his writer on any further information they can locate regarding this. They were queried regarding the specifics of the fall and Manager C explained CNA M turned to grab Resident #602's wheelchair and as the CNA was turned the resident readjusted himself on toilet, fell and hit his face on the floor. Manager C was asked if there were statements from the CNA or nurses regarding their fall and they stated there were not. A discussion was held regarding the facility's investigation related to the fall. It was explained their Event Report for Resident #602's fall did not have any statements from facility staff (Nurse H, CNA M and Nurse L), it was not able to ascertained from the report who the CNA was in the bathroom or the other nurse that assisted following Resident #602's fall, no mention of the X-ray order, findings of X-ray or notification to physician regarding the findings, subsequent emergency room visit and CT results. It was further explained the investigation lacked thoroughness and completeness. The DON and Unit Manager C expressed their understanding. On 3/26/2024 at 5:10 PM, an interview was conducted with Nurse L regarding Resident #602's fall on 2/26/2024. The nurse reported she observed CNA M wheel Resident #602 back onto the unit and into his bathroom, as she was right outside his door with the medication cart. Nurse L stated she could hear their conversation with one another and head the CNA state she was going to move something. The CNA turned her back and then she heard a bump noise and knew Resident #602 had fallen. Nurse L ran into the bathroom and observed Resident #602 laying on this left side, with an abrasion/raised bump on his head and bleeding nose. They were able to stop the bleeding and applied an ice pack as well. Nurse L she contacted the physician and talked over the fall with him. There was no emergent need to send him to the emergency room and they ordered x-ray's for the following day as nothing appeared to be broken at the time of his fall. On 3/27/2024 at 9:20 AM, Unit Manager C, ADON and DON (Director of Nursing) explained upon Resident #602's return from the emergency room they, too, questioned the brain bleed, and completed further review of the hospital records and found it was an epidural hematoma. They were queried on where the documentation from their nursing staff and Nurse Practitioner derived from and they stated from Resident #602's children. This writer expressed concern over the lack of clarification within the residents' medical records related to this incident and delay in treatment as the Physician was never notified of the x-rays/recommendations. It was also conveyed the account of events provided in their fall event versus staff statements did not align. They expressed understanding of this writer's concern. On 3/27/2024 at 12:20 PM, Physician J reported he was aware Resident #602 as he did recall the facility contacting him. Upon arriving to the facility on [DATE] to complete his rounds, Resident #602's x-ray results were in his mailbox. He stated the facility did not contact him upon receipt of the results and he sent the resident to the emergency room based on the recommendation from the x-rays and his clinical judgment. Physician J stated the CT found subdural hematomas. Review of facility policy entitled, Resident Change in Condition, revised December 2022. The policy stated, .The facility will contact the Physician at the time of residents condition change that is unrelieved with nursing interventions or requires medical intervention that is not available by Standing Order .Notification of the physician is the responsibility of the Licensed Nurse . Review of facility policy entitled, Fall Prevention, revised June 2020. The policy stated, .(Facility) has devised a specific data collection form to be completed upon a resident falling . The policy does not mention fall investigations.

This Citation Pertains to Intake Number MI00138983. Based on observation, interview and record review, the facility failed to institute and operationalize comprehensive monitoring, documentation, assessment, and interventions for three residents (Resident #20, Resident #44, and Resident #313) of three residents reviewed, resulting in a lack of timely assessment, documentation, and treatment of an injury of unknown origin for Resident #20, edema for Resident #44, and Resident #313 experiencing a displaced tibia (large bone in lower leg) fracture, lack of investigation, delayed care, unnecessary pain using the reasonable person concept, and the likelihood for decline in overall health status. Findings include: Resident #20 On 8/22/23 at 11:37 AM, Resident #20 was observed sitting a wheelchair in their room. A dark purple colored bruise was observed over the Resident's right eye. An interview was completed at this time. When asked what happened to their eye, Resident #20 replied, Bumped it in bed. Bilateral upper side rails were noted on the Resident's bed. When queried if they had bumped their face on the side rail, Resident #20 reiterated they bumped their head on the bed but did not elaborate further. When asked if their eye hurt, Resident #20 chuckled and indicated it only hurts when they touch it. When queried when they had bumped their face, Resident #20 was unable to provide a specific date but confirmed it had occurred in the facility. Record review revealed Resident #20 was most recently readmitted to the facility on [DATE] with diagnoses which included heart failure, pneumonia, supplemental oxygen dependence, diabetes mellitus, atrial flutter (irregular heart rhythm), and cerebral infarction (stroke) with subsequent right sided hemiplegia and hemiparalysis (one sided paralysis). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required limited to extensive assistance to complete Activities of Daily Living (ADL's). A review of Resident #20's Electronic Medical Record (EMR) documentation did not reveal any documentation related to an injury and/or the bruise. Incident and Accident Reports for Resident #20 were requested from the facility Administrator on 8/23/23 at 1:59 PM. The Administrator stated the facility did not have any Incident and Accident forms for Resident #20. An interview was completed with Unit Manager Registered Nurse (RN) G on 8/24/23 at 9:50 AM. When queried regarding the bruise above Resident #20's right eye, RN G revealed they were unaware of the bruise and/or how the bruise had occurred. RN G was queried regarding the lack of documentation in Resident #20's EMR related to the bruise and where skin assessments are completed per facility policy/procedure and revealed skin assessments are completed as part of the focused assessment. RN G proceeded to review Resident #20's EMR documentation and confirmed there was no documentation of the bruise in the EMR progress notes and/or focused assessment documentation. When queried why the bruise was not assessed and/or documented by nursing staff when it was obviously present on the Resident's face, RN G replied, That is a valid point. RN G was then queried if nursing staff should assess and document alterations in skin integrity, RN G confirmed any/all injuries and/or alterations in skin integrity should be documented in the EMR. No further explanation was provided. At 2:09 PM on 8/24/23, a follow up interview was conducted with RN G. When queried regarding Resident #20, RN G revealed they observed the bruise over their right eye. RN G detailed they spoke to Resident #20 regarding the bruise and the Resident had also told them they bumped their eye on their bed at the facility. When asked why an Incident and Accident form had not been completed, RN G was unable to provide an explanation. Resident #44: On 8/22/23 at 2:05 PM, an observation of Resident #44 occurred in their room. The Resident was in bed, positioned on their back with their eyes closed. Family Member Witness SS was sitting in the room in a chair. An interview was completed at this time. Resident #44 was tall, and their feet were pressed against the footboard. The Resident's Bilateral Lower Extremities (BLE) and feet were visibly edematous. When spoke to, Resident #44 opened their eyes, stated they needed to use the restroom, and moved their feet. A visibly deep indentation was present in the bottom of the Resident's left foot where it had been pressed in the footboard. When queried where their call light was, Resident #44 was unable to locate the call light and Witness SS got up from their chair to locate the call light. The call light was on the right side of the bed, near the head, and on the floor. Witness SS obtained the call light and pressed it for assistance. When queried regarding the call light not being within the Resident's reach, Witness SS stated, Not the first time and revealed the call light had not been in Resident #44's reach multiple times when they had visited the Resident. Certified Nursing Assistant (CNA) TT entered the room to assist Resident #44 to the bathroom. CNA TT transferred the Resident to their wheelchair by themselves without using a gait belt or other assistive device to wheel the Resident into the bathroom. When queried regarding the Resident's BLE being very edematous, CNA TT indicated they would have to ask the nurse. Witness SS stated, (Resident #44) is supposed to have those compression socks (TED hose) on. There were no TED hose/compression socks observed in the room. CNA TT was queried regarding compression socks and revealed they did not see any in the room but confirmed the Resident was supposed to have them in place. Witness SS then stated that Resident #44 gained 19 pounds in one week. When asked what the facility had done to assess and treat the Resident's edema, Witness SS revealed they had been told it was related to Resident #44 receiving steroid therapy but were unaware of what the facility was doing in relationship to monitoring and/or treatment. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses which included malignant brain neoplasm (tumor), left sided hemiplegia (paralysis), cognitive communication deficit, aphasia (difficulty speaking), hypertension, and Benign Prostatic Hyperplasia (BPH- enlarged prostate). Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required limited to extensive assistance to complete ADL Review of Resident #44's care plans revealed the Resident did not have a care plan and/or intervention in place which included TED (compression) hose/stockings. A care plan entitled, (Resident #44) has nutrition risk dt (due to) significant weight gain x 1 month . Increase in appetite/weight dt steroid use (Start Date: 8/3/23). The care plan included the interventions: - Monitor for s/s (signs/symptoms) fluid imbalance (Start Date: 8/3/23). - Nutrition education as needed (Start Date: 8/3/23) - Send diet as ordered, offer lower calorie snacks between meals, honor food preferences (Start Date: 8/3/23) - Weights per protocol (Start Date: 8/3/23) Review of Resident #44's Health Care Provider (HCP) orders revealed the following: - [NAME] Hose on 6 AM and off at HS (bedtime) 9 PM Twice A Day . (Start Date: 8/9/23) - Weight daily - Once A Morning 06:00 (AM) (Start Date: 8/2/23) - Dexamethasone (steroid) 4 mg (milligrams) . once a day 0900 (AM) (Start Date: 8/7/23) - Dexamethasone (steroid) 2 mg . once a day at bedtime . (Start Date: 8/7/23) - Furosemide (Lasix- diuretic) 40 mg . oral . once a day . (Start Date: 8/10/23) Review of Resident #44's weight documentation revealed the Resident was not weighted daily and had gained 11.8 lbs. during their stay at the facility. Weight documentation detailed: - 8/2/23 at 10:42 AM: 242.2 lbs. (pounds) - 8/9/23 at 9:03 AM: 257.2 lbs. - 8/16/23 at 12:16 PM: 253.8 lbs. - 8/22/23 at 10:30 PM: 254 lbs. Review of Resident #44's Electronic Medical Record (EMR) revealed no documentation related to refusal of weight monitoring and/or TED hose application. On 8/24/23 at 9:16 AM, an interview was completed with Registered Nurse (RN) Y. When queried regarding Resident #44 weight gain, RN Y reviewed the Resident's documentation in the EMR and confirmed the Resident had gained weight. When queried regarding the reason for the edema, RN Y indicated the Resident was receiving steroids related to treatment of their brain tumor. When queried regarding monitoring and treatment, RN Y replied, Two to three weeks of Lasix. RN Y was asked if the Resident's edema had improved after the initiation of Lasix, RN Y did not provide an explanation. RN Y was then asked how frequently the Resident's weight was supposed to be obtained and/or monitored. RN Y reviewed the EMR and stated, Daily. RN Y was then asked how often the Resident's weight had been obtained by facility staff and replied, Being done approximately weekly. When queried why the weight was not being obtained and monitored daily as ordered, RN Y was unable to provide an explanation. RN Y was then asked if Resident #44 was supposed to have TED hose in place. RN Y reviewed the EMR and confirmed there was a HCP order for TED hose daily. When queried regarding Resident #44 not having TED hose in place and Witness SS statement indicating staff were not applying the TED hose, RN Y was unable to provide further explanation. An interview was completed with Unit Manager RN G on 8/24/23 at 9:22 AM. When queried how frequently Resident #44's weight is supposed to be obtained/assessed, RN G reviewed the Resident's HCP orders and stated, Daily. When asked how often the Resident was being weighed, RN G replied, About weekly. When asked why the Resident was not being weighed daily as ordered, RN G indicated the order was entered into the EMR incorrectly and did not trigger the staff to document on the task daily. RN G was queried why no one had identified the error when it was ordered 22 days prior, RN G was unable to provide an explanation but indicated they would correct the error. RN G if the Resident was supposed to have TED hose in place during the day and confirmed they were. RN G revealed they had observed Resident #44's BLE edema on the prior day when in the Resident's room due to their legs opening and beginning to weep. When asked, RN G confirmed the Resident's BLE edema had worsening and was now weeping. When queried why the TED hose were not being applied as ordered which may have prevented worsening, RN G indicated they spoke to the Resident's spouse who had informed them the staff stopped applying the TED hose because they were hurting the Resident. When asked the reason the TED hose was hurting the Resident and if the correct size were being used, RN G was unable to provide an explanation but stated they were going to contact the Doctor to ask if ACE wraps could be used instead. When asked if there was any documentation of Resident #44 refusing TED hose application in the EMR and/or the reason for refusal, RN G replied, No. RN G was then queried regarding care coordination and modification of interventions if staff are not documenting current interventions are ineffective and stated, I have been talking to staff about that. RN G indicated staff need additional education. When queried regarding the reason for Resident #44's BLE edema, including severity and observations, RN G replied, Steroids, (Resident #44) has been on since July. When asked if they were saying the Resident's weight gain was solely related to steroid use, RN G replied, No, I doubt it is all from that. When asked if the Resident's Physician was aware of the Resident's ongoing edema, lack of weight monitoring as ordered and TED hose use, RN G indicated they would inform the Physician. No further explanation was provided. Resident 313: On 8/22/23 at 2:35 PM, Resident #313 was not present in their room. A passing staff member in the hall was asked where Resident #313 was and indicated they may be working with Therapy but were not sure. On 8/23/23 at 8:40 AM, Resident #313 was observed in the central activity room area of the unit alone sitting in their wheelchair. The Resident's wheelchair was positioned against the table. The Resident was holding a cardboard container of chocolate milk. An unopened container of apple juice and an open applesauce with no spoon was sitting in the table in front of them. Resident #313 was wearing one shoe on their left foot. On their right foot, Resident #313 had a regular sock but no shoe. Their right lower extremity was visibly edematous. Bilateral (left and right) footrests were in place on the wheelchair. Their left foot with the shoe was positioned directly on the floor, between the footrests and their right foot was positioned on the footrest. An interview was completed at this time. When asked how they were doing, Resident #313 made eye contact and replied Okay. The Resident had a flat effect. When asked additional questions, Resident #313 stared blankly but did not provide any further verbal response. An interview was conducted with Licensed Practical Nurse (LPN) Z and Registered Nurse (RN) L on 8/23/23 at 8:46 AM. When queried regarding Resident #313, LPN Z reviewed the Resident is dependent upon facility staff for their needs. When asked if the Resident had any current skin alterations, LPN Z stated, I know (Resident #313) has a patch on their coccyx for protection and a (drainage) tube for their gallbladder. LPN Z explained the Resident needed to have their gallbladder removed but a drainage tube had been placed in the hospital until the Resident was medically cleared to have the surgical procedure. When asked why the Resident was only wearing one shoe, RN L stated, (Resident #313) has swelling in the one ankle and indicated staff were unable to put on the Resident's shoe due to the swelling. The staff were asked if Resident #313 had a fall and/or any other injury. RN L replied, Not that we see. With further inquiry, RN L revealed an x-ray had been completed but the results were not back. When queried regarding Resident #313's cognitive status and communication, RN L stated, (Resident #313's) pretty aphasic and indicated the Resident will occasionally answer questions with one-word responses. RN L revealed they work midnight shift and do not typically interact with the Resident during the day. When queried if they were working day shift today, RN L stated, We had a call in and revealed they were working their sixth straight night shift and had stayed over. Record review revealed Resident #313 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included malignant brain neoplasm (tumor), dysphagia (difficulty swallowing), aphasia (difficulty speaking), right sided flaccid hemiplegia (paralysis), difficulty walking, and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive to total one-to-two-person assistance for bed mobility, transfers, locomotion, toileting, and personal hygiene. The MDS further detailed the Resident had impaired one-sided Range of Motion (ROM) in their upper and lower extremities. Review of Resident #313's care plans revealed a care plan entitled, (Resident #313) is limited in ability to perform ADL's (Activities of Daily Living)/hygiene/transfers related to: Decline in mentation and concentration; Neoplasm of brain; Epilepsy; Left foot drop; Tremors (Problem Start Date: 10/21/21). The care plan included the intervention, (Resident #313) uses [NAME] Lift with one assist for all transfers (Approach Start Date: 10/21/21). Another care plan present in Resident #313's Electronic Medical Record (EMR) was titled, Falls . at risk for falling R/T (related to) muscle weakness; Neoplasm of brain; Left foot drop; Tremors; Epilepsy; History of falls; decline in cognition and poor safety awareness (Problem Start Date: 10/21/21). This care plan included the interventions: - Encourage (Resident) to assume a standing position slowly (Start Date: 10/21/21) - Give (Resident) verbal reminders not to ambulate/transfer without assistance (Start Date: 10/21/21) - Observe frequently and place in supervised area when out of bed (Start Date: 10/21/21) - Provide (Resident) with safety device/appliance . door alarm; Floor mat; Entry Door alarm; Bed . Chair alarm in recliner in room; Velcro alarming seatbelt in w/c (Start Date: 10/21/21). Review of Resident #313's progress note documentation in the EMR revealed no progress notes were completed on 8/19/23, 8/20/23, and 8/21/23. Review of subsequent progress note documentation detailed: - 8/22/23 at 5:38 PM: Nursing . Right ankle swelling present, will start on potassium (supplement) and Lasix (diuretic), X-ray ordered. - 8/23/23 at 8:58 AM: Physical Therapy . Due to swelling in R (right) ankle and pending X-Ray order standing and ambulation activities will be suspended from PT (Physical Therapy) as patient has no goals for standing and ambulation. Standing activities completed prior with request from patient's sister at care conference stating (sister) had been walking with patient before hospitalization . Patient has had no verbal complaints or outward signs or symptoms of pain with therapy sessions as of this note. - 8/23/23 at 12:34 PM: Nursing . RLE (Right Lower Extremity) x-ray completed. Results: distal tibia fracture with mild displacement. No significant joint malalignment. Mild soft tissue swelling. Updated provider with orders to send to ER or obtain orthopedic consult. Patient's POA (Power of Attorney) updated and decided to send patient to ER for evaluation and treatment for quicker orthopedic intervention. POA also stated they noted a bruise under patient's eye and patient's mother noticed redness to back. Skin assessed to find no bruise or dark area under either eye as well as no redness to back. - 8/23/23 at 5:26 PM: Nursing . Residents (family) . called to update. Resident will be returning with a splint to be kept in place until F/U (follow up) w (Physician) next week . Non weight bearing to R leg, Splint is to remain in place, do not remove and wrap in Bag for showers. Orders put in and manager aware. - 8/23/23 at 10:50 PM: Nursing . Resident arrived back from (Hospital) via (EMS) stretcher around 10 PM. Resident is stable vitals are in stable condition . Resident has a Tibial ankle fracture with mild soft tissue swelling and is to remain non weight bearing on right foot. Resident has a splint, and it is to stay on at all times until she has a follow up with (Physician) transfers will be used with a maxi (mechanical lift which uses a sling to lift and transfer) left until further notice . An interview was conducted with the Director of Nursing (DON) on 8/23/23 at 12:43 PM. When queried regarding Resident #313, the DON stated, (Resident #313) fell and no one reported it. The DON continued, The X-ray showed a fracture. The DON was asked about Incident and Accident (I and A) documentation and stated, Have not completed an I and A. The DON indicated the facility was initiating an investigation related to the fall. Any documentation completed was requested at this time. Review of Resident #313's Radiology Report dated as completed on 8/22/23 revealed Report Date: 8/23/23 at 5:24 AM . Ankle Complete . Right . Distal tibia fracture with mild displacement . Conclusion: Acute appearing distal tibia fracture . On 8/23/23, the facility Administrator provided documentation that a Facility Reported Incident (FRI) was submitted to the State on 8/23/23 at 9:00 AM. The FRI documentation detailed, Injury of Unknown Source . Date/Time Incident Occurred: 8/20/23 3:00 PM . Incident Summary: It was determined on 8/22/23, (Resident #313's) right ankle/lower leg had swelling and pain with palpation of site. An X-ray was ordered and completed 8/22/2023 with results provided on 8/23/2023 at 7:29 am with a confirmed right distal tibia fracture. (Resident #313) had fallen on 8/20/23 during a transfer with mother and father, with no pain or injury noted at time of fall. (Resident #313) participated in therapy on 8/21/23 and 8/22/23 with no pain noted during therapy sessions. The Administrator also provided a typed Fall Investigation document dated 8/23/23. The document detailed: On 8/22/23, (Resident #313's) sister noted right ankle/lower leg swelling and pain with palpation of site . reported to nursing requesting an x-ray. (Physician) was notified of swelling concern with orders to start Lasix and potassium daily. X-ray completed to right lower leg. Results obtained via fax on 8/23*/23 at 7:29 AM with the following result: distal tibia fracture with mild displacement. (Physician) contacted . (Resident #313) made NWB (non-weight bearing) to right lower extremity and staff to use maxi lift for transfers. (Physician) gave orders for ortho consult or to send to ER pending family decision . Nurse Manager (RN G) contacted (Physical Therapist Assistant [PTA] NN) . (PTA NN) has documented that (Resident #313) has been actively working active and passive range of motion sitting exercises. (Resident #313) has attempted sit to stand transfers in parallel bars with maximum assistance and three therapy staff to initiate movement of bilateral legs . (RN G) began contacting staff for statements starting with staff that working with (Resident #313) in 8/20/23 . (Certified Nursing Assistant [CNA] OO) who was assigned to (Resident #313) on 8/20/23 was called and asked if any abnormalities were noted with (Resident #313) . (CNA OO) stated they were notified that their assistance was needed . that (Resident #313) was on the floor after their parents attempted to transfer them out of their chair. (RN Y) who was (Resident #313's) nurse on 8/20/23 was called for further information regarding fall reported. (RN Y) stated as they were walking down the hall during medication pass . noticed (Resident #313's) patents struggling to keep (Resident) standing. As (RN Y) was entering the room, (Resident #313) slip to the floor. (RN Y) assisted in getting (Resident #313) back to bed with (CNA OO) and (Resident #313)0 was assessed for any injuries. No abnormalities noted to legs or buttocks . did not show any signs or symptoms of pain at that time. (RN G) then contacted (Witness KK) asking if any incident or fall occurred on Sunday afternoon. (Witness KK) stated, 'It wasn't actually a fall, went down on their butt, like legs gave out and melted on down' . contacted (Witness N) would like (Resident #313) sent to (Hospital ER) for evaluation and treatment for quicker orthopedic intervention . An interview was completed with Resident #313's Mother Witness KK on 8/24/23 at 8:10 AM. When queried regarding Resident #313's fracture, Witness KK revealed they were visiting the Resident with Witness LL (Resident #313's Father) on Sunday 8/20/23. When asked what had occurred, Witness KK stated, (Witness LL) and I were transferring (Resident #313) from their wheelchair to their La-Z-Boy. (Resident #313's) legs were very weak and when we were going to them in their chair, (Resident #313) just kind of went down to the floor. Witness KK then stated, That is what I think happened. When asked if they were in the Resident's room, Witness KK confirmed they were and indicated they had taken the Resident back to their room so they could watch the ball game. When queried if any facility staff were present in the Resident's room at the time of the fall, Witness KK revealed there was not. Witness KK then stated, (Witness LL) and I were trying to pick (Resident #313) back up. (RN Y) was walking by and came in. (RN Y) and (Witness LL) picked (Resident #313) up. Witness KK was asked how the Resident was picked up and replied, Under their arms. When queried if a facility CNA assisted and/or entered the room, Witness KK replied, No, not at all. Witness KK reiterated RN Y came into the room because they were walking past when they saw what was happening. Witness KK was queried why they were transferring Resident #313 without staff assistance, Witness KK indicated they frequently transferred the Resident without staff assistance. Witness K was asked if Resident #313 always transferred the same and stated, No, used to be able to stand pivot. (Resident #313) could always pivot their feet. When queried if they received training from the facility regarding how to safely transfer the Resident, Witness KK replied, No, I know the rules. (Resident #313) has been there six years. When asked how the Resident was supposed to be transferred, Witness KK indicated a pivot transfer with two people is utilized. Witness KK was then asked if Resident #313 had any pain following the fall and replied, (Resident #313) had a lot of pain with that. Witness KK then revealed that Resident #313 does not verbally complain even when they are having pain. When asked about the Resident's position when they were lowered to the floor and if they recalled anything further, Witness KK stated, When we had (Resident #313) at the hospital, they said it is very possible that their leg or foot twisted. On 8/24/23 at 8:40 AM, an interview was conducted with RN Y. When queried what had occurred with Resident #313 on 8/20/23, RN Y stated, I caught both the parent's mid transfer. They were in the process of lowering (Resident #313). RN Y was asked where this occurred and revealed the Resident was in their room. RN Y specified they were walking down the hallway to administer medications to a different Resident and happened to look into Resident #313's room as they were walking past. When asked what they did, RN Y revealed they went into Resident #313's room. With further inquiry, RN Y revealed that as they were entering the room, Resident #313 was going down to the floor. When asked, RN Y specified the Resident's was on the floor with their legs out in front of them. When asked what happened next, RN Y stated, We just two-assist (Resident #313) back into their wheelchair. RN Y was asked who they were referring to and how the Resident was assisted into their wheelchair. RN Y revealed the Resident was picked up under their and with Me on the right and (Resident #313's) father on left. When asked if a gait belt was in place and/or used, RN Y revealed it was not. When queried if they assessed the Resident for injuries following the fall, RN Y indicated they did not observe any injuries. RN Y was then asked where they documented the fall and their assessment following the fall and stated, I have always been told that we don't consider a lower to the floor a fall. When queried if they documented an assessment and/or progress note regarding the fall and subsequent assessment, RN Y confirmed they did not because the Resident was lowered to the floor, and they had been previously instructed by facility leadership that when a Resident was lowered to floor it was not a fall. RN Y further revealed they did not complete an Incident and Accident (I and A) report for the same reason. When queried if Resident #313 had the cognitive capacity to verbalize injury and/or pain, RN Y replied, (Resident #313) is non-verbal and has a flat effect. They don't complain of pain, and it is difficult to identify. RN Y was asked if a CNA or other staff member came to the room to assist when the Resident had fell , RN Y revealed no other staff came to the room or were present. When queried why they did not call another staff member for assistance to transfer the Resident off the floor, RN Y did not provide an explanation. When queried regarding facility policy/procedure related to assisting a Resident following a fall including if adaptive equipment is supposed to be used, RN Y replied, Not to my knowledge, as long as we can physically do it (lift the Resident). RN Y was then asked if Resident #313's parents had transferred the Resident previously and replied, Not aware that parents even attempted to transfer (before) but (Resident #313) was on a different unit before. RN Y revealed the Resident was previously in the long-term unit of the facility, went to the hospital, and was placed in the short-term unit (current unit) after returning. RN Y was queried regarding the level of assistance Resident #313 required for transfers and stated, (Resident #313) was a sit to stand at the time when (the parents) attempted to transfer them and I don't know if they knew that. When queried if the family had received education related to how to safely transfer the Resident, RN Y replied, Not that I know of. When queried if the family had been educated regarding the need for staff assistance when transferring the Resident, RN Y revealed they were unsure as they were not aware the family ever transferred the Resident. An interview was conducted with Unit Manager RN G on 8/24/23 at 9:35 AM. When queried regarding Resident #313's right lower extremity edema and fractured tibia, RN G indicated they were not aware the Resident had fell until after the fracture was found and they started an investigation. RN G was queried where facility nursing staff document assessment findings, including edema and indicated documentation would be completed in an assessment or a progress note. When queried who first identified the Resident's right lower extremity edema, RN G revealed Resident #313's family member Witness N had verbalized concern about the Resident's leg being swollen to nursing staff. RN G was asked if facility nursing staff identified, documented, and/or assessed the edema prior to being notified by Witness N. RN G then reviewed Resident #313's medical record and specified there was no documentation until after nursing staff were notified by the Resident's family. RN G was asked if the assisted fall should have been reported and if an assessment should have been completed and documented following the fall, RN G stated it should have been. When queried why the edema was not identified by nursing staff during care completion and/or when completing nursing assessment, RN G indicated it should have been but was unable to provide an explanation. When asked if documentation would be in any other location, RN G revealed they would review the Resident's medical record again and provide any pertinent information. A policy/procedure related to nursing assessment and documentation was requested at this time. No documentation was provided by the conclusion of the survey. An interview was completed with Physical Therapist (PT) RR on 8/24/23 at 11:49 AM. When queried regarding Resident #313, PT RR revealed the Resident was currently receiving therapy services. PT RR was asked if they were aware of the Resident's fracture and revealed they were. When queried how much assistance Resident #313 required for transfers, prior to identification of the fracture, PT RR stated, (Resident #313) is a two-person total assist. (Resident #313's parents) can't do that. When asked what they meant, PT RR explained that Resident #313's parents are not physically capable of transferring the Resident due to the level of assistance Resident #313 requires. When asked if therapy ever worked with and educated Resident #313's parents regarding transfers, PT RR stated, Back when (Resident #313) could walk, we did do family training. When asked, PT RR revealed they were unsure of the specific date when the family had been trained but that it was not recently. PT RR revealed they would review the Resident's medical record and provide any documentation located related to family training. On 8/24/23 at 1:30 PM, PT RR provided Physical Therapy Education documentation from[TRUNCATED]

Based on observation, interview and record review, the facility failed to prevent facility- acquired pressure ulcers for one resident (Resident #4), resulting in Resident #4 developing a Stage IV pressure ulcer to the right heel, developed osteomyelitis (inflammation caused by infection), and required an intravenous antibiotic. Findings include: Record review of the facility 'Skin Care Protocol for Prevention of Pressure ulcers' policy dated 12/2022 revealed that all residents will be given the necessary care to prevent the development of pressure ulcers. All residents will be assessed for the risk of potential of impaired skin integrity. Record review of the facility 'Pressure Ulcers: Standard of Care for Prevention & Treatment' policy dated 6/2021 revealed a pressure ulcer is defined as any reddened, blistered, or open skin area related to pressure, friction, shear, or maceration of tissue. Pressure ulcer staging guide: Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Stage IV: Full thickness tissue loss with expose bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed . Resident #4: Record review of the facility CMS 802 Roster Matrix form dated 8/22/2023 identified Resident #4 as having pressure ulcer. It was not identified if it was facility acquired or the staging severity. In an interview on 08/22/23 at 10:26 AM with Resident #4 while lying in bed with her feet elevated up on a pillow. Resident #4 stated that her right foot has pressure areas from being here (at building). In an interview on 08/23/23 at 10:43 AM with the Registered Nurse/Unit manager C regarding Resident #4's skin. RN C revealed that Resident C only wound is on the right foot was obtained from the resident's new [NAME] foot pedals were applying pressure. It (pressure ulcers) was obtained here in the facility, at least three months ago. The wound had a wound vac off she wears blue boots and will be evaluated for the use of the [NAME] prior to the use of it. The RN C was notified by the State surveyor of Resident #4's observation of bloody towels and soaker pad from the day were observed by the surveyor on the floor with no staff present in the room. RN C stated that it should not have happened. Interview and record review on 08/23/23 at 02:37 PM with the Interim Director of Nursing (DON)/Registered Nurse/Infection Preventionist. The DON stated that Resident #4 had in May 2023 antibiotic use. The antibiotic Rocephin 2 grams intravenous for osteomyelitis of the right foot from 5/9/2023 to 6/23/2023. Observation and interview on 08/24/23 at 07:55 AM with Licensed Practical Nurse (LPN) PP of Resident #4's right foot pressure wound. LPN PP revealed Resident #4 did get intravenous (IV) antibiotic when she came back from the hospital on ceftriaxone (Rocephin) or something, she did have a right upper arm peripheral intravenous central catheter (PICC) line at the time. LPN PP stated that the wound started as a deep tissue purple in color and then she went to the hospital, and they debrided the wound, it was the entire area of the right heel. The surveyor observed LPN PP removed the old dressing of Kirlex wrap with no date noted, with a 4 x 4 gauze laid over the wound. There was no date or initials of the wound care nurse that placed the dressing. Observation of right wound with open area with no drainage noted. LPN PP stated that Licensed Practical Nurse (LPN) D is the wound care nurse and does the measurements weekly. LPN PP stated that the wound looks much better. LPN PP applied normal saline to wound bed, gauze 4 x 4 pat dry, and silicone proximal dressing 2-inch foam boarder dressing applied with date and initials. Right foot wound wrapped in Kirlex gauze. An interview on 08/24/23 at 08:02 AM with Resident #4 revealed when she was sitting up in her [NAME] my feet were on the pedals, and she didn't feel it. Resident #4 revealed that a nurse found it one day and that it was a dark spot on both feet. It was rubbing on the bottom/back of my foot. Resident #4 revealed that she had on house shoes and slipper socks. Observation on 08/24/23 at 08:09 AM of Resident #4's bathroom with a manual wheelchair in front of sink area, and a red [NAME] in the shower. There was no black/blue [NAME] found with in the room. In an interview and record review on 08/24/23 at 12:15 PM with Licensed Practical Nurse (LPN) D wound care nurse, LPN D revealed Right heel was identified on March 15th, 2023, unstageable necrotic. LPN D stated that the wound was already necrotic/eschar (black dead tissue) when she was notified of the wound. LPN D revealed that Resident #4 had a power chair/[NAME] the family brought in and did not get it properly fit to her and the foot pedals were to high up. Her legs were pushing down into the pedals. It was not evaluated by therapy, and that's the only change and then she had the Pressure Ulcer to the feet. It is a Facility acquired pressure ulcer that she did get here. It was necrotic/eschar the first time that LPN D saw the wound. It did get large, and she went to the hospital and came back with a wound vac. Left heel after a hospital stay was deep tissue and then went to red non-blanchable and the resolved, it was hospital acquired. On 3/25/2023 it was necrotic tissue measuring 5.5 cm X 5 cm. Resident #4 did get Osteomyelitis from the right foot wound and went to the hospital and came back with Peripheral Inserted Central Catheter (PICC) line and intravenous (IV) antibiotics in May 2023 through June 2023 the resident received antibiotics. LPN D did state that Resident #4 did get very sick and went to the hospital a couple of times and came back. Record review of Resident #4's Wound management Detail Report dated 3/15/2023 through 8/22/2023 noted in house acquired right heel wound. On 3/15/2023 at 5:17 PM noted necrotic (eschar) tissue of wound measuring 5.5 cm length x 5 cm width necrotic (eschar)tissue. Noted wound observed on resident's (right) heel. Resident received new power chair from family and states the foot pedals are too high resulting in foot being pressed into pedal. Resident was wearing her slippers. Slippers removed and blue boots placed. Resident also no longer using new power chair . On 4/11/2023 at 5:51 PM noted 5.5 cm length x 5 cm width with serosanguineous (pale red to pink, thin and watery) stage III . On 4/27/2023 at 9:20 AM noted Resident #4's right heel wound to be stage IV (4). Record review of Resident #4's nursing progress noted dated 4/27/2023 at 9:17 AM noted: Resident had appointment at wound clinic on 4/25/ (2023). During appointment right heel was debrided. Orders received from wound clinic to start a wound vac to right heel. Wound vac placed over heel with setting at 125 mmg continuous using black foam. Resident tolerated procedure well. Record review of the Infection Control line listing for May 2023 revealed that on 5/19/2023 (resident patient identification number circled by Infection Preventionist) was receiving antibiotic Rocephin 2 grams (IV) for osteomyelitis of the foot.

This Citation will have three Deficient Practice Statements (DPS). DPS #1 and DPS #2 pertain to two separate elopements resulting in two Immediate Jeopardies (IJ). Deficient Practice Statement #1 This Citation pertains to Intake Number MI00136527 Based on interview and record review the facility failed to respond to audible alarms and instead silenced the alarms, without verifying the source and ensuring that all residents were accounted for, resulting in one resident (Resident #110) eloping from the facility and crawling alongside the perimeter of the facility over grass, pavement and rocks on his hands and knees with the potential for serious harm and/or injury of two residents reviewed for wandering/elopement. Immediate Jeopardy: On 4/18/2023 at 7:20 PM, Resident #110 self-propelled in his wheelchair into the Wheels A/B Unit Atrium and is observed (on camera) standing up from his wheelchair, walking toward the exit door and opening the door at 7:25 PM. His gait was observed to be unsteady as he ambulated around the front of the facility. At 7:32 PM he was observed crawling around the perimeter of the facility on his hands and knees. He crawled through the grass, pavement, and rocks as he made his way to the Beaches Unit door. He knocked on the Beaches exit door and attempted to wave down multiple vehicles that passed by. From 7:35 PM to 7:44 PM Resident #110 crawled on his knees around the door until Nurse L observed him at the door. Nurse L left Resident #110 outside and unsupervised to retrieve his wheelchair from Wheels A/B Unit. Nurse L returned at 7:46 PM with Nurse K to assist the resident back into the building. The Immediate Jeopardy (IJ) began on 04/18/2023 when Resident #110 eloped from the facility through delayed and alarmed egress door without staff knowledge or staff response to audible alarms. The Immediate Jeopardy was identified on 08/10/2023. The Nursing Home Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/11/2023 at 11:00 AM. The surveyor confirmed by observation, interview, and record review on 08/11/2023 that the Immediate Jeopardy was removed on 04/19/2023, and that the deficient practice was corrected on 04/21/2023, prior to the start of the survey and, therefore, Past Non-Compliance was granted for the elopement of Resident #110 only. Findings Include: Resident #110: On 8/9/23 at approximately 1:30 PM, Nurse Manager's G and H, were queried regarding Resident #110's elopement. Resident #110 eloped out the delayed egress doors on Wheels Unit and was located on Beaches Unit at the exit doors. Resident #110 was able to hold down on the push bar for 30 seconds which opened the door, he crawled on the ground and knocked on Beaches exit door. Nurse Manager's G and H, further explained the alarms were sounding but an agency aide standing by system silenced the alarms as he thought it was the security guards checking the alarms on their unit. They watched the camera which confirmed the CNA (Certified Nursing Assistant) and Nurse were standing at the system and canceled out the alarms without first verifying if it was security or a resident. The Manager's were asked if a head count was completed during this time, and they stated there was not. Nurse K heard knocking and found the resident outside of the facility. They reeducated staff on their elopement policy, checking doors when alarms are going off, to not clear the alarms at the [NAME] Comm system and to not assume it is maintenance or security completing door checks. Nurse Manager's G and H, acknowledge their staff inaction in this incident as no one responded to an audible alarm, put timely interventions in place when the Resident #110 expressed multiple times his intention to go home and silencing the alarms without completing appropriate checks for resident safety. On 8/9/2023 at approximately 2:30 PM, a review was completed of camera footage (from differing cameras) from Resident #110 eloping from the facility on 4/18/2023. Resident #110 walked out the facility at 7:20 PM and facility staff brought him back in at 7:48 PM. There were multiple staff in the vicinity of the audible alarm, and none responded to the alarms. 7:20:48: Resident #110 comes into frame as he self-propels in his wheelchair into the Wheels Atrium that faces Hospital Road. He is the only person it the atrium at this time. 7:21:24: Resident #110 locks his wheelchair, stands up and walks to the Wheels exit door. He is actively pushing on the alarmed door attempting to exit. 7:25:19: Resident #110 breeches the alarmed exit door and walks outside. He is seen walking down the path and turning to the left alongside the perimeter of the building. On the ceiling is an indicator that flashes red when the exit door is breeched. When Resident #110 exited the door, it is seen actively flashing red. He is seen walking in the grass and going off frame. 7:25:19: At time Resident #110 exited the facility there are 2 staff by the nurse's station and they continue to work and are not startled or alerted to anything. 7:25:50: CNA W comes into frame and is looking at the [NAME] Comm system at the nurses station. Nurse L approaches and they have an exchange in which CNA L points toward the Wheels Day Room. CNA W is seen touching the [NAME] Comm system and still speaking to Nurse L about it. CNA W peers down the hallway to Wheels Day Room and then continues his other tasks. It can be noted there were 3 staff at the nurses station and 1 staff in the dining room charting. 7:28:02: CNA W walks back to the [NAME] Comm system and touches on the screen at what appears to be an attempt to clear the audible alarm. 7:31:26: CNA W walks back to the [NAME] Comm system and is touching the system. CNA W goes back to the [NAME] Comm system two more times at 7:34:24 PM and 7:37:44 PM. 7:32:29: Resident #110 is seen slowly crawling on all fours in the grass and rocks outside of Beaches Atrium. 7:34: 30: Resident #110 is seen peering through the Beaches exit door and knocking. As vehicles drive by he is attempting to flag them down. 7:37:41: Resident #110 is still sitting outside of Beaches exit door. At times he will peer into the he door and knock again. He continues to crawl on his hands and knees just outside of the door. 7:41:39: Nurse L is at the [NAME] Comm system and then takes a phone call at 7:42:23 (which is from Nurse K). He then walks toward the Wheels Day Room. 7:43:54: Nurse L walk into Wheels Day room and onto the closed COVID unit. He walks past Resident #110's wheelchair that he left parked by the exit door. 7:44:44: Nurse L enters the Beeches Atrium and sees Resident #110 outside the door. He then leaves the Resident #110 (who is still outside and appearing to be playing with the rocks). 7:45:15: Nurse L runs back through Wheel's Day Room toward the nurse's station. 7:45:42: Nurse L runs through the Day Room and gets Resident #110's wheelchair, unlocks it and goes back toward the closed COVID unit. 7:45:54: Nurse L opens the Beeches exit door. Nurse K comes back into frame to assist with getting the resident back into the facility. Nurse U enters just as they get the resident back in his wheelchair and they wheel him into the facility at 7:47:56 PM. 7:49:12: Nurse U propels Resident #110 in his wheelchair through the day room and stops to check the exit door. Nurse L is seen slightly pushing on the Wheels exit door and it opens without the 30 second delay. 7:54:03: Nurse L and another facility staff enter the frame. The unknown facility staff put a key into the box above the door which turns off the audible alarms from that door. On 8/9/2023 at approximately 3:00 PM, a review was completed of the facility investigation into Resident #110's elopement. The resident eloped at approximately 7:25 PM and was found outside of Beaches exit door at approximately 7:47 PM. Agency CNA W Statement: To whom it may concern, I did not see (Resident #110) on Tuesday when he eloped. I was doing round I became aware of the situation once the nurse informed me. Nurse K Statement: Yesterday approx 7:30 PM I head a faint banging noise that I felt was coming from wheel AB unit. I called 7701 and spoke to (Nurse L). He stated there was no patients at the end of the hall. He told me he would go and look. I heard him saying to me over the wall that there was no one over there. Then he said Oh wait I see him, outside the door. No alarms were sounding at this time. I go over to wheels AB and (Nurse L) is already down to end of 40's hall trying to open the door, it was only open about 1 inch. I told him I know how to open it and then I went down to the nurses station and found the black box (emergency release button), lifted the cover and pushed the button. Alarms were sounding at this time Went back down the hallway and (Nurse L had door open and I placed a table in front of door the keep open. (Nurse L) had a wheelchair and we lifted the pt back into the wheelchair, at this time female nurse was there handing on to the w/c and she proceeded to wheel pt back to the unit. I turned the button back to black and went back to my unit. Nurse U Statement: .was called out of another residents rooms to help find room [ROOM NUMBER] Resident. Resident was found outside Beaches/AB Wheels doors. Writer observed other unit nurse and wheels nurse assisting Resident back in wheelchair and back into building. Writer tool resident back to Rm 288. Complete head to toe assessment vitals complete. Unit Manager notified, left message with daughter, wanderguard placed on R ankle. Agency Nurse L Statement: On 4/18/2023 sometime between 2000 and 2100, I noted (CNA W) was attempting to silence a wander guard alarm on the call light system, and another nurse mentioned that it might be security doing their wander guard rounds. I went on with my patient care at that time and returned to see that the alert was still on the call light system screen. The notice indicated that is had been alarming for just over 16 minutes. I stated to walk towards the COVID unit where the alert indicated that the alarm was, when nurse from Beaches unit called and asked me if we had any patients on the COVID unit. I told her that we did not, and she informed me that she is hearing what sounds like someone pounding on a table over there. I let her know that I was just on my over to check an alarm, I noted an empty wheelchair in the glass that connects Wheels to the COVID unit, there were no audible alarms or patients in that area, so I continued on believing that I was just a spare wheelchair that was left in that glass room. I continued onto COVID unit and did not se or hear anyone, I informed the nurse on Beaches unit over the wall that I will keep looking to be sure, but it appeared empty. I continued my search down the hall when I noticed something moving outside the glass room at the far end of the COVID unit, upon looking closer, I noted that it was a foot that was moving. So, I went down to the room and noted that a patient was on his hands and knees outside, attempting to get up. I ran back toward the Wheels unit, shouting to the nurse on Beaches that there is a resident outside, and I am going to get his nurse and get him back inside. I ran over to Wheels and notified his nurse, then ran back grabbing the empty wheelchair in route and attempted to get out of the door to the patient. The door would not open and the nurse from Beaches informed me that it does not open unless a button is pressed at the nurse's station. She went down and pressed the button, allowing me to open the door, which sounded the alarm, and stated making the call lights flash. We propped it open with a table, brought the wheelchair outside and assisted the patient back onto the wheelchair. Patient denied pain and said that he could not get back inside. We brought the patient back to his nurse and examined the door that the wheelchair was sitting next to, believing that it may have been the door that he went out. The door opened easily with a single push which caused the alarm to start sounding and made the call lights flash. Attempted to call security to notify them of the open doors and alarms but did not get an answer. I then went out to the front desk and found maintenance, I informed him of the issue, and he came back to the COVID unit and secured the doors, which turned off the alarms. Facility Incident Summary: .On April 18,2023 at approximately 7:25 pm, when staff reported that (Resident #110) was observed outside of Beaches Atrium door on the ground and was brought back into the building by a nurse. Nursing reports that (Resident #110) was stating that he was looking for his truck keys and wanted to call his daughter to go back home .Upon investigation of the event (Resident #110) was reviewed on security cameras self-propelling in wheelchair into Wheels AB unit. (Resident #110) stood up form the wheelchair, stood and open exit door to outside atrium with success of door opening at 7:35 pm. (Resident #110) began to ambulate around building and was noted crawling outside close to building on Beach unit at 7:42 pm. (Resident #110) sat outside on his buttocks knocking on door/window to Beach Atrium area. Nurse observed (Resident #110) outside of door at 7:44 pm nurse went to obtain wheelchair to assist (Resident #110) back inside at 7:47 pm .Staff reported that (Resident #110) stated he was looking for his keys and wanted to talk to his daughter. (Resident #110) was observed to be close to building on sidewalk area closets to the building, approximately 2 feet away from building and never left the facility grounds .(Resident #110) attempts to ambulate and then falls onto ground two feet from building and crawls toward Beach Atrium door . On 8/10/2023 at approximately 9:45 AM, a review was completed of Resident #110's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Syncope and collapse, Diabetes, Impaired mobility, generalized weakness, Chronic Kidney Disease, Gastritis, Cerebral Ischemia and Rhabdomyolysis. Resident #110 had severe cognitive deficits, required one person assist for activities of daily living and utilized a wheelchair. Further review yielded the following: Progress Notes: 4/14/2023 at 01:25: Resident observed in the hallway in wheelchair looking for something to do as he stated I was laying with my wife and she fell asleep so I need something to do Writer assisted resident back to room, as he stated where did my wife go she was just here sleeping I redirected resident that he was at (facility) for rehab, there was no one else in his room and it was time to rest for the night and tomorrow was a new day. resident stated OK, thank you. call light within reach. Will continue to monitor. 4/18/2023 at 07:30: Resident daughter notified writer she has noticed an increase of confusion with Resident and request a urine sample to be collected to test Resident for an UTI. Writer attempted to get urine sample and was unsuccessful. Writer passed along in shift report to follow-up to attempt again. 4/19/2023 at 00:49: Writer was called by other nurse to assist in getting resident back in the building. Resident was found outside doors of beaches and A/B wheels. Resident was assisted back into wheelchair by other nurse and nurse from beaches. Writer took resident back to room a complete head to to toe assessment completed, resident denies pain, no injuries noted, vitals as follows: 126/66, HR 74, resp. 18, O2 97% on RA. Unit manager informed staff informed to write statements, Daughter called unable to reach left message. resident at this time is sitting at nurse's station with staff, in wheelchair with baggage next to him. Resident stated he is ready to leave and would like writer to give him his car keys Nothing else was stated, continuing to sit at nurse's station with baggage at his side, Unit manage ok's wonder guard to be put on resident. Will continue to monitor. Wander guard applied to right ankle. Physical Therapy Evaluation: 4/12/2023: .Bed Mobility= Min (A).Transfers=Mod (A); Assistive Device During Transfers=Two-wheeled walker .Distance Level Surfaces=5 feet; Assistive Device=Two-wheeled walker. Deviations: Patient exhibits forward lean of trunk and knee instability which are associated with underlying causes of muscle instability and muscle paresis/weakness. Gait Pattern: The patient exhibits the following characteristics during gait: decreased cadence, diminished single limb support time, decreased velocity, decreased stride length and wide base of support. Fall predictors: Asymmetrical stance, Discontinuity of steps, Delayed anticipatory reactions, Poor negotiation of obstacles, Reduced quad strength and Reduced reactive balance .Pt is 75 y/o male with deficits to include: decreased strength, decreased endurance, decreased balance, syncopal episodes, and confusion. Pt would benefit from skilled therapy to improve muscular strength, endurance, and balance to assist with functional mobility . On 8/11/2023 at 10:35 AM, an interview was conducted with Maintenance Supervisor X regarding the delayed egress doors in the Atrium. He reported the doors on the units are checked monthly. Monthly, his staff ensure the doors are locked, they then open the door to sound the audible alarm and walk up the hallway to ensure it can be heard by facility staff. They also verify the red flashing light (affixed to ceiling) flashes when the door is opened. They walk back to the door, disarm it, and ensure it is relocked. Supervisor X explained if that doors is opened it will also alarm at the nurse's station and display on the [NAME] Comm monitor which door was opened. This monitor has a separate audible alarm that will sound if the atrium door is opened. Supervisor X was queried if the Wheels door was checked for functionality prior to Resident #110's elopement from the facility and he stated it was. Review was completed of Simple Work Order Listing, and it indicated all LTC (Long Term Care) delayed egress doors were checked for functionality on 4/6/2023, twelve days prior to Resident #110's elopement. On 8/11/2023 at 11:35 AM, this writer and Supervisor X toured the Wheels and Beaches Unit. Wheels Atrium faces Hospital Road and is labeled as Door #5. Supervisor X explained the door is delayed egress and takes 30 seconds for the door to open. Upon holding the bar on the door it began to beep for 10 seconds which indicated it was open. A second alarm tone sounded and then at 30 seconds the door opened. Affixed to the ceiling was a light that flashed red as soon as the door bar pushed continuously. This writer walked down the hallway to ascertain if the alarm was head on the unit. As this writer walked up the hallway the alarm became distant but the doorbell alarm at the [NAME] Comm system at the Nurse's station was easily heard as it sounded like a doorbell consistently going off. At the [NAME] Comm monitor it displayed a red banner across the top of the screen with the specific door that was opened. Supervisor X shared the alert goes to the nurses and nurse manager's phone. We walked outside of Door #5 to walk the route Resident #110 took when he eloped from the facility. From the Wheels Atrium door to Hospital Road (busy 55-mph highway without sidewalks) was approximately 120 feet. From Wheels Atrium Door to Beaches Atrium Door was approximately 125 feet to 150 feet per Supervisor X. He was queried if they complete drills to test if staff will respond to the alarms. He stated they only check for the functionality of the doors/alarms. Review of CNA W's human resource file was completed and showed the following: Email chain between past DON, Human Resources and Unit Manager G, regarding CNA W: Sent by Human Resources: 4/21/2023 AT 7:04 AM: .I am not aware of what happened. Does HR have the complaint information yet? Sent by Nurse Manager G: 4/20/2023 at 4:10 PM: After speaking with (DON) and due to the nature of the elopement situation she does not want (CNA W) to return. Please let me know if you have any further questions. Sent by DON: 4/26/23 at 11:22 AM: .I know we have had previous emails and discussions regarding (CNA W). I have again spoke with (DON) to clarify, we do not want him returning for any more shifts. Can one of you please reach out to the agency to notify them of this change? Sent by Nurse Manager G: 4/26/2023 at 11:41 AM: The last thing he did was turn off the door alarm from the nurses station multiples times and allowed an elopement to occur because no one responded to it. Also (Nurse L) the nurse was aware and completely told the manager different. Core Orientation Checklist- Medical Rehab & LTC- CENA was completed by CNA W on 3-7-2023 but the orientation did not cover elopements, door alarms or wander guard system. Per Educator P he completed the Core Orientation Checklist with all new hires/agency staff and Nurse Manager's complete the New Employee Unit Orientation Checklist with the new hires/agency staff. The facility was unable to produce the Orientation Checklist or any other documentation of CNA W's training on response to alarms and elopement. Review of Nurse L's human resource file was completed and showed the following: Core Orientation- Medical Rehab & LTC Nurse training was signed by Nurse L but did not indicate a date of completion. On 11/9/2022, Nurse L completed New Employee Unit Orientation Checklist. Apart of that training was Elopement book, Wanderguard's and Call light system. On 8/11/2023 at 12:20 PM, an interview was conducted with Nurse L related to Resident #110's elopement. On mention of the elopement Nurse L began to laugh and then stated it was not his patient that day. Nurse L recalled coming out of a patient's room and hearing the call light system ([NAME] Comm system) alarming, he stated it goes off on occasion when facility security completes their nightly doors checks for approximately 20-30 seconds. Nurse L stated one of the aides (CNA W) was at the monitor attempting to silence the alarm sounding and he informed the CNA they (staff) do not mess with that system, and it should go off soon. He informed CNA W there is nothing they can do to silence the alarm and he assumed it was just going turn off soon. Nurse L reported he knew the doorbell sound indicated it was the wanderguard system alerting and the only time he had heard the alarm was when security was checking the doors. Nurse L stated they had no residents on their unit with wanderguard's so he assumed it was a test being performed by facility security. Nurse L left the nurse station and walked into a resident's room, about 15 minutes later the door bell was still sounding at the nurses station. Nurse L shared it should not have still been going off and thought it was malfunctioning, but the monitor read Beaches/Wheels AB. Nurse L stated that is the closed down COVID unit and he decided to walk over to that unit at an attempt to find why the alarm was still sounding. Prior to leaving the desk Nurse K called from Beaches unit and questioned if they had any residents on Wheels AB unit and Nurse L informed her there were no residents down there as that unit was closed. Nurse K reported she heard someone pounding on something on that unit and Nurse L informed her he was already headed that way and would investigate the noise as well. Nurse L proceeded to check the unit and walked by Door #5 (door Resident #110 eloped out of) and did not see anything to indicate someone had left the building. He stated he did not think twice about the wheelchair being there as it's a common occurrence to have them parked throughout the units. Nurse L was asked if the alarm at Door #5 was audibly alarming, and he stated it was not. As he walked down the hall he called out and received no response and was talking to the nurse on Beaches to inform her he was not seeing what was causing the wander guard alarm. Nurse L was at the Beaches exit door and saw a shoe outside the door and that did not immediately register to him. He then saw the shoe moving and when he looked outside the door, he saw Resident #110 crawling on his hands an knees on the pavement. Nurse L yelled to Nurse K that a resident was outside, but he was unable to get the door open. Nurse L left Resident #110 outside and ran back to Door #5 to retrieve the wheelchair he saw and informed Nurse U they needed some extra assistance bringing a resident back into the facility. Nurse K and Nurse L were unable to open the exit door, Nurse K returned to Beaches nurses station and pressed the black emergency release button for the door which allowed Nurse L to open the door. They propped the door open and placed Resident #110 back into the wheelchair. Resident #110 informed them he was not hurt and that he was not able to get back into the facility on ce he exited. Nurse L went back to Door #5 as he realized that was the door the resident exited out of and when he pushed on the door it easily opened and then the door alarm began to [NAME]. He stated prior to that moment that alarm was not sounding. Nurse L had to locate maintenance as they have to disarm it with a key. Nurse L reported the alarm is loud and could be heard at the front reception desk. Nurse L reported the alarm at Door 5 did not alarm when Resident #110 exited the facility. On 8/11/2023 at 1:00 PM, an interview was conducted with Nurse K regarding Resident #110's elopement. Nurse K shared she works on Beaches unit on night shift from 7 PM - 7:30 AM. Nurse K was charting on her unit and heard faint knocking but it wasn't consistent. She called Wheels unit and Nurse L answered and reported there were no residents on the COVID unit. Nurse K told Nurse L about the noise she was hearing, and he said he was going to check it out. Nurse K explained their unit is separated by a half wall so as Nurse L was checking the unit, he was reporting he was not seeing anything or anyone on the unit. Nurse L then suddenly reported it was a resident outside the Beaches exit door. Nurse K made her way to the door, but they were unable to open it, she returned to her unit to press the emergency release button which released the door. By the time Nurse K arrived back to the door Resident #110 was being assisted into a wheelchair by Nurse L and another nurse. Nurse K reported the resident was crawling outside on all fours, but he did not appear to be harmed or in any distress. Nurse K was asked if she heard any audible alarms sounding and she stated she did not. Nurse K reported the door alarms are very loud and she would have heard them easily on her unit, she stated the door alarm sounded when she pressed the emergency release button. She stated nursing staff cannot disarm the exit doors only maintenance as they use a key to disarm it. On 8/11/2023 at 2:10 PM, an interview was conducted with CNA W regarding Resident #110's elopement from the facility. CNA W reported he heard the alarm sounding and did not know what it was and thought it was a room call light. CNA W stated it was only sounding at the nurse's station and the sound was nothing that would alert him to an elopement. He stated he checked the monitor ([NAME] Comm System) but was not well versed in how to operate that system. CNA W stated he had an 8-week contract at the facility, and he did receive orientation but does not recall if they covered information related to their alarm systems. CNA W shared no one on the unit was aware Resident #110 had eloped. Nurse W was asked if she investigated the source of the alarms and she stated she did not. On 8/11/2023 at 3:50 PM, the DON and Administrator explained at the time of Resident #110's elopement facility staff were able to silence the door alarms at the nurse's station. Since that incident they have disabled their ability to further do so. They further acknowledged the failure of staff not responding to audible alarms. On 8/15/2023 at 8:08 AM, an interview was conducted with Nurse U regarding Resident #110's elopement. Nurse U stated after receiving report, Nurse L was running down the hall and reported a resident had eloped. Nurse U followed behind him and upon arriving a Beaches exit door they were already bringing Resident #110 back into the facility. Nurse U was asked if she heard any alarms sounding prior to Nurse L alerting her to the elopement. Nurse U shared she did hear an alarm going off but could not distinguish if it was a bed, room or wanderguard alarm sounding. Nurse U stated earlier the alarm systems were begin checked and was not certain if it was the actual alarm or them being checked again. Nurse U was asked if she investigated the source of the alarms and she stated she did not. Immediate Jeopardy Removal: The Immediate Jeopardy that began on 4/18/2023 was removed on 4/19/2023 when the facility completed the following: 1. Ambulatory and self-propelling residents have the potential to be affected by this practice. All residents who are at risk for elopement have wander guards in place and have had their care plans updated. 2. All residents at risk for elopement have their pictures placed in the Elopement Book on all neighborhoods and at South Lobby Front Desk, this is updated with any change in the Elopement Risk Assessment and was reviewed on April 19, 2023. 3. The WestCom System at the nurses' station which had the ability to cancel the alarms, which notify staff that Exit Doors are open. The ability to turn off exit door alarms at the nursing station was immediately disabled. Past Non-Compliance for the Elopement of Resident #110: The deficient practice was corrected on 4/21/2023 after the facility completed the following actions to remove the immediacy and correct the noncompliance: 1. The LTC staff have been in-serviced on prompt answering alarms on exit doors. In-service was started on April 19, 2023 and completed on April 21, 2023. 2. The Neighborhood nurse managers and the social workers are responsible to implement this plan of correction. The Director of Nursing and the Licensed Home Administrator were responsible to ensure ongoing compliance. 3. Maintenance is currently performing exit door alarm checks monthly and will continue to leave alarm sounding until staff respond appropriately. These checks will continue to be monthly. 4. The results of these audits will be shared with the Director of Nursing and presented monthly at the Quality Assurance Committee for review and recommendations. Deficient Practice Statement #2 This Citation pertains to Intake Number MI00138575. Resident #101: Based on interview and record review the facility failed to provide monitoring and supervision to prevent the elopement from the facility of one resident (Resident #101) resulting in the facility being unaware of the resident's whereabouts with the potential for serious harm, injury and/or death of two residents reviewed for wandering and elopement. Immediate Jeopardy: On 7/25/2023 at approximately 6:58 PM, Resident #101 was observed (on camera) emerging from his room and walked toward the south lobby entrance. There are no facility staff observed in the hallway. At 7:00 PM, Resident #101 walked out the South entrance past Receptionist A, unsupervised. He traveled down the sidewalk and onto the south parking lot and turns left on Hospital Rd (two-lane, busy, 55 MPH road, without sidewalks and uneven ground). He walked down Hospital Rd toward [NAME] Rd (a well-traveled, busy intersection with large ditch at 4- way stop) approximately 1/2 a mile. At 7:13 PM Security Guard B left the facility with CNA J to retrieve Resident #101 on [NAME] Rd right past the 4-way intersection. Resident #101 was placed in

This Citation pertains to Intake Number MI00131576. Based on interview and record review, the facility failed to ensure that continuous, weekly, regular, wound measurements and subsequent assessments and treatments for treatment of a pressure ulcer were conducted for one resident (Resident #102) reviewed, resulting in the worsening and declining of the pressure ulcer and resulting pain and discomfort. Findings include: A Stage II pressure ulcer is partial-thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents as an abrasion, shallow center or blister. High risk residents (immobile, bed bound) should be assessed weekly, when a condition change or as needed and preventive measures should be in place including pressure relieving devices, position changes, and dietary supplements. National Pressure Ulcer Advisory Panel (NIPUAP) Record review of the facility's 'Skin Care Protocol for Prevention of Pressure Ulcers' policy, dated 12/2022, revealed all necessary care to prevent the development of pressure ulcers included: Procedure: 1. (F.) Weekly skin assessment. (G.) Assess skin integrity for pressure areas. Record review of the facility's 'Wound Care and Dressing Change Procedure: aseptic/non-sterile' policy, dated 12/2021, revealed the procedure: Step #32. Document the following in the medical record; (a.) Color of wound. (b.) Note any drainage and amount, color, odor. (c.) Patient/resident tolerance of procedure. (d.) Length, width and depth of wound. In an interview on 1/18/2023 at 11:20 AM, Licensed Practical Nurse (LPN) A, wound care nurse, stated that they started in the position as wound care nurse at the end of July 2022. LPN A had signed to the position description as a wound care nurse a year earlier, but due to low staffing I had to stay on the floor as a floor nurse. Resident #102: Record review was conducted of Resident #102's Admission assessment, dated 4/24/2022 at 5:06 PM. Skin assessment noted area around open are macerated and purple in color. Healed long incision to mid-to-lower back, scattered bruises on abdomen and left-hand scab area at right jugular per report site where resident was getting an infusion. Wound: location-Coccyx, Length- head to toe direction (centimeters): 9.7, Width- hip to hip direction (centimeters): 4.5, depth- measure deepest part of visible wound (centimeters): 0.3 Record review of 'Pressure Skin Issues' form, dated 4/27/2022, revealed that Resident #102 coccyx wound measured 4.2 X 0.5; current treatment Medi honey. The wound was not staged. An interview on 1/20/2023 at 8:23 AM with Licensed Practical Nurse (LPN) A, wound care nurse, revealed that she believed Resident #102's that the difference between the admission 4/24/2022 coccyx wound measurements and the next measurement on 4/27/2022, was that the admitting nurse measured the larger purple area of the coccyx and not the open wound itself. Measurements of wound care are done once a week and usually on Wednesdays. There were no wound measurements found for Resident #102 for the week of 5/4/2022. Record review of 'Pressure Skin Issues' form, dated 5/11/2022, revealed that Resident #102 coccyx wound measured length 5.0 X width 3.0 X depth 3.0, which is larger than previous measurements. The treatment was changed to Silver Alginate. The wound was not staged. Record review of 'Pressure Skin Issues' form, dated 5/18/2022, revealed that Resident #102 coccyx wound measured length 5.0 X width 3.0 X depth 2.8 which is larger than previous measurements. The treatment was changed to Silver Alginate. The wound was not staged. Record review of 'Pressure Skin Issues' form, dated 5/25/2022, revealed that Resident #102 coccyx wound measured length 5.0 X width 3.0 X depth 2.8 which is larger than previous measurements. The treatment was changed to Silver Alginate. The wound was not staged. There were no measurements found for Resident #102 the week of 6/1/2022. There were no measurements found for Resident #102 the week of 6/8/2022. Record review of Resident #102's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of June 2022 revealed that the Silver Alginate treatment continued. Record review of Resident #102's 'Wound Management Detail Report', dated 6/17/2022 at 8:38 AM revealed Licensed Practical Nurse (LPN) A noted wound length 5 cm x width 2.5 cm x depth 2.5 cm with moderate exudates (drainage) of serosanguinous (pale red to pink, thin watery) consistency. The wound was staged as unstageable deep tissue with slough. Treatment was changed to Dakin's moist woven gauze, covered with a proximal and change daily. Record review of Resident #102's 'Wound Management Detail Report' dated 6/21/2022 at 1:23 PM, revealed that Licensed Practical Nurse (LPN) A noted wound length 5 cm x width 3 cm x depth 3 cm with heavy exudates (drainage) of seropurulent (yellow or tan, cloudy and thick) consistency with a very strong odor which smelled like BM (bowel movement). The wound was staged as unstageable deep tissue with slough and/or eschar. Comment noted: Wound significantly declined. Bottom of wound open. Area expanding from wound is not open, skin is grey looking. Open wound contains a large amount of black looking slough. Wound has a very heavy amount of drainage. Very strong odor also noted to area. Treatment was changed to Dakin's moist woven gauze, covered with a proximal and change twice daily. Record review of Resident #102's 'Wound Management Detail Report', dated 6/30/2022 at 9:56 AM, revealed Licensed Practical Nurse (LPN) A noted wound length 7 cm x width 5.6 cm x depth 3.2 cm with heavy exudates (drainage) of seropurulent (yellow or tan, cloudy and thick) consistency. A very strong odor, unstageable deep tissue with slough was noted. Record review of Resident #102's progress notes, dated 6/30/2022 at 10:03 AM, revealed new wound order to change dressing every shift. Record review of Resident #102's nursing progress notes, dated 7/1/2022 at 1:29 AM, revealed dressing changed to coccyx. Wound cleansed with normal saline, wound bed covered with black eschar, yellow tissue at the 3 o'clock position, packed per treatment order, proximal applied. Patient turned toward right side with pillows under her buttocks. Record review of Resident #102's nursing progress notes, dated 7/1/2022 at 9:27 AM, revealed that Resident #102 became lethargic and was sent out to the hospital. Record review was conducted on 1/20/2023 at 8:23 AM with Licensed Practical Nurse (LPN) A of the wound measurements records and reviewed by the state surveyor for the timeline of Resident #102's coccyx wound. The facility could not locate any wound measurements for 5/4/2022. Record review of the wound measurement's records revealed that there were no wound measurements located electronically nor in paper format for the week of 6/1/2022 and the week of 6/8/2022. No wound measurements were found until the week of 6/17/2022 when the treatment was changed. It was noted that the wound changed on 6/11/2022 with color of drainage, but nothing in the treatment changed. Licensed Practical Nurse (LPN) A stated that the Silver Alginate treatment was left in place too long from 5/11/2022 through 6/22/2022. Silver Alginate is a debride and was used too long. Licensed Practical Nurse (LPN) A stated that the floor nurses only have to acknowledge the wound location, dressing is dry and intact, but wound nurses only do measurements weekly. The facility did not have a wound nurse at that time and the unit manager was doing them, but then she retired, and no one picked them up and, as a result, a couple of weeks were missed.

Based on observation, interview and record review, the facility 1) Failed to prevent the development of one Stage 2 pressure ulcer (Stage 2 pressure ulcer- open shallow wound) and one Stage 3 pressure ulcer (full thickness skin loss - slough may be present but does not obscure the depth of tissue loss) for one resident (Resident #74), 2) Failed to cover a bleeding pressure ulcer for Resident #74, and 3) Failed to prevent the development of bilateral heel pressure ulcers for one resident (Resident #110) of three residents reviewed for pressure ulcers, resulting in a new uncovered bleeding right heel pressure ulcer and a new lower buttock pressure ulcer for Resident #74 and new bilateral heel pressure ulcers for Resident #110 with the likelihood of continued skin breakdown, infection and pain. Findings include: Resident #74: On 5/22/22, at 11:16 AM, Resident #74 was lying on their back with their heels on the bed. There were two padded heel boots lying on the floor. On 5/23/22, at 9:01 AM, Resident # 74 was lying in bed on their back. The heel boots remain on the floor and not on the resident. On 5/23/22, at 3:57 PM, Resident #74 is lying on their back with bilateral heel boots on. On 5/24/22, at 3:00 PM, Resident #74 is lying on their back with bilateral heel boots on. On 5/24/22, at 3:15 PM, a record review of Resident #74's medical record revealed a readmission on 8/31/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #74 required extensive assistance with all Activities of Daily Living and had severely impaired cognition. A review of the Treatment Administration History: 05/01/2022-05/25/2022 revealed No sting to darkened area on Rt. Heel. Once a day . Start/End Date 04/09/2022-05/25/2022 . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Once a day . 05/25/2022 A review of the PRESSURE SKIN ISSUES DATE: 5/18/22 revealed Resident #74 had three wounds on the log: Rightish (ischium) Coccyx Leftish There were no measurements for the right heel Stage 3 pressure ulcer nor the right lower buttock Stage 2 pressure ulcer. On 5/25/22, at 8:15 AM, Resident #74 is lying on their back with bilateral heel boots on. On 5/25/22, at 10:45 AM, an observation of Resident #74's skin was conducted along with CNA WW and Nurse SS. CNA WW removed bilateral heel boots that revealed a bloody open wound to their right heel. The wound was approximately 1 inch by 1 inch round open area. The wound had yellow stringy tissue hanging down about an inch long from the wound bed. There were six bloody areas noted to the bed sheet. The heel boot was grossly dirty with numerous areas that appeared to be dried bloody drainage. Nurse SS wiped no sting (a clear protective film) to the open wound. Nurse SS was asked why they applied that to the wound and Nurse SS stated, that is the order and now that it had opened back up they would call the doctor for a dressing order. Nurse SS was asked if it looked like there was slough to the wound and Nurse SS stated, yes. Nurse SS did not apply a dressing to the open wound. CNA WW reapplied the dirty heel boot to the open right heel wound. Resident #27 was then rolled to their left side with 100% staff assistance that revealed three border dressings and an open undressed area to the lower right buttock that measured approximately 1 centimeter (CM) long by 0.5 cm wide by 0.1 cm deep with the wound bed being a bright red appearance. Nurse SS provided treatment to the three dressed wounds, left the newer area undressed. Nurse SS was asked why there wasn't a dressing to the open area near the lower right buttock and Nurse SS stated, that is new one too and that they need to ask Unit Manger PP what to do. On 5/25/22, at 11:25 AM, the Director of Nursing (DON) was alerted the new pressure ulcers observed to the buttock and the heel of Resident #74. The DON was also alerted that Resident #74 was observed on their back for everyday of the survey and also the first two days without their heel boots on and the DON stated, maybe if you would have told me two days ago, we could have stopped the pressure ulcers. On 5/25/22, at 12:50 PM, an observation of Resident #74's right heel wound along with Unit Manager (UM) PP and Nurse SS was conducted. UM PP walked into the room carrying gloves, donned the gloves and removed the old dressing with no hand hygiene. UM PP reached down into the trash can to pull up the liner that had fallen down in the trash can then returned to the resident to assist in holding the foot up. Nurse SS measured the right heel wound resulting 2.2 cm wide by 1.8 cm long and 0.2 cm deep. Three-quarters of the wound bed had yellow slough (dead tissue) and the remaining a bright red. Nurse SS was asked if the right heel wound was better or worse and Nurse SS stated, worse, and offered that there was a history of [CONDITION(S)] prior but had been closed. UM PP was asked if the wound clinic was treating the wound and UM PP stated, no, we just found this. UM PP was asked if they saw slough and UM PP stated, yes. On 5/25/22, at 1:21 PM, A record review of Resident #74's hard chart at the nursing station was conducted to reveal no wound measurements and UM PP was asked to provide the wound measurements for Resident #74's wounds. A record review of the wound measurements and care plans for Resident #74 along with UM PP was conducted in their office. UM PP had numerous piles of documents on their desk. UM PP shuffled through the documents, wrote dates on top of the second page and provided. UM PP was asked to provide the wound care plan. A record review along with UM PP of the most recent wound care plan revealed the right heel closed on 12/21/21. UM PP was asked to provide the last 6 visits from the wound clinic for Resident #74 and a record review of the hard chart revealed only the after visit summary and did not contain the treatment provided or the treatment recommended. UM PP stated they would call the wound clinic and have the last six visit notes faxed to the facility. The notes were not offered prior to exiting the survey. On 5/25/22, at 2:42 PM, the DON was asked to provide all wound notes for Resident #74 including the wound clinic treatment notes. The DON was alerted there were no wound treatment notes in the hard chart. The wound clinic treatment notes were not provided prior to exiting the survey. Resident #110: During initial tour, Resident #110 was observed sitting in his wheelchair watching television. Both of his feet were resting on the bar of the bedside table. that was directly in front of him. Resident #110 stated he had wounds on both of heels and added that he wears his bilateral heel protectors when he is in bed. On 5/24/22 at approximately 7:50 AM, a review was completed of Resident #110's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #110 is cognitively intact and able to make his needs known. Further review revealed the following: Care Plan: Problem: Start date: 5/3/22 (Resident #110) is at risk for pressure ulcer R/T: history of pressure ulcers to bilateral heels: Right heel currently red/boggy; left heel has dark discoloration. Approach: .Conduct a systematic skin inspection with showers and prn .Use blue boots to relieve pressure on the heels while in bed . On 5/24/22 at approximately 4:30 PM, an interview was conducted with Nurse Manager R regarding Resident #110's wounds. Manager R reported the resident does not have any wounds that she is aware of. This writer and Manager R walked to Resident #110's room to observe his heels. The resident was sitting in his wheelchair with both feet resting on the foot pedals. On Resident #110's right heel was large brown/black in color wound, that covered most of his heel. His left heel was reddened and soft to the touch. Nurse T was at the medication cart by Resident #110's room and was asked if she was aware of the pressure ulcers on his bilateral heels. Nurse T reviewed her report sheet and stated she was not aware he had ulcers on his heels. Review of his chart was completed by Manager R who was able to find the initial progress notes regarding pressure ulcers upon admission but the last note regarding his wounds from nursing staff was on 5/2/22. Weekly wound notes, measurements and assessments were requested. Further record review was completed of Resident #110 and there were no weekly assessments of the wound after 5/2/22 by facility nurses, until this writer discussed it with the nurse manager on 5/24/22. It can also be noted the three nurses' notes that depicted the residents' wounds were inconsistent. At admission his wounds were classified as pressure ulcers, four days later they were classified as deep tissue injury, and after observation of the wounds on 5/24/22 Nurse T documented dried out blood blister on the right heel but did not mention the left heel. Progress notes: 4/28/22 at 20:33: Resident resting comfortably in bed at this time with no s/s pain or distress. Alert and pleasant .Left heel red and mushy. Right heel has a large brown area measuring 5.0 cm (W) x 6.0 cm (L). Soft cushion boots applied to both feet . 5/2/22 at 02:48: .Patient has bilateral deep issue injuries to bilateral heels and heel protectors are in place . 5/24/22 at 19:02: Examined and measured the dried out blood blister on the( R ) heel. Edges starting to lift. Peri wd intact with no signs of infection. Trace [CONDITION(S)] noted. Measured 4.5 x 6.0 no sting applied. Physician Notes: 5/2/2022: .While hospitalized he developed heel decubitus ulcerations, stage 1 on the left and stage II or the right . 5/9/2022: .He has two pressure ulcers, one on each heel . 5/11/2022: .Right heel stage 1 pressure ulcer. Left heel stage 2 pressure ulcer . Wound Management (section within medical record) - There are no wound type identified for this resident at this time. On 5/25/22 at 8:42 AM, an interview was conducted with Nurse Manager R regarding Resident #110 bilateral heel pressure ulcers. Manager R reported she misspoke the day prior, as she was aware the resident had the heel wounds. She expressed he admitted with the wounds, the physician documented as such and there were care planned interventions. A discussion was held with Manager R regarding the failure of staff to assess the wounds weekly and have consistent documentation. The notes of the inconsistent charting were reviewed with the manager, and she expressed understanding of the concern. On 5/25/22 at 10:25 AM, an interview was conducted with the DON (Director of Nursing) regarding wound documentation. The DON reported they do not currently have a wound nurse but weekly, the Nurse Manager and an assigned nurse complete weekly wound measurements/assessments of the residents on their specific unit. On 5/25/22 at 4:10 PM, the Pressure Skin Issues, document was provided. Resident #110's name was not listed as having wounds until 5/24/22. Nurse Manager R was queried if there were other weekly sheets that proved his wounds were being assessed weekly. Manager R stated there were not and explained they were focused on his orthostatic blood pressure, and this must have been overlooked.

This Citation pertains to Intake Number MI 591. Based on interview and record review, the facility failed to 1) prevent the development of five pressure ulcers; 2) assess and monitor the pressure ulcers; 3) implement appropriate interventions timely and 4) prevent infection for one (Resident #815 ) of three residents reviewed for pressure ulcers, resulting in the development of pressure ulcers to bilateral heels, bilateral buttocks, a Stage 4 pressure ulcer to their coccyx, [DIAGNOSES REDACTED] (bone infection) of both feet and coccyx and the need for hospitalization , IV antibiotics and surgery. Finding include. On 11/4/20, at 1:00 PM, a record review of Resident #815's electronic medical record revealed an admission on 7/16/20 with a readmission on 7/29/20 with [DIAGNOSES REDACTED]. Resident #815 required extensive 2 Person assistance with activities of daily living (ADL's) and had impaired cognition. Resident was discharged to the hospital on [DATE] for continued high temperature. A review of the admission skin assessment 7/29/20 . skin no open areas to note . A review of the admission Braden Scale for Predicting Pressure Sore Risk 7/29/2020 . At Risk . A review of the skin care plans revealed the following: Potential for Impaired Skin Integrity Date 7-30-2020 . Goal Skin integrity will not be impaired . Interventions . Braden Score - 15 Visual head to skin checks every shift and complete shower sheet . Maintain repositioning program while in bed: Every 2 hours . Pressure relieving devices: Pillows As pt will allow Heel boots Pressure relieving devices: Bed Air Chair Roho . Review Date 8/11/20 . Date 8/13/20 . open area R & L buttock 9/12 coccyx open area . Goal (no) pain (no) infection . FYI (for your information) Res. Often turns onto back after positioning on side . Interventions . Elevate heels off bed using appropriate Positioning device Pillow/boots turn and reposition while in bed 2 (hour) PRN (as needed) . There were no physician orders or date of implementation on the care plan for the air bed and roho cushion. A review of the wound notes from admission to discharge revealed the following: Wound Location: Coccyx Date/Time Identified: 09/12/2020 . Present on admission/Re-entry? No . Date/Time Observed: 09/12/2020 . Length . centimeters 6 Width . 7 can depth be measured? No . Percent of wound covered by slough (dead) tissue 50 . 09/16/2020 . Length . 6 Width . 5 Depth . 0.5 . Percent of wound covered by slough tissue 50 . 09/22/2020 . Length . 6 Width . 4 Depth . 0.5 . wound healing status: Improving . 10/01/2020 . Length . 6 Width . 4 Depth . 1 . Exudate color [MEDICAL CONDITION] (tan, yellow, green or brown in color. It's never normal in a wound bed, and indicated infection) . 10/06/2020 . Length . 6.5 Width . 4 Depth . 2.5 . wound odor . Malodorous (smelling unpleasant) . Stage IV (4) . Wound Type: Pressure Ulcer Wound Location: Right buttock Date/Time Identified: 08/13/2020 . Present on Admission . No . Length 1.5 (centimeters) . Width . 1.5 Depth . 0.1 . Date/Time Observed: 10/06/2020 . Length . 1.5 Width . 1.5 . Depth . 0.1 . Wound Type: Pressure Ulcer . Location: Left buttock Date/Time Identified: 08/13/2020 . Present on admission . No . Length 1 centimeters Width . 0.7 Depth 0.2 . Date/Time Observed: 10/06/2020 . Length . 1 Width . 0.5 . Depth 0.1 . A review of the progress notes revealed the following: 10/01/2020 04:45 (4:45 am) COCCYX WOUND: . changed dressing to coccyx this morning. Purulent (pus) drainage, irregular wound edges . Measurements . 6 x (by) 4 x 1 cm (centimeter) deep. Temp 99.0 . 10/1/2020 10:23 SEVERE [MEDICAL CONDITION]: Writer was informed this AM that the pt's Hgb (hemoglobin) came back and it's 6.6. Writer notified (physician --) and Dr ordered to have the pt be transfused . will continue to monitor pt . There was no notification to the physician of the purulent/pus drainage of the wound. 10/05/2020 10:50 FEVER: Pt has been running a temp on and off for the last few days . contacted (physician) and Dr gave order to check for UA, culture wound to coccyx, chest x-ray . There were no progress notes for the dates of 10/4/20 and 10/3/20. The doctor was still not notified of the purulent drainage found in the wound 5 days earlier. 10/06/2020 10:00 (Physician S) notified. Resident continues to have a temp of 100.6. New order to send to hospital for evaluation . A review of the Resident #815's temperatures revealed they had been running a temperature on and off for seven days. 09/30/2020 06:26 (6:26 AM) Temperature: 99.6 . 100.1 . 10/1/2020 . 99.0 . 10/06/2020 101.6 . Upon further review of the wound notes, skin assessments, bath/shower worksheets and progress notes revealed no assessment or acknowledgment of the bilateral heel pressure ulcers the resident had on admission to the hospital. A review of the hospital records for Resident #815 revealed the following: ED provider notes . Comments: Stage 4 decubitus ulcer that is 5 cm in diameter . coccyx . Diagnosis: [REDACTED]. rule [MEDICAL CONDITION] Condition: guarded . Wound Culture . Coccyx Collected 10/06/20 . Resulted: 10/11/20 . Rare Staphylococcus aureus Comment: [MEDICAL CONDITION] Resistant(MRSA/antibiotic resistance bacteria) . Extremities: b/l (bilateral) heels with necrosis (dead tissue) . Skin: Stage 4 sacral ulcer (coccyx) . BONE IMG (imaging) - OSTEO[DIAGNOSES REDACTED] . Indication: Pain osteo[DIAGNOSES REDACTED] . Impression: Findings appear to correspond to [DIAGNOSES REDACTED] of the left aspect of the sacrum (coccyx) , lateral malleolus (ankle) of the right ankle, and posterior calcaneus (heel) of the left. 10/09/2020 . OPERATION PERFORMED: Excisional Debridement of stage IV Sacral decubitus ulcer ANESTHESIA: General endotracheal . Discharge Summary . 10/19/2020 . Discharge Diagnosis: [REDACTED]. Decubitus of heel, bilateral . [DIAGNOSES REDACTED] - IV abx (antibiotics) . On 11/5/20, at 9:40 AM, the Director of Nursing (DON) was asked who is responsible for turning and repositioning the resident and the DON stated, the cena's (nurse aides) are and the nurse is responsible for making sure. On 11/5/20, at 1:00 PM, a phone interview with Unit Manager (UM) T was conducted regarding Resident #815's stay. UM T stated that they were keeping track of the wound and that they had a specialty low loss air mattress since admission. UM T was asked why they didn't update the care plan with additional interventions after noting the resident would roll onto their back and UM T stated, I wouldn't have changed it to every 1 hour, every 2 hours was good. The UM T further stated that they did not assess their heels and did not know they had pressure ulcers on their heels. UM T was alerted the resident's coccyx wound was infected and the resident had [DIAGNOSES REDACTED] upon admission to the hospital and the UM T stated, his skin was good when he came in and further stated when you have an incontinent resident with a coccyx wound it is always a challenge to keep the dressing clean and dry. On 11/5/20, at 1:30 PM, a phone interview with Physician S was conducted. Physician S was asked if they assessed the coccyx wound and Physician S stated, No. Physically I didn't look at the coccyx. Physician S was asked if they assessed the bilateral heel pressure ulcers and Physician S stated, the heel ones I was aware. I did give orders for them. Physician S was alerted that there were no progress notes, assessments or orders noted in the electronic medical record of the bilateral heel wounds and Physician S stated that the wounds were the biggest issue for the stay in the facility. On 11/5/20, at 2:00 PM, the facility provided policy change in patient condition: early response Revised 4/13 revealed . Criteria Guidelines for Initiating Physician Call: Staff member worried . Temperature greater than 100.4 Fahrenheit . A review of the facility provided policy Assessment: Nursing Revised 1/17 revealed To identify patient/resident needs at time of admission and throughout hospitalization . To provide individualized care . To provide for written plan of care, implementation of interventions and positive outcomes . A review of the facility provided policy Skin Care Protocol for Prevention of Pressure Ulcers Revised February 2008 revealed Any resident identified at risk for skin breakdown will have the following interventions implemented: Initiate and individualize prevention care plan. Evaluate and update the care plan as need arises . Initiate individualized repositioning and turning schedule and weight shifting program . A review of the facility provided policy Skin Care Treatment Protocol Pressure Ulcers . Revised February 2008 revealed All residents will be given the necessary preventive measures to prevent the development of pressure ulcers. A resident with pressure ulcers will receive necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing .

This Citation pertains to Intake Number MI 631. Based on observation, interview and record review, the facility failed to assess and monitor the PEG tube insertion site for one resident (Resident #21), resulting in Resident #21 complaining of pain and discomfort and requiring hospitalization and antibiotic therapy for an infection of the PEG tube site. Findings include: Record review of Resident #21's Minimum Data Set (MDS), dated [DATE], (5 day assessment) revealed an middle aged female with medical [DIAGNOSES REDACTED]. A Brief Interview of Mental Status noted 15 out of 15, cognitively intact. Pain assessment noted occasionally painful. Resident #21 weight of 71 pounds with difficulty with swallowing, mechanical altered diet. From 5/25/2020 through 7/22/2020 Resident #21 resided on the Wheels short-term rehab unit. On 7/22/2020 Resident #21 was transferred to the Garden long term care unit. Record review of Resident #21's electronic medical record progress notes, dated 6/24/2020 at 6:29 PM, revealed: Resident returned from having peg tube placed, is having discomfort at site, prn (as needed) [MEDICATION NAME] given at 5:56 PM. Resident did tolerate procedure well, per procedure nurse. May start using peg in 4 hours, around 8:30 PM. There was no noted observation of peg tube site noted upon return to facility with a description of the skin color (pink, red, or bruised) or if swelling at the site noted. Record review of Resident #21's 'Focused Observation' assessment note, dated 6/24/2020 at 6:44 AM, did not note the peg tube insertion site. The next 'Focused Observation' dated 6/25/2020 at 6:33 AM noted pain and discomfort in LLQ (Left Lower Quadrant) related to new peg tube placement. The facility printed off 'Focused Observation' notes from 6/23/2020 through 7/24/2020 at 1:56 AM. Record review of Resident #21's nursing progress note dated 7/2/2020 at 3:16 AM revealed the resident complained of pain at peg tube site and was given pain medication. Was no description of the skin color (pink, red, or bruised) or if swelling at the site noted. Record review of Resident #21's nursing progress note, dated 7/5/2020 at 4:07 PM, revealed: Prn (as needed) [MEDICATION NAME] (pain medication) given at 1:05 PM for generalized pain and peg site insertion site discomfort. Site is without s/s of infection, still just very tender to touch when cleansed Record review of Resident #21's nursing progress note, dated 7/8/2020 at 11:56 AM, revealed: Resident stated she has been having chills. Staff took resident's temperature and noted that her temperature was 101.0. Staff stated that when auscultating her lungs, they were clear in bilateral lung fields. Resident states that it hurts when she breaths in. Writer notified (physician) and resident to have a chest x-ray done Record review of Resident #21's nursing progress note, dated 7/8/2020 at 9:35 PM, revealed x-ray results show no apparent acute cardiopulmonary process. Record review of Resident #21's nursing progress note, dated 7/10/2020 at 4:38 PM, revealed a temperature of 100.9. Record review of Resident #21's nursing progress note, dated 7/14/2020 at 4:28 PM, noted .peg site remains tender to touch, slight redness around site . prn (as needed) [MEDICATION NAME] given for complaints of peg tube site pain. Record review of Resident #21's nursing progress note dated 7/18/2020 at 3:19 AM noted . new peg tube was placed and there is some redness around peg site . Record review of Resident #21's nursing progress note, dated 7/19/2020 at 1:53 AM, noted . new peg tube was placed and there is some redness around peg site . (Resident) complaining of discomfort in stomach and nausea. Writer held tube feeding due to intolerance at this time. Record review of Resident #21's 'Peg Feeding' observation information sheet, dated recorded 7/19/2020 at 11:44 PM, revealed residual of 100 mg and signs and symptoms of intolerance of nausea and pain noted by the nurse. Record review of Resident #21's nursing progress not,e dated 7/19/2020 at 7:13 PM, noted .there is small amount of drainage on old split gauze from around peg site and surrounding skin is slightly pink and tender to touch. Resident has continued to complain of increased discomfort/pain around peg site and when resident eats anything she states her stomach feels very full and some discomfort. Area around peg site when palpated is slightly firm, feels like it is the mushroom that is holding the peg in place. Will leave voice mail with dietician about possibly lowering rate of feeding and inform on coming shift that possibly x-ray may be in order to verify nothing unusual around site in abdomen In an interview on 9/2/2020 at 9:00 AM, Registered Nurse (RN) N was asked what was meant by the peg tube was mushrooming on the 7/19/2020 progress note? RN N stated: She (Resident #21) had a peg tube put into her abdomen, we call the disc that is attached to the tube feeding under the skin a mushroom. That internal disc felt like it was the only thing holding the tube feeding tube in place. Some tubes have a balloon that inflates, and some have a soft disc under the skin on the tube that holds the tube in place. Occasionally she had drainage and irritation from healing. Her stomach was always tender to her because it was new. Record review of Resident #21's nursing progress note, dated 7/22/2020 at 4:30 PM, noted resident was transferred to the Garden unit. Record review of Resident #21's nursing progress note, dated 7/25/2020 at 2:24 PM, noted peg tube patient, 0 ml residual noted at 9:00 AM and 20 ml noted at 1:00 PM. Nurten 2.0, 250 ml bolus at 9:00 AM, Gave 50 ml bolus at 1:00 PM related to resident stated felt full and nauseated Record review of Resident #21's 'Tube Feeding' observation information sheet, dated 7/25/2020 at 2:43 PM, by Licensed Practical Nurse (LPN) R revealed sign and symptoms of intolerance of nausea. Record review of Resident #21's nursing progress note, dated 7/25/2020 at 2:39 PM by LPN R, noted: PRN (as needed) [MEDICATION NAME] 100 mg given for complaints of stomach and lower back pain . Record review of Resident #21's nursing progress note, dated 7/26/2020 at 8:01 PM by Licensed practical Nurse (LPN) R, revealed: PRN (as needed) [MEDICATION NAME] 100 mg given at 9:34 AM for general pain, effective. PRN [MEDICATION NAME] given at 3:34 PM for complaints of pain at peg site. Noted serosang (blood cells and clear serum fluid) drainage from site. Was able to visualize balloon at stoma site. RN assessed also and call was placed to doctor. In an interview on 9/3/2020 at 4:16 PM, Licensed Practical Nurse (LPN) R revealed: I had assisted her earlier in the day. She was fine at morning medication pass around 8 AM, took her meds crushed with pudding. I looked at her tube it was patient no residual or issues. She came to me and said 'look at this' showed me her tube site. it didn't look right. It looked like it was starting to protrude, it was under the skin. It was like the balloon part was starting to come through the hole in the stomach. It looked so drastic because she is so thin. She said that it was sore, painful. There was drainage at the site. I had the RN Tierra come and look at the site. Tierra said that it looked like it was coming out. We called the doctor and sent her to the hospital. I don't believe that she would pull on the tube. I am not sure what happened. The peg site was like the balloon was pushing up at the stoma hole. I would say not the tissue swollen, but the balloon itself was pushing up. i think it was pink at the edges. She was getting bolus tube feeding and oral foods during the day. Behaviors? No, I would say she is a little depressed but no physical behaviors that I have seen or heard about. Record review of Resident #21's nursing progress note, dated 7/26/2020 at 4:12 PM by Registered Nurse (RN) O, noted: New Order: (physician) was notified that residents peg tube balloon is protruding at the insertion site . Record review of Resident #21's nursing progress note, dated 7/26/2020 at 6:57 PM by Registered Nurse O, noted resident complained of severe pain at peg site. Physician notified and ordered for resident to be sent to hospital emergency room for evaluation. Resident transferred to hospital via ambulance at 6:55 PM. Family notified. In an interview on 9/3/2020 at 12:37 PM, Registered Nurse (RN) O stated that she was the desk nurse on 7/26/2020 when LPN R asked her to look at Resident #21. RN O stated that she went to Resident #21's room to assess her peg site. RN O stated she looked at the abdomen and saw the tube feeding balloon through the skin, it was not normal. RN O stated she thought that if the resident was in pain then let's send her out. RN O described a peg site that was red, swollen and you could see the roundness/shape of the balloon through the skin. In an interview and observation on 9/1/2020 at 9:20 AM with Resident #21 in room [ROOM NUMBER] on the Garden unit, observed resident up in wheelchair in room propelling around. Signs posted that no straws to be used for beverages. Resident #21 stated that she did have a tube feeding, but that it had fallen out. Resident #21 stated It (peg tube) was being used in July. I told them (Nurses) that I had pain at the tube site. They hooked it up and ran my feeding. And the next day it was bulging, and they ran the feeding again. On the third day it was popping out a little bit and it was painful. I was sent to the hospital. and while I was at the hospital the tube feeding fell out. The hospital told me it was infected, and I was started on antibiotics IV. I was in the hospital for a week. I told the nurses here (LTC facility) that it hurt when I was living on the Wheels unit I had stomach pain, it hurt more than when it first was put in, and they kept using it. From the Wheels unit I was moved to the Garden unit to this room and when I came here to this room, I also told them that it was hurting, they said that they were watching it. They kept using the peg tube, even when I complained. The hospital said that it was red and swollen when I got to the hospital. Record review of Resident #21's hospital record, dated from 7/26/2020 through 7/31/2020, revealed Emergency Department arrival on 7/26/2020 at 7:29 PM noted female brought to Emergency department for pain and redness around peg tube site. Patient had peg tube placed 5 weeks ago. Patient reports that for the past week, she has been experiencing increasing pain around the peg tube site, but that for the past 4 days, she does have excruciating pain whenever they try to use the peg tube, but that they have continued to use the peg tube anyway. She does admit to pain with any manipulation of the peg tube itself. Emergency Department Provider noted: Peg tube in place in left upper quadrant. The site around the peg tube is red and swollen, with purulent (yellow, green, or brown thick drainage) discharge, as pictured below. The end of the peg tube appears to be ballooning up, just underneath the skin. There is tenderness around the site of the peg tube, and pain with any manipulation of the tube. This patient is still symptomatic with peg tube malfunction with signs of infection and has not achieved medical stability for safe discharge from hospital. Concerns with adverse events like peritonitis/worsening infection may occur. We will proceed with medically necessary hospitalization due to the need for IV (intravenous) antibiotics and peg tube replacement . Diagnosis: [REDACTED].) Pain around peg tube site (3.) Peg tube malfunction.

This Citation pertains to Intake Number MI 309. Based on observation, interview and record review, the facility failed to adequately supervise two residents (Resident #27 & Resident #28) with known behaviors, Dementia, Anxiety and Mood Disorder of 3 residents reviewed for falls, resulting in a fall with a laceration, hospitalization and sutures, and the likelihood of a fall with injury and hospitalization due to fall preventive measures not being in place. Findings Include: Resident #28: Review of the Face Sheet, Minimum Data Set (dated ,[DATE]), Physician, Nurses and Social Worker progress notes dated [DATE] through [DATE], Care Plans and Hospital Records dated [DATE], revealed Resident #28 was [AGE] years-old, admitted to the facility on [DATE], had decreased cognition and was not able to make own healthcare decisions and was ambulatory with dependence on staff for all Activities of Daily Living (ADL's). The resident's [DIAGNOSES REDACTED]. The resident was living on the locked Dementia unit while at the facility. Review of Resident #28's Death Certificate dated [DATE], revealed she had deceased on [DATE], at the facility of Advanced Dementia. Review of the facility incident report dated [DATE], revealed Resident #28 was found on the floor of the dining room (Lighthouse Grill/Day Room/Dining Room) on [DATE] at 5:15 p.m. The facility concluded per video that Resident #28 was pushed by Resident #27, fell backward, and hit her head on the floor. The resident had walked into the dining room and Resident #27 walked over to her and pushed her down. Staff were in the dining room at the time. The resident received a laceration to the back of her head from falling and was transferred to the hospital emergency room (ER) for treatment. On [DATE], when this surveyor requested to view the video, the Director of Nursing said the facility had saved it, and it could be viewed. When this surveyor was at the facility on [DATE] and requested to see the video of the fall incident on [DATE], the DON said it had accidentally been erased. Review of the Nurses notes dated [DATE] at 6:02 p.m., stated Resident observed on floor in dayroom (also used as dining room). 2 cm x 3 cm laceration noted on back of her head. PCP (primary care giver) contacted received orders to send her to acute care for eval (evaluation) and tx (treatment). Review of the hospital records dated [DATE], revealed Resident #28 had been evaluated and treated for [REDACTED]. The resident received 8 sutures to the back of her head and was put on an antibiotic. The resident returned to the facility on [DATE]. Review of the Nurses notes dated [DATE] at 11:26 p.m., stated Resident returned from (Hospital) at 22:40 (10:40 p.m.) via ambulance, with serosanguineous drainage from the back of the head, with sutures uncovered. Resident has 8 sutures due to laceration. Resident #28's of progress notes dated [DATE] through [DATE], regarding agitation, wondering, crying, and moaning out is as follows: -On [DATE]: orientated x1 (to self only) and highly agitated. -On [DATE]: Decision to move patient to Great Lakes unit for her safety (wandering/exit seeking). -On [DATE]: Wandering around the unit. -On [DATE]: She may express paranoid thoughts as she wanders, such as, they're going to cut me in half, or they are killing other people; she may moan out frequently. -On [DATE]: Wander about the neighborhood; express anxiety that we are going to cut her i (in) half or kill her. -On [DATE]: Will wander in others room and will sometimes get upset and start crying when she is redirected. -On [DATE]: She wonders in and out of activities of the most of the time. (Resident #28) becomes upset and cries when she is being redirected at time. -On [DATE]: Followed for moderately severe dementia, Alzheimer's type. She may express often in high pitched whiny type voice that often starts with words, become repetitive then deteriorates into nonsense sounds. The understandable content reflects paranoid thought about killed or the killing of others and/or self-derogatory statements. Resident #28 had a history of [REDACTED]. During an interview done with a second surveyor on [DATE] at 10:00 a.m., Nursing Assistant/CNA U stated I seen (Resident #28) come into the dining room (on [DATE]) and (Resident #27) got up and pushed her, she fell to the ground. (Resident #28's) head was bleeding, she cried. (Resident #28) is a crier, (Resident #27) probably told her to be quiet (prior to this incident on [DATE]). Maybe we should of kept them apart; one is a wanderer and one is a screamer, one can get annoying and the one can get hit by the other residents. She (Resident #28) screamed out anytime, mostly all day; mostly all day she would breakout in cries, her cries were loud. She (Resident #27) did yell and tell her to be quite (prior to the incident on [DATE]). Maybe we could of watched her (Resident #28) more, (Resident #27) did end up getting a one-on-one. Staff should have kept them apart. During an interview done with a second surveyor on [DATE] at 10:20 a.m., Nurse, RN V stated she (Resident #28) was loud, she would cry most of the day. It was annoying, some residents would tell her to shut up, (Resident #27) was one of the residents who did tell her to shut up. I watched the tape (Video from the facilities camera, unavailable to surveyor); I was sitting at my desk, (Resident #27) wanders then walked in and sat down on a chair by the ice maker (in the dining room on [DATE]). (Resident #28) walked in the day room (also known as dining room) and (Resident #27) immediately walked out to her and pushed her down. (Resident #28) fell and started crying, it was deep (the back of the [MEDICAL CONDITION]); (Resident #27) pushed her with both hands. I only seen one CNA in the room (dining room on [DATE]), (Resident #27) walked right by her. She (Resident #27) came and would tell me I wish she (resident #28, prior to [DATE]) would shut up. I watched the video several times. Our whole unit could be supervised better. Review of facility baseline care plans and nursing care plans dated [DATE] to [DATE], revealed the resident had behaviors of wandering in other residents rooms, had anxiety, displayed feeling of being overwhelmed and would cry and moan while ambulating around the unit. No nursing or social worker care plan for these behaviors was found in the closed record, nothing was documented as interventions for staff due to the excessive crying and moaning. These behaviors confuse and up-set other residents with Dementia and require interventions from staff for the safety of all residents. During an interview done with a second surveyor on [DATE] at 11:30 a.m., Nurse Manager H stated She (Resident #28) cries periodically, yes I think it was a behavior for her. During an interview done on [DATE] at 12:13 p.m., Social Worker T stated Yes, she had a behavior of crying, whining. It would have been appropriate to have it (a care plan for crying & moaning behaviors) under Mood or Behavior care plan. Review of the facility Behavioral Management and Monitoring Program dated ,[DATE], revealed monitoring with staff interventions should have been put in place for Resident #28 due to the wandering, crying and moaning behaviors. The Behavioral Management Program stated Purpose: To identify those residents in need of a behavioral management program, to identify a resident's specific interventions to effectively redirect inappropriate behavior. Identified Resident: Continuously yell, scream (including excessive crying and moaning), or pace if these behaviors cause an impairment in functional capacity. Experience psychotic symptoms not exhibited as dangerous behaviors or as screaming, yelling, or pacing but to cause the resident distress or impairment in functional capacity. Additionally (the facility) shall also include those residents who exhibit: Behavioral symptoms which constitute a source of distress for the resident or represent a danger or threat to the resident or others regardless of their [DIAGNOSES REDACTED]. Exhibit behaviors which make it difficult to comply with State and Federal regulations. Review of the facility Nursing Care Plans, Extended Care Center policy #108.10 dated July, 2018, stated the purpose of care plans are a written integrated resident centered/individualized plan of care, each problem/[DIAGNOSES REDACTED]. All resident problems (including targeted behaviors of crying/wining) have a care plan with initialized interventions. Review of the Administrative Manual Bill of Rights policy dated ,[DATE], stated Each patient/resident will be free from verbal, sexual, physical (including being pushed down and receiving a laceration with 8 sutures) and mental abuse, corporal punishment and involuntary seclusion. No additional documentation was provided by the facility prior to exit. Resident #27: Record review of resident #27's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental status of out of 15, severe cognitive impairment. Medical [DIAGNOSES REDACTED]. Resident #27 was admitted to the facility in 2016. Resident #27 is followed by psych services. Record review of Resident #27's progress note dated [DATE] at 12:06 PM written by social worker T revealed: On [DATE] psych consult- Resident #27 presented with continued elated behaviors with bouts of being agitated, irritable. She often displayed hypomanic like episodes, especially in mid-afternoon. She tends to exit seek often carrying her coat or other clothing items with her. She may get very upset when redirected away from exit doors. She receives scheduled 3:00 PM dose of [MEDICATION NAME] (anti-anxiety medication) 0.5 mg oral for agitation which is often effective at helping reduce Resident #27's irritable mood and agitated behaviors. To further manage these hypomanic episodes [MEDICATION NAME] (anti-psychotic medication) 25 mg oral added to the 2:00 PM dose . Record review of Resident #27's progress note dated [DATE] at 2:51 PM written by social worker T revealed: On [DATE] psych consult- Nursing reports some increase in pacing, restlessness, agitation and irritability especially in mid-afternoon . [MEDICATION NAME] afternoon dose adjusted. [MEDICATION NAME] 100 mg poral at 2:00 PM. No other changes at this time . Record review of Resident #27's 'Fall Occurrence Report & Post Fall Worksheet' dated [DATE] at 5:25 PM revealed that Resident #27 was noted to be pulling away another residents walker when she fell Record review of Resident #27's progress note dated [DATE] at 9:53 AM written by social worker T revealed: On [DATE] psych consult- Resident #27 tends to sleep in. When awake she roams about the neighborhood aimlessly. She is more anxious in early afternoon . In an Interview [DATE] at 12:32 PM with Social Worker T on the Great Lakes Dementia care unit- Resident #27 is a busy body, but a [MEDICATION NAME] person. Yes, she has extra anxiety in the afternoons, and we added [MEDICATION NAME] (Anti-anxiety medication). We also added [MEDICATION NAME] (anti-psychotic medication).(NAME)has sundowning in the afternoons, her type of behavior is anxiety, more confusion, becomes busier, pacing, restlessness. Usually re-directable, we encourage activities in her room as interventions. She does get an afternoon dose of [MEDICATION NAME] and [MEDICATION NAME]. She has anxiety that builds almost to aggression, it's in my progress notes. Record review of Resident #27's 'Occurrence Reporting Worksheet' dated [DATE] at 5:15 PM (late afternoon) revealed that in the Great lakes (dementia unit) in the Light House day room, Resident #27 alert & oriented only to self, placed both of her hands on (Resident #28) shoulders and pushed her backwards causing her (Resident #28) to fall and hit her head. Record review of both Resident #28 and Resident #27's 'Occurrence Reporting Worksheet' dated [DATE], revealed that there were no witnesses to the incident. The Occurrence document was written by Registered Nurse V. In an interview on [DATE] at 10:20 AM with Registered Nurse RN V stated that she watched the video of the fall like 4 times. RN V stated that she saw Resident #27 walk into the day room, sat in a chair by the Ice machine. Then Resident #28 walked into the day room and Resident #27 stood up and went over to Resident #28 and put out her arms and pushed Resident #28 over. Yes, both were standing up. Resident #27 would come to my desk and say that 'I wish that they would shut her up (Resident #28). Resident #27 would be annoyed by the screaming/crying of resident #28. The surveyor asked about Resident #27's Behaviors? RN V stated that Resident #27 would have anxiety in the afternoons, anxious behaviors, she paces the hallways, passes out snacks, and pushes another resident's wheelchair around. Resident #27 has sundowning in the afternoon is a trigger for behaviors. The surveyor asked about Behaviors toward Resident #28. RN V stated that Resident #27 would come to me and say 'I wish someone would tell her to shut the hell up' . RN V stated that Resident #27 does get antianxiety [MEDICATION NAME] medication in the afternoon or she gets manic and restless. After the event of pushing Resident #28 down we put Resident #27 on one to one supervision. In an interview on [DATE]@9:40 AM with Certified Nurse Assistant (CNA) U, who worked the Great Lakes Dementia unit, the surveyor discussed resident to resident incident that occurred on [DATE] with Resident #28 and #27- CNA U stated that she was working that day. She saw Resident #28 come into the dining/day room and Resident #27 was sitting in the dining room. Resident #28 was talking to another resident, when Resident #27 got up from her chair and went over to Resident #28 and put both her hands out and pushed Resident #28 over. It was on the video of the dining room. Resident #27 has a history of wandering around the unit and would tell Resident #28 to shut-up because Resident #28 would cry/scream as a behavior. Resident #28's crying/screaming would upset other residents and they would say/tell her to shut-up. Resident #28 would scream/cry and the other residents would tell us staff to shut her up. Resident #28 would cry/scream loudly most of the day. Most residents would yell out to tell her to be quiet. Monitoring of the day rooms? staff are to monitor the day rooms, I was in the lighthouse dayroom on that day, I didn't have time to get to the resident before she fell . Resident #27 is restless in the afternoon and aggressive at times. Resident #27's reaction would be she would shout 'shut-up' at Resident #28. Record review of Resident #27's [DATE] progress notes revealed that there were no progress notes written by nursing or social services for 20 days from [DATE] through [DATE] the day of the incident. According to the Director of Nursing services the video of the dayroom was destroyed and not able to be viewed upon request for the day of [DATE]. Record review of the 'Great Lakes 1st shift 5-man Assignment Sheet' dated [DATE], revealed that there was no staff scheduled to be in the dayroom. Record review of Resident #27's psych progress note dated [DATE] revealed: Initially, (doctor) spoke with the nurse manager and the social worker is here and they both have informed me that the (Resident #27) is lately acting out strangely, especially when another resident is crying on the unit. She (Resident #27) went up and hit the resident and very assertive and aggressive and without provocation . In order to control her aggressive assertive behaviors, I have decided to add [MEDICATION NAME] (For bi-polar manic phase).

This citation pertains to Intake Number MI 514. Based on interview and record review, the facility is placed in Immediate Jeopardy due to the facility's 1) failure to do a complete assessment and monitor one resident's (Resident #257) new enteral Percutaneous Endoscopic Gastrostomy (PEG) tube feeding for feeding intolerance (nausea, vomiting/emesis, abdominal distention, tenderness/pain, bleeding inside the tube or at the tube site and residual feeding), 2) failure to discontinue or hold the resident's tube feeding upon signs and symptoms of feeding intolerance, and 3) failure to hold medications via tube administration upon evidence of a condition change. This deficient practice resulted in, 1) fluid (tube feeding contents, water flushes), air, and debris (blood and crushed medications) within the abdominal musculature (muscle within the abdomen), 2) abdominal distention and hardness with extreme pain, 3) kidney damage, 4) systemic [MEDICAL CONDITION] response syndrome (response to an infection, which may affect multiple organs), 5)[MEDICAL CONDITION] (immune system response to an infection), 6) peritonitis (inflammation of the peritoneum/abdominal wall), and 7) abdominal wall [MEDICAL CONDITION] (infection of the skin), further resulting in Total [MEDICATION NAME] Nutrition (TPN) (nutritional feeding given intravenously) being implemented, the placement of an abdominal drain to drain the fluid from the abdomen, IV antibiotics and an extended hospitalization . In addition to the serious harm referenced above, this deficient practice is likely to cause serious injury, serious harm, serious impairment and/or death to 12 other residents, who have feeding tubes in place. This Immediate Jeopardy began on [DATE] at 7:30 p.m., when, per interview done on [DATE] at 11:02 a.m., LPN [NAME] stated Resident #257 had an emesis. LPN [NAME] failed to document that a complete assessment was performed on Resident #257 after the resident had an emesis on [DATE] at 7:30 p.m. after having a new PEG tube put in that day (on [DATE]). The facility transferred the resident on [DATE], for a new PEG tube placement after the first one was pulled out at the facility. The hospital confirmed the new PEG tube placement by an x-ray, dated [DATE], prior to transferring the resident back to facility (on [DATE]). A review of the facility's physician's orders [REDACTED]. In an interview done on [DATE] at 11:02 a.m., LPN [NAME] stated that on [DATE] between 7:00 p.m. & 7:30 p.m., the resident had an emesis which was yellow in color. On [DATE], LPN [NAME] hung the residents tube feeding at 8:00 p.m., in spite of the earlier emesis. Per interview done on [DATE] at 11:02 a.m., LPN [NAME] stated that the resident had a second emesis (on [DATE]) between 11:00 p.m. and 11:30 p.m., which was yellow. On [DATE] at 12:43 a.m., LPN [NAME] documented the resident had a negative assessment with no tube feeding residual. On [DATE] at 6:47 a.m., LPN [NAME] documented the resident was, guarding and grimacing, tube feeding is bright pink in color (blood), 160 cc of residual, emesis x 2 this shift. LPN [NAME] called the residents primary physician (Physician J). There was no answer and a message was left. Per the Electronic Medication Administration Record [REDACTED]. On [DATE] at 7:15 am, LPN [NAME] documented Residents abdomen distended, BS (bowel sounds) x 4, (Physician J) notified and left message again (for the second time), awaiting for returned call and new orders. On [DATE] at 7:30 a.m. day shift nurses , LPN G and RN F, assessed the resident. LPN G documented, left upper quad distended Lg area around peg site hard and very painful. Noted in peg tubing bright red coloring (blood). On [DATE] at 8:30 a.m., the resident was transferred to the Emergency Department and did not return to the facility. The Immediate Jeopardy was identified on [DATE]. The Administrator and Director of Nursing were notified on [DATE] at 3:00 p.m. of the Immediate Jeopardy that began on [DATE] at 7:30 p.m., due to 1) the facility's failure to do a complete assessment and monitor one resident (Resident #257), who had a new PEG tube placed, 2) the facility's failure to discontinue the resident's tube feeding upon signs and/or symptoms of feeding intolerance, and the facility's failure to hold medications via the PEG tube when the resident had a change of condition. This led to Resident #257 being hospitalized due to the tube feeding contents going into the resident's abdomen, and severe infections with multiple system involvement. These deficient practices placed a total of twelve residents with tube feedings, out of a census of 192 residents, at risk for serious harm, including infections, severe pain, hospitalization and/or death. Findings Include: Reviews of the Face Sheet, Minimum Data Set (MDS) -dated [DATE], Physicians' notes, Nurses' notes and Social Service notes-dated [DATE] through [DATE], and Hospital records- dated [DATE] through [DATE], revealed that Resident #257, was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident was alert with confusion, non-ambulatory, and had a Foley catheter (urinary catheter), a PEG tube, and a [MEDICAL CONDITION] (artificial opening in neck for breathing) with a speaking valve. Resident #257 required total staff assistance with all Activities of Daily Living (ADL's). The resident's [DIAGNOSES REDACTED]. Resident #257 had a history of [REDACTED]. Prior to admission to the facility, Resident #257 was involved in a motor vehicle accident in (MONTH) (YEAR), which required multiple extensive post trauma surgeries. The resident was placed on a mechanical soft with honey thick fluids diet with a PEG tube placed for additional nutrition due to decreased intake). On [DATE], the PEG tube was pulled out and the resident was transferred to the hospital for another PEG tube to be placed. The resident returned to the facility with a new tube on the same day ([DATE]). Feeding tubes may become fully or partially dislodged, causing such problems as bleeding and gastrointestinal tract perforation. A new tube should be verified for placement at least each shift and as needed. The patient may complain of pain near or at the insertion site, heart rate and blood pressure may increase due to pain and there may be increased agitation and restlessness. American Nurse Today, Nurse Line, (MONTH) (YEAR) Vol 12 No 1 A review of the physician's orders [REDACTED]. Review of the facility Speech Therapy notes, dated [DATE], revealed the resident had difficulties with chewing and swallowing, and had a PEG tube for nutrition with a honey thick, mechanically altered diet. Review of the facility code status documentation, dated [DATE], revealed that Resident #257 had a full code status (CPR/Mechanical Ventilation, IV Hydration, Tube Feedings and hospitalization ). Review of nurse's note, dated [DATE] at 4:18 p.m., revealed sent to (Hospital) ER (emergency room ) per (ambulance) per Dr order DT/T (related to) (Family member) pulling out PEG tube out. Review of the resident's Hospital Record, dated [DATE], revealed presents to the emergency department after noticing (Resident #257) PEG tube was pulled, it was pulled around 1000 AM (10:00 a.m.). Patient appears to be in nontoxic in no acute distress. Abdomen is soft nontender. We were able to find out the patient had 18 French PEG tube, and this was replaced without any complications. [MEDICATION NAME] study (for feeding tube placement confirmation) performed does show there is adequate placement in the stomach. Patient was discharged back to (the facility). Review of the Hospital abdomen X-ray, dated [DATE], revealed Indication: Peg tube placement, Findings: The initial scout film shows a percutaneous gastrostomy tube (PEG tube) in place. The bowel gas pattern is within normal limits. Impression: Percutaneous gastrostomy tube is in the stomach. Review of a nurse's note, dated [DATE] at 5:30 p.m., revealed Resident return @ (at) 1730 (5:30 p.m.) with new 18 FR (18-inch French feeding tube), PEG tube placed in left upper quad of abd (abdomen). PEG checked for placement by auscultating, flushing and aspirating sm (small) amount of contents (stomach contents). PEG in place no redness, bleeding or pain at the site. P (after) meds (medications) given for back pain which were effective. Review of the physician's orders [REDACTED]. Levenox medication is used to thin the blood and to prevent a blood clot' which increases the chance of bleeding. Review of the resident's facility At Risk for Bleeding Care plan, dated [DATE], revealed staff were to be aware the resident received a blood thinner and monitor the resident for risk of increased bleeding (including bleeding at a PEG site and blood noted in the PEG tube). Review of the resident's facility Debility, Nutritional Care Plan' dated [DATE] and ,[DATE], revealed that the resident was to be repositioned every two hours by staff and stated Observe for s/s (signs & symptoms) tube feeding intolerance (nausea, vomiting, bright red colored tube feeding formula or red in tube, discomfort, pain & tenderness, abdominal distention and abdominal hardness and feeding residuals) and report abnormal findings to MD (Physician J or Medical Director K). Review of the resident's facility Pain Care Plan, dated [DATE], revealed Unrelieved pain is to be reported to the resident's physician ASAP (as soon as possible, including abdominal distention with pain). The resident's facility nurse's notes, dated [DATE] at 6:47 a.m. through [DATE] at 10:29 a.m., were reviewed and revealed as follows: -Nurse note, dated [DATE] at 6:47 a.m., stated Resident became agitated when giving meds via peg tube this shift, resident was guarding and grimacing, Tube feeding is bright pink in color, 160 cc of residual, emesis x 2 this shift, accucheck 290, given 6 units of insulin. VSS (vital signs), (Physician J) called no answer, left message at 0640 (6:40 a.m.), will continue to monitor and assess. Review of the resident's Electronic Medication Administration Record [REDACTED]. -Nurse note, dated [DATE] at 7:15 a.m., stated Residents abdomen is distended, bs (bowel sounds) are active x 4 (all quads), (Physician J) notified and left message again (the second call placed), awaiting for returned call and new orders. -Nurse note dated [DATE] at 10:29 a.m., and entered by LPN G, stated At 0730 (at 7:30 a.m.) resident awake and alert. Left upper abd quad (abdomen) distended. Lg (large) area around peg site hard and very painful. Noted in peg tubing bright red coloring (blood). VS (vital signs) stable, (Family member) at bed side wanted (Resident #257) to be sent to (Hospital). (Physician J) called times 2. Message left. Notified unit manager (Manager I). Resident sent to the ER per (ambulance) at 0830 (8:30 a.m.). A total of 650 cc's of tube feeding formula (65 cc's an hour for 10 hours) had infused from 8:00 p.m. (on [DATE]) to 6:00 a.m. (on [DATE]). Review of Resident #257's facility Tube Feeding Record, dated (MONTH) 2019, revealed (an arrow indicating up) 8P (an arrow indicating down) 6A, 65 ml x 10 (hours), total frequency of water flush (flushes of water before and after tube feedings and between medications) 7P-7A 450 (450 cc's). On [DATE], the 7 p.m.-to-7 am shift had documented that the resident had received a total of 939 cc's of fluid. During an interview done on [DATE] at 7:35 a.m., Unit Manager, RN I stated, She (the resident) got 10 to 20 cc's of flush before and after each med and the 650 cc's of feeding, 710 cc's at the least. During an interview done on [DATE] at 9:36 a.m., Nurse Educator DD stated You flush with 50 cc's before and after meds, and a minimum of 10 cc's between meds (100 cc of flush, 10 cc's between 3 medications and 650 cc's of feeding formula totals a minimum of 780 cc's the resident received via tube [DATE] through [DATE]). Review of a facility blank Administration of Enteral Tube Feeding Medication Competency Evaluation check-list, stated Using gravity install 50 ml of water into [DEVICE] port before and after medication. Assess Resident/Patient for tolerance, observe for emesis and seepage around the tube. Review of the Mobile Medical Response Patient Care Report, dated [DATE], revealed Pt. (patient, Resident #257) is found to have some bleeding coming from her peg tube, abdominal distention, pain abdominal upper left. Pt's abdomen on the left side appeared to be distended, and tender. Staff attempted to draw back on the feeding tube, and found blood mixed with tube feed. Pt's (Family Member #1) would like her taken to (Hospital) to be evaluated for the blood, pain, and distention. During an interview done on [DATE] at 11:02 a.m. (accompanied by a second surveyor), LPN [NAME] stated She (Resident #257) had one emesis during shift change at 7:00 p.m. to 7:30 p.m., it was yellow (bile-like). That's normal for a new tube placement. At approximately 11:00 p.m. to 11:30 p.m., (the resident) vomited again, it looked like yellow bile, liquidly. (The resident's) PEG tube was running all night so I thought it was ok to give (the resident) meds. I did give (the resident) most of (resident) meds, I couldn't give all of them, she started swatting at me, she was in pain, she was guarding and grimacing. I shut it (tube feeding) off (for the residents 6:00 a.m. medications, the feeding infused from 8:00 p.m. through 6:00 a.m.). I just noted her abdomen was distended and bowels sounds were active. I did check for placement; I just didn't chart it. I didn't put it (chart), but I did listen to her lungs. I thought you were supposed to give meds with 160 cc's of residual. In (MONTH) I was hired, I did get checked off on PEG tubes. I could of charted more, if you didn't chart it, you didn't do it. I did call (Physician J), I was trying to give (Physician J) time to call me back. I did know this was an emergency when I saw the blood (at 6:47 a.m.), I knew that something was wrong. I do think I should have tried to call the Medical Director (Physician K) after my phone call at 6:47 a.m. (to Physician J). No one talked to me about this, they (Unit Manager, RN I) told me my charting was alright. When this surveyor asked LPN [NAME] how often a resident with a new PEG tube should be assessed she stated, Like every hour you check your resident. Review of the Resident #257's facility Tube Feeding Record-Extended Care Center sheet, dated May, 2019, (reviewed by this surveyor and LPNE) revealed LPN [NAME] had documented on [DATE], that she had checked tube placement, residual, lungs sounds, bowel sounds, nasal/oral, head of bed, tube feeding set, and for accuracy of tube feeding formula. Review of Tube Feeding Record (,[DATE]) also had documentation by LPN [NAME] (a circle with a line through it) the resident had no signs & symptoms of feeding intolerance and an N (for no) to tube replacement. The resident had just come back from the hospital (on [DATE]) toward the end of day shift (7:00 a.m. to 7:00 p.m.) after having a new PEG tube put in. Also the resident had vomited more than once on second shift (7:00 p.m. to 7:00 a.m.), had abdominal distention with pain, and blood had been found in her PEG tube. Continued with the interview done on [DATE] at 11:02 a.m., LPN [NAME] was asked by this surveyor why she had documented on the resident's Tube Feeding Record on [DATE], that her PEG tube was not replaced when the resident did have a new one put in (on [DATE]), and why she documented the resident had no signs/symptoms of feeding intolerance. LPN [NAME] told this surveyor she had documented on the resident's Tube Feeding record before the shift was over stating, about, around 3:00 a.m. or 4:00 a.m., I did it before my shift was over and forgot to go back and change it. During the second interview done on [DATE] at 9:46 a.m. (accompanied by a second surveyor), LPN [NAME] stated I started the tube feeding at 9:30 p.m., I started it late because she was having emesis, she had an emesis at shift change (7:00 p.m. shift change) and (at) 7:15 p.m. and a smaller one at about 8:30 p.m., it was yellow fluid, bile-like (now a total of 3 emesis are reported by LPN G). I started it because previously (while employed at another facility) when I took care of a fresh tube (new PEG tube), they had a little emesis. When they had emesis, I would call the doctor and they would say hold it and monitor and start it if ok; I would not do that again. On [DATE], at 7:00 p.m. and 7:30 p.m. she (the resident) had a emesis, at 8:00 p.m. an emesis, I hung the tube feeding at 9:30 p.m., I got rid of the tube feeding (discontinued it) between 6:30 a.m. and 6:45 a.m. (per this interview the resident's feeding was running at 65 an hour for 9 hours to 9 hours and 15 minutes). I never dealt with blood in the PEG tube. When I saw her belly distended (charted distended abdomen at 7:15 a.m.), yes, I did think it was a medical emergency. Maybe I should read the care plans a little more. There was two nurses in the front hall (on the same unit), I did not call them. I saved the residual for the nurse (LPN G) in a cup, she said she thought it was blood. I didn't call the doctor, but it was shift change, I was running around. It was really busy. It's stressful when I can't get a hold of (Physician J), I don't know who I can call and who I don't call. I don't like drama and I felt like that was drama. I asked (the facility Medical Director/Physician K) one time and I did not feel comfortable calling him. I am sorry but I am telling the truth; (Physician K) can be very sarcastic with me. As a nurse I feel very uncomfortable going to him. I am trying to further my career and I do not need nothing on my license. I am human, this is a lesson learned for me, I have to tighten up on my charting, sometimes you just get laxed. I am doing what I have to do here. LPN [NAME] said during her facility orientation they did not go through tube feeding in depth because, the other girl was an RN and she (Nurse Educator, RN DD) knew I had been an LPN for a while (for [AGE] years). I felt like I had to learn all over again because I did not have a lot of hands-on experience (with tube feedings). There were inconsistencies in LPN E's interview statements from [DATE] to [DATE]; her recall of the events and details had changed. When this surveyor asked her why the number of times the resident had an emesis from [DATE] on second shift through [DATE] had changed and why the times of when she started the resident's tube feeding changed, she had no answer. During an interview done on [DATE] at 9:46 a.m., LPN G stated I came in (on [DATE], 7:00 a.m. to 7:00 p.m. shift) and the nurse (LPN E) told me in report that (Resident #257's) tube feeding got disconnected (stopped) at 6:00 a.m. She told me that it looked like Pepto-Bismol (blood and tube feeding formula mixed) when she took apart the tube. She said it started coming through the tube itself. She (the resident) was laying there and had some grimacing going on, she let me see her tube. I touched it, barley brushed my hand and she screamed, you could see distended on the left side (of the resident's abdomen), about an inch higher then the right side. The distention was like a circle around with a little shelf under her breast. In the PEG tube itself was red, it looked like it (the blood) was mixed with feeding, I assume it was blood. Then (Family Member FF) came in, I told her what was going on, the third shift nurse (LPN E) had told me she had called the doctor. If the doctor does not answer, we are supposed to call the manager (Unit Manager I) or the Medical Director (Physician K). When I called and talked to (the Unit Manager I), I told her it was a new PEG, and this is what's going on right now. I wasn't happy about it, I just couldn't believe it, I just wanted to get her out (to the hospital). I think she (LPN E) should have tried a little harder, it's posted all over the desk, it says her (unit manager I) cell phone, the on-call cell phone and the doctors and the DON's number (Director of Nursing). We have all talked about calling the Medical Director or Manager in nurses' meetings recently. There is no excuse I can think of for this nurse (LPN E). I know she was new (hired in ,[DATE]), but she had taken care of her before. If she didn't feel comfortable, she should have grabbed another nurse or the Medical Director. The other nurses said they didn't know how to take her (LPN E), how she does things, like how she takes care of people. We did not get education on tube feedings after the situation (on [DATE]). During the second interview done on [DATE] at 10:42 a.m., LPN G stated When I came on, I wanted to get her (the resident) out (to the hospital). Her abdominal was miss-shaped and she had pain; she screamed, and she never screams. I think most of it (the tube feeding formula) went in because of how distended she was. During an interview done on [DATE] at 12:36 p.m., Unit Manager I stated For a new tube (PEG tube), assessment would be, check site, check placement, bowel sounds, if emesis I would call the doctor right away. I would of held the meds because you got a problem, it's a brand-new PEG tube, you got grimacing and the red drainage, the blood. If you know there is an issue, if they call the doctor and they don't call back, I would of called the Medical Director. I would give it 5 minutes, if I didn't hear from the doctor. My nursing judgement, I would of sent (the resident) out (transferred to the hospital) earlier, I would of called the Medical Director right away, yes it was an emergency. Review of the Enteral Feeding Education (un-dated) given to this surveyor as part of the facility abatement staff education stated that signs and symptoms of feeding intolerance were nausea, diarrhea, aspiration, emesis, distention, cramps, pain. During an interview done on [DATE] at 10:29 a.m., RN H stated I work days, I came in on the eleventh ([DATE]), (LPN G) called me and said she wanted me to come back for a minute (to the resident's room). She said something's not right. She said the hospital had placed it (the resident's PEG tube) correctly. I walked in the room (Family Member FF) was in there. The resident looked like she was in discomfort, it was distended around the PEG tube about an inch or two out, it was noticeable. I touched it and it was hard as a rock, she was grimacing while I was touching it. We tried to get residual (LPN G and RN H), there was a blood clot at the distal end of the tube, nearest to the abdomen. She was moaning at the time. I then told (LPN G) I was going to call (Physician J) and get her evaluated. We sent her out right away. If you don't get a hold of a doctor, we are told to call the Medical Director, he always answers. I would have checked for residual, placement, tenderness, lung sounds, GI (gastrointestinal) all quads, vitals and I would not have given meds if there was abnormal. She (LPN E) needs to be educated on PEG tubes. She should of used nursing judgement, when she seen the blood coming out, she should of never given the meds and I would of got a hold of somebody. Hospital Records dated [DATE] through [DATE], are as follows: -Date: [DATE], ED (Emergency Department) notes: Radiology Report, reported that there was a large collection of fluid, air, and debris within the patient's abdominal musculature (muscle area in abdominal area). Further, the PEG tube was in the abdominal musculature as well. General surgery, we should remove the PEG tube and place NG (nasal gastric tube, tube from the nose to the stomach) to low intermittent suction. Diagnosis: [REDACTED]. The resident was admitted to the hospital for further evaluation and advanced care. -Date: [DATE], CT Abdomen/pelvis, Findings: PEG tube identified with the bowel situated in the extraperitoneal compartment of the abdominal wall, within the rectus muscle sheath (muscles located in the abdominal region, made up of internal and external abdominal oblique muscles). Collection of fluid, debris and oral contrast is present within the extraperitoneal compartment of the ventral abdominal wall (in the resident's abdomen, not the stomach). Interstitial [MEDICAL CONDITION] and fluid are present with the muscular abdominal wall. 1. Dislodged PEG tube with prolonged situated (dislodged tube for an extended time) within the left rectus muscle sheath, and likely represent examination of feeding tube contents, hematoma (collection of old blood) and air. -Date: [DATE], Physician Consultation, (Resident #257) is having some pain over the left rectus sheath area with some drainage of some kind of serous bloody type material out of the PEG tube site. -Date: [DATE], Physician Consultation, Reason for consultation: acute kidney injury. (Resident #257) was evaluated in the emergency room and was found to have a displaced PEG tube with extravasation into the anterior abdominal wall. Assessment and Plan: Acute kidney injury, most likely acute tubular necrosis (damage to the kidney cells) in the setting [MEDICAL CONDITION] (immune system response to an infection throughout the body).[MEDICAL CONDITION] with systemic [MEDICAL CONDITION] response syndrome (body's response to an infectious insult, may affect multiple organs). Likely source is the displaced percutaneous (through the skin) endoscopic gastrostomy tube (PEG tube) and abdominal wall infection. Chronic [MEDICAL CONDITION]. Patient is ventilator dependent, with a [MEDICAL CONDITION]. -Date: [DATE], Physician Consultation, Problem: [MEDICAL CONDITION], Peritonitis (inflammation, infection of abdomen), [MEDICAL CONDITION] (infection of tissue), Sirs (systemic [MEDICAL CONDITION] response syndrome, in response to infection). The hospital administered IV (intravenous) antibiotics and consulted Infectious Disease. -Date: [DATE], Physician Consultation, (Resident #257) does have an elevated white blood cell count at 26.04 (normal=4.5 to 11.0, usually indicates infection), we will try to get all of this (fluid in the residents abdomen) to drain and watch (resident) very closely. -Date: [DATE], Physician Consultation Note, Infectious Disease adjusted medications and diagnosed with [REDACTED]. Patient was lethargic throughout exam however at times did follow simple one-step commands. [MEDICAL CONDITION] in place, Foley catheter intact, TPN infusing (Total [MEDICATION NAME] Nutrition, nutritional feeding given intravenously). -Date: [DATE], Left rectus sheath fluid collection secondary to a malpositioned gastrostomy tube. The hospital placed a drainage catheter in the residents left abdominal area for the drainage of the abdominal fluid. Extremely thick, dark red fluid most likely represents blood clot and will be markedly difficult to drain percutaneously. Procedure Specimens Removal: 80 ml dark red, thick fluid. During an interview done on [DATE] at 10:10 a.m., RN M stated If you can't get a hold of the doctor, you wait about 5 minutes and call again. Call the manager or the on-call person. You can also get orders from the Medical Director to send out. She (LPN E) should have been checking her (the resident's) bowel sounds, (residents) placement, I wouldn't of waited until the next shift that's for sure. The DON told us to call her and she would call the Medial Director. I have not worked with her (LPN E) but I get report from her, she say's I didn't get this done, she is very vague, that's not good. During an interview done on [DATE] at 12:04 p.m., RN F stated With something serious as that, you can call the Medical Director. With (the resident) being skilled, we are supposed to do a head-to-toe assessment. We can call (the DON) anytime, she does not get mad. During an interview done on [DATE] at 7:10 a.m., the MDS Coordinator, RN Z stated She (LPN E) should have checked for placement before she hung the feeding (at 8:00 p.m.). As a standard of practice, she should have documented it. During an interview done on [DATE] at 9:36 a.m., Nurse Educator DD stated, Our checklist has every little steps for tube feeding, do this, this and this; they (nurses during orientation) take it on the floor. Educator, RN DD informed this surveyor that she was not able to locate LPN E's orientation checklist that had documentation that she had demonstrated the correct procedure for PEG tube flushes, tube feedings and medication administration via the tube. Educator DD said she did not have the required tube feeding equipment available during LPN E's orientation for her to demonstrate tube feeding competency. I would put it in my nurse's notes, how they (resident's) are tolerating; they (nurses) do need to check for residual too. I would have called the doctor if she would had vomited (per interview done on [DATE] and [DATE] with LPN [NAME] the resident vomited between 7:00 p.m. and 7:30 p.m.), she could have asked another nurse too. It should not have to be told; nurses should not have to be spoon feed. Use your judgement, call the doctor, It's common sense. I count on them (new nursing staff in orientation) to let me know if they don't understand. I don't know if they are doing it right every time, they need to let me know. They take the tube feeding medication competency (check-off) to the floor, they are supposed to come back to me. Review of the facility Core Orientation-Medical Rehab & LTC (Long Term Care), dated [DATE], with LPN E's signature stated, We did not have equipment to instruct new member, TF (tube feeding) machine. Review of the facility Education & Training Record, dated [DATE], with LPN E's signature on, stated Had no pump availability TF pump Review of the facility Enteral Tube Feeding policy, dated ,[DATE], given to this surveyor by the DON, stated Observe the resident for nausea, diarrhea, aspiration, distention, cramps or pain. All variances e.g. lack of patency, skin breakdown, and any signs of tube feed intolerance e.g. residual and/or chronic diarrhea shall be carted in the nurse's notes. Review of the facility Medication Via Feeding Tubes policy, dated ,[DATE], stated Assess patient/resident for tolerance, observe for emesis and seepage around tube. Review of the facility Change in Patient Condition policy, dated ,[DATE], given to this surveyor by the DON, stated A system is in place to provide an avenue to escalate concerns over changes in a patient's condition. Criteria: New onset of agitation, restlessness (the resident swatted LPN [NAME] when she was giving her meds via her tube and she displayed abdominal pain), Immediately implement treatment or diagnostic services as ordered. Review of the facility Assessment: Nursing policy, dated ,[DATE], given to this surveyor by the DON, stated Patient/resident

Based on observation, interview and record review, the facility 1) failed to ensure the proper transfer of a resident from the floor to the bed after a fall, 2) failed to report the occurrence of the fall to the nurse, 3) failed to assess the resident post fall and 4) failed to ensure that a STAT (immediate)-ordered x-ray was completed timely for one resident (Resident #136) of 13 residents reviewed for falls, resulting in a delay in assessment, evaluation, treatment and hospitalization after a fall, which caused a [MEDICAL CONDITION] to go undetected and untreated in a timely manner, further resulting in acute pain and a decrease in mobility. Findings include: A review of Resident #136's medical record revealed an admission into the facility on [DATE] with readmissions on 4/9/19 and 4/15/19 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment revealed that the Resident had severely impaired cognition and needed extensive assistance of a two-person physical assistance with bed mobility and dressing and was total dependant on a two person physical assist with transfers, toilet use and personal hygiene. A review of the facility document entitled, Fall Occurrence Report and Post Fall Worksheet for Resident #136, revealed: -Date and time of fall, 1/26/19 at 4:40 AM. -Location of fall in the Resident's room. - Fall resulted in injury, marked yes. -Type of injury sustained, marked other: Left shoulder pain. A review of the facility document entitled, Fall Summary Report For (Resident #136), prepared by Nurse AA, revealed the following: -This is a report regarding an incident on (MONTH) 26, 2019 at approximately 4:40a.m. when staff observed resident (#136) lying on the floor next to his bed on his right side. Resident was times one (one person assist) back into the bed . Later in the evening around 6:00p.m. the resident's son (name) informed staff that the resident was complaining of his left shoulder and wrist hurting and that resident was lying on his left side against the half rail and that maybe he was having some discomfort from that. Staff went immediately to assess resident and it was noted that resident was complaining of left shoulder pain upon movement. Call was placed to (Doctor) and an order was received to have an x-ray done to the left shoulder area . resident is a 2 assist with Maxi lift for transfers . Upon investigating the complaint of pain to the left should/wrist area it was reported by staff on (MONTH) 26, 2019 at approximately 6:00pm that the resident 'almost fell out of bed' early on (MONTH) 26, 2019 at approximately 4:40am . When talking with the CENA, (CNA PP) via phone who seen (Resident #136) at 4:40am, (CNA PP) stated that (Resident #136) did not fall out of bed that he almost fell out of bed that his legs were off the bed but his upper half of his body was on the bed still. I then asked him if he reported to the nurse and he stated that he did. When asking the nurse (name, Nurse TT) if she was reported about (Resident #136) falling out of bed she stated 'No, (CNA PP) only reported to me when I was warming up my soup that (Resident #136) almost fell out of the bed' . (CNA PP) yelled for (CNA QQ) to come down the (number) hall into (Resident #136's) room, when they walked into the room (the Resident) was observed on the floor on his right side of the bed . (CNA QQ) stated that after (CNA PP) and she asked (Resident) if he was alright, (CNA PP) asked her to lower the bed and she did and (CNA PP) picked (Resident) up off the floor and put him into bed . (CNA QQ) also stated the (CNA PP) then asked her who his nurse was and she told him (Nurse TT) and he stated ok and she then left to go answer call lights. I then asked her why she didn't inform (Nurse TT) of the fall and she stated she thought (CNA PP) was going to tell her. I then talked to the nurse (Nurse TT) and asked her if she was aware of any of this and she stated, 'no' . A review of the investigation report of a statement typed by Nurse RR, dated (MONTH) 26, 2019, revealed, At approximately 1750 (5:50 PM), I was at shred box on Nurse Station B, when I was approached by (room # of Resident #136's) son. He states, 'I think my dad lying on his arm, he's complaining of a lot of pain. Can someone reposition him?' I entered room and upon assessment, Resident arms were both lying directly next to his body in alignment. I touched his Left arm by wrist to pick it up to show son it wasn't under him. Resident grimaced and said, 'Ow ow ow!' I asked where he arm hurt. Resident pointed to left Shoulder. I stated, 'I can ask you Nurse if you can have some pain medication and put your arm up on a pillow. He shook his head. When I lifted arm for pillow. He again grimaced, 'Ow ow ow' . Resident Left Shoulder appears slightly different in appearance from Right, with noted grimacing and complaint of pain with movement and touch. 1820 (6:20 PM) (Doctor) notified and ordered received to continue Tylenol for pain and to Obtain left Shoulder X-Ray. (X-Ray Company Name) notified to complete X-Ray STAT. At 9AM (1/27/19) (X-Ray Company) had still not arrived and had been phoned twice, to which they said a STAT is usually 4 hr window, but they had other orders and we are first in line, should be half hour. (X-Ray Company) arrived 11am, Resident continued to complain of pain. Swelling noted at Left shoulder joint. 1300 (1:00 PM) X-ray conclusion: Acute Humerus Neck Fracture with mild displacement. 1320 (1:20 PM) (Doctor) ordered to Transfer to ER. Unable to reach Son x(times)4, messages left. 1420 (2:20 PM) Resident transferred (ambulance). A request to Unit Manager, Nurse I was made for progress notes regarding Resident #136's care during the occurrence on 1/26/17 and, upon deliverance, were reviewed. The following was revealed: -Patient Progress Notes, dated 1/26/19 at 18:48 (6:48 PM), Nurses Notes by Nurse RR, revealed, Resident lying in bed, complaining of pain in Left shoulder and arm with movement or touch. (Doctor) notified and new order received to obtain shoulder X-Ray continue Tylenol for pain. Order noted. -Patient Progress Notes, dated 1/26/19 at 21:22 (9:22 PM), CENA notes, revealed, pt (patient) complains of left shoulder pain pt keeps tugging at his catheter nurse notified -Patient Progress Notes, dated 1/27/19 at 11:15 (AM), Nurses Notes by Nurse RR, revealed, Resident continue to complain in Left shoulder Pain with movement. (X-Ray Company) called at 7am and 9:15 am. Technician arrived and completed X-ray at 1100 (11:00 AM). -Patient Progress Notes, dated 1/27/19 at 13:42 (1:42 PM), Nurses Notes by Nurse RR, revealed, Reviewed Left Shoulder X-ray results with (Doctor), conclusion Acute Humerus neck fracture. New order received to Transfer to Covenant ER . -Patient Progress Notes, dated 1/27/19 at 14:27 (2:47 PM), Nurses Notes by Nurse RR, revealed, Resident transferred to (ambulance service) at 1420 (2:40 PM). -Patient Progress Notes, dated 1/27/19 at 22:40 (10:40 PM), Nurses Notes by Nurse RR, revealed, Notified (Doctor) of Resident return from (Hospital) at 2115 (9:15 PM), and that they sent him with a Left arm sling and said he is not a surgical candidate. Reviewed currently on Tylenol for pain management. No new orders received . A review of Resident #136's X-Ray of the left shoulder, revealed: -Reason: Pain in Left Shoulder. -Examination: Shoulder Complete, Min 2V (two views), Left. -Results: There is a fracture involving the neck of the humerus with mild displacement. The humerus head remains articulating with the glenoid. There is diffuse osteopenia. -Conclusion: Acute humerus neck fracture. -Electronically signed on 1/27/19 at 1:00 PM. A review of Resident #136's care plan, dated 4/9/19, revealed, Problem/Need, Fall Risk/R/T (related to) [MEDICAL CONDITION](stroke), [MEDICAL CONDITION], non-ambulatory. Interventions included, Fall Risk assessment quarterly PRN (as needed) Transfer: x(times)2 assist Maxi (mechanical lift to assist in transfers). On 5/22/19 at 11:47 AM, an observation was made of Resident #136 lying in bed. The Resident had fall mats next to his bed. A call light was on the floor under the bed. The Resident was queried regarding any falls and stated, Yeah, once I rolled out the bed. I am supposed to call to get up. I want to get up now. On 5/24/19 at 1:32 PM, an interview was conducted with Unit Manager, Nurse AA and Unit Manager, Nurse I, regarding the incident and the Fall Summary Report of Resident #136's fall on 1/26/19. The Manager AA stated, We are on call on the weekends and that was my weekend to come in and I started the investigation. It occurred at 4:40 AM on (MONTH) 26th and the Resident complained of pain that evening on 1/26/19. (X-Ray Company) came in the next day. The x-ray was ordered at 18:20 (6:20 PM on 1/26/19) STAT. When she (Nurse RR) came in the morning (1/27/19) and the x-ray was not done, she called again. We were next in line. They came at 11:00 AM and did the x-ray. When queried why the x-ray company did not complete the x-ray STAT, the Manager AA stated, I have no idea why they didn't come stat. Manager AA stated, (CNA QQ) tells me she observed (Resident #136) on the floor when she went in to the room and (CNA PP) picked him up and put him on the bed . Once the Resident is on the floor, they have to go get the charge nurse. Unit Manager I stated, She (the Nurse) has to do an assessment before he is put back to bed. He was trying to reach over to the radio. He was hanging on the side of the bed with his left arm pinned. He thought she reported it. No one reported it. When queried regarding the STAT x-ray, Manager I stated, It's usually a four hour turn around. They should have come within 4 hours after. When queried regarding the Resident's transfer status at the time of the occurrence, Unit Manager I stated, He was a Maxi (mechanical lift device used to assist in transferring a resident) lift assist. On 5/30/19 at 9:15 AM, an interview with CNA QQ was conducted regarding the fall on 1/26/19 of Resident #136. The CNA stated, (CNA PP) called us in to help, we went in and (Resident #136) was laying on the floor. The other CNA that came in with me left. He (CNA PP) asked me to lower the bed. He put his arm around his back and the other around his legs. Like in a cradle and put him back into bed. When queried if CNA QQ was assigned care of Resident #136 during the occurrence on 1/26/19 at approximately 4:40 AM, the CNA stated, Yeah. When queried what the Resident's transfer status was at that time the CNA stated, Hoyer lift transfer when this happened. When queried why the Hoyer lift was not used to transfer the Resident back to bed, the CNA stated, I don't know. Just cuz he was close to the bed. When queried if the Nurse was informed, the CNA stated, No. Lights were on and he (CNA PP) asked who the Nurse was. I thought he was going to tell. He was my resident and I should have relayed the message to the Nurse. When queried if any conversation was conducted, with the Resident's nurse, of the Resident observed on the floor and the transfer back to bed without the Hoyer lift, the CNA stated, No not that night. When queried if CNA PP explain why the Resident was on the floor, the CNA responded, (CNA PP) said he was hanging on the side rail, hanging by the side rail, I believe. He said he was stuck between the rail and the bed. On 5/30/19 at 9:32 AM, a phone call was made to Nurse TT regarding the occurrence on 1/26/19 of Resident #136's fall, but there was no answer and a message left. The Nurse returned the call at 3:00 PM, but an interview was not able to be conducted prior to the exit of the survey. On 5/30/19 at 9:36 AM, an interview via phone was conducted with Manager UU of the x-ray service that the facility called for the x-ray of Resident #136's left shoulder to be completed. When queried regarding when the first call had been received for the x-ray, the Manager stated, On 1/26/19 at 6:30 PM. When queried if the order was STAT, the Manager stated, It was a STAT order. When queried how soon a STAT order is completed, the Manager stated, It depends on how many there are to do. There is no turn around time for STAT's. Depends on the weekend. They called again on 1/27/19 at 9:15 AM. When queried regarding the document entitled (X-Ray service name) Portable Diagnostic Services Agreement that revealed, X-Rays Ordered as STAT: Procedures ordered as STAT will be resulted and reported within 6 hours of receiving the order from the Facility barring unforeseen factors beyond our control (i.e Accidents, snow storms, etc.), the Manager stated, It was a weekend. On weekends we have limited staff. When queried if there was any documentation of adverse weather conditions, the Manager stated, I am not seeing any notes on weather conditions. I don't see anything specific, no. That's pretty much all they are doing on the weekends are STATS. Depends on how many STAT's are ordered before that one. When queried if the x-ray company informed the facility of the delay, the Manager stated, We don't call. They just get to them as soon as they can. When queried if the X-Ray Company doesn't or can't make it out in the 6 hour time span, as in the contract agreement, they do not inform the facility so the facility can make other arrangements, the Manager stated, Yeah, we don't (call). They get to them in the order they come in. On 5/30/19 at 11:48 AM, an interview was conducted with Unit Manager, Nurse I regarding the fall on 1/26/19 of Resident #136. I was not on at the time and (Nurse AA) started the investigation. I was notified that the Son complained (the Resident had) pain and an X-ray was ordered. Meanwhile a second shift CNA says (the Resident) had pain in his arm. Another CNA says 'don't you know he fell last night'. We didn't know what happened. No one reported that he fell the night before. The X-ray comes back positive for a fracture and we send him to the hospital for evaluation. They were unable to do surgery and he came back with a sling. (CNA PP) says he almost fell but his arm was still on the bed, feet off. (CNA PP) didn't think it was a fall. When queried when the Resident is lowered to the floor ., the Unit Manager stated, it's considered a fall. When queried regarding facility policy the Unit Manager stated, They should have reported it before getting him back in (to bed). Don't touch the patient until assessed by the Nurse. There was an improper transfer and did not report to the nurse. When queried if an assessment was done by Nurse TT, who was assigned care of the Resident at the time of the occurrence, the Unit Manager reviewed the Resident's medical record and stated, No assessment was documented at the time of the fall. The first note about an assessment was on 1/26/19 at 18:48 (6:48 PM) by (Nurse RR). On 5/30/19 at 12:10 PM, an interview was conducted with CNA PP regarding the fall on 1/26/19 of Resident #136. When queried regarding the incident, the CNA stated, I heard him (Resident #136) yelling. When I went in, I seen him hanging on the bed by his shoulder. The left side. He said he was stuck. He was in danger of falling so I put him on the floor. His arm was up against the rail, pinned with legs out of bed. I picked up the top part of his body to loosen his arm up and laid him on the floor. He was sitting up slightly against the bed and his weak side was drooping. His left side is his weak side. The left side what was stuck. It didn't look out of place and no pain. We lowered the bed and placed him back in in a laying position. I picked up his right arm and left leg to get him up. He put weight on his right foot. When queried why the lift was not used, the CNA stated, We had only three aides and a lot of work to do. When queried regarding the Resident's transfer status, the CNA stated, At the time I did not know what he was at that time. He wasn't my Resident. (CNA QQ) was his original care giver. I told her he was falling out of bed and I lowered him to the floor. When queried if he had reported the incident to the nurse the CNA stated, I seen her and told her he almost fell . Gave a brief summary and said he seemed fine. Once I told her what happened I kept going and doing my work. I didn't think it was a fall because only his legs were off the bed. I told (Nurse RR) that he was hurting and wondered if it was something that happened the night before. On 5/30/19 at 12:30, an interview with the Unit Manager, Nurse I continued regarding the fall on 1/26/19 of Resident #136. When queried regarding the x-ray order, the Unit Manager reviewed the order and stated, It wasn't put in as a STAT. A review of the conversation with the Manager of the x-ray company that indicated the order was called in as a STAT and the investigation statement by Nurse RR that the x-ray company was notified to complete x-ray as STAT, the Unit Manager stated, We wait the time for them to come out and get the x-ray. If it is a fracture, we send them out to be evaluated in ER (emergency room ) then the time is not wasted. A review of the agreement with the x-ray company of the 6 hours for a STAT to be completed and the conversation with the Manager of the x-ray company not notifying the facility that the time frame can not be reached, the Unit Manager stated, If their window is 6 hours, yes, of course they should let us know so the Nurse can get a hold of the doctor to see if we need to send them out to ER instead. A review of the facility document entitled, (X-Ray Company) Portable Diagnostic Services Agreement, dated 10/12/18 by the Facility and dated 10/26/18 by the Regional Sale Director, revealed, . (k) (X-Ray Company name) will provide facility with necessary reports (i.e TAT) on STAT/ASAP radiology orders as necessary for Facility to assure turn-around time requirements are met. (Exhibit B) . Exhibit B X-Rays Ordered As STAT: Procedures ordered as STAT will be resulted and reported within 6 hours of receiving the order from the Facility barring unforeseen factors beyond our control (i.e Accidents, snow storms, etc.)

Based on interview and record review, the facility failed to provide quality care and treatment for 2 (#1, #2) of 2 sampled residents, resulting in (1.) Resident #1 developing a stage III pressure ulcer of the coccyx, dehydration and urinary tract infection with hepatization; (2.) Resident #2 receiving three times the physician-prescribed dose of [MEDICATION NAME]([MEDICATION NAME] opioid medication) resulting in lethargy and need for oxygen and hepatization with the potential harm or death form overdose. Findings include: Record review of facility 'Assessment: Nursing' policy No. 102.11, revised date of 1/2017, revealed all residents will receive nursing care based on documented assessments of individual needs/problems. purpose (4.) to provide for monitoring and evaluation of care. Procedure: (4.) Resident needs will be reassessed when condition changes, but no less then every shift and quarterly. (5.) Assessments will include biophysical (biological structure and processes) . (7.) Residents nursing care will be based on identified nursing [DIAGNOSES REDACTED]. (10.) Nursing will collaborate with the Treatment Team/other disciplines to the resident needs and to promote positive outcomes. Resident #1: Record review of resident #1's Minimum Data Set (MDS) quarterly, dated 6/18/18, revealed an elderly female resident bed/wheelchair bound with bilateral lower extremity impairment. MDS section G- Functional Status noted the resident was total dependence with assist of one person for bed mobility, transfers, locomotion on and off the unit, and personal hygiene. MDS section J- Skin Conditions noted no unhealed pressure ulcers at stage I or higher noted and no venous or arterial ulcers noted. Medical [DIAGNOSES REDACTED]. Record review of Resident #1's 'Physical Assessment' notes, dated 8/22/18- Nursing assessment: Level of conscious- alert, Orientation- person, Speech- Clear, Pupils- equal, reactive, Grips- equal and strong, Emotional status- content, Behavior problems identified- No, Apical pulse-regular, Pacemaker-no, Right radial pulse-strong, left radial pulse- strong, Capillary refill- less than 3 seconds, Left lower ext.- none, Generalized [MEDICAL CONDITION]- none, ted hose-none, Auscultation- clear, bilateral, diminished, Cough- none, Trach- N/A, Suction- no, Oxygen- room air, GI- assist, Bowel sounds- WNL (within Normal limits), Last BM- 8/21/18, Voids- incontinent, urine- clear yellow, Note: Resident able to make needs known. Alert & oriented times 1. No complaint of pain at this time (There was no assessment or description of the coccyx area for redness or open areas) Record review of Resident #1's 'Physical Assessment' notes dated 8/23/18 by Registered Nurse (RN) E, Incontinent of bladder and bowel, small amount of stool, soft, with one person assist. Coccyx wound measuring 1.7 cm (Centimeter) X 1.5 cm X (with depth of) 0.1 cm (open wound) Wound bed pink, surrounding skin red and blanchable. New order to cleanse coccyx with normal saline, apply [MEDICATION NAME] AG, cover with [MEDICATION NAME] foam. Change every 3 days and PRN (as needed). Continue to turn every 2 hours and get out of bed daily. Family notified. No physician notification documented. Record review of Resident #1's 'Impaired skin Integrity' care plan dated 8/23/18 revealed open area to coccyx. Record review of Resident #1's 'Physical Assessment' notes dated 8/29/18 revealed coccyx wound changed per protocol with assistance. Length 1-inch X width 1-inch X depth 3 mm (Millimeter). Eschar (dark dead tissue) in center with pink edges. No odor or discharge. Brief changed, Sensicare (lotion) applied. Patient tolerated well. Patient repositioned, legs elevated, blue boots on. Daughter visiting. An interview on 3/21/19 at 3:45 PM with Registered Nurse (RN) E, while record reviewing wound flow sheets for Resident #1's coccyx wound, revealed that on 8/23/18 wound measurements were 1.7 cm (Centimeter) X 1.5 cm X (with depth of) 0.1 cm it's an open wound and would be stage II/III. RN E stated that the wound was found on 8/23/18 already open. Record review of Resident #1's 'Wound Assessment Flowsheet' undated but authored by RN E (she stated it was done on 8/23/18), revealed that the treatment nurse was not notified of wound. Record review of Resident #1's 'Wound Assessment Flowsheet' undated but authored by RN E (she stated it was done 8/27/18), revealed that the treatment nurse was not notified of wound. Record review of Resident #1's 'Wound Assessment Flowsheet' undated but authored by RN E (she stated it was done on 8/28/18), revealed that the treatment nurse was not notified of wound. Record review of Resident #1's 'Physical Assessment' dated 9/1/18 by the day shift nurse, revealed: Resident currently resting in bed. No complaints of pain. No signs/symptoms of distress. Call light within reach. Resident able to make needs known. Treatment to coccyx completed as per order. Wound bed is largely eschar with red edges. Will continue to monitor. Record review of Resident #1's 'Physical Assessment' dated 9/1/18 by the afternoon/night shift nurse, revealed: Resident has been lethargic during this shift. Residents oxygen level was 84% at 7:20 PM and put on 2.5 liters (oxygen) and came up to 97%. Her apical pulse (heart rate) was 41 (bradycardic). Doctor ordered to send to emergency room for evaluation and treatment. Daughter contacted by desk nurse. Awaiting MMR (ambulance) now. Record review of resident #1's physician progress notes [REDACTED]. Physical exam: skin- wound to lower extremity. There was no assessment of the coccyx wound identified on 8/23/18 and its increase in size on 8/29/18. Late chart entry dated 9/5/18 (4 days post event) at 8:26 AM by RN E (day shift nurse), noted doctor notified about resident being lethargic, not eating, minimal amount of fluid intake, apical pulse (heart rate) 41 (bradycardic) respiratory rate 22, oxygen level 84% on room air, 02 (oxygen) 97% 2 liters via NC (nasal cannula), blood pressure 105/67. New order send to hospital ER for eval and treat. Family notified Record review of Resident #1's hospital emergency room record dated 9/1/18 revealed decubitus ulcer that is grade 2-3. emergency room Diagnosis: [REDACTED]. Heart rate noted in the 40's. Resident #2: Record review of '20th Anniversary Edition, Davis's Drug Guide for Nurses', (Deglin/Vallerand) copy wright 2009, located at the Patriot nursing station within the facility, revealed on page 843, [MEDICATION NAME]/MS Contin- high alert medication, schedule II opioid [MEDICATION NAME], binds to opiate receptors in the central nervous system (CNS) and alters the perception of and response to painful stimuli while producing generalized central nervous system depression. Mostly metabolized by the liver and excreted renally (kidneys). Assess geriatric patients frequently, older adults are more sensitive to the effects of opioid [MEDICATION NAME] and may experience side effects and respiratory complications. Toxicity and overdose: If an opioid antagonist (antidote) are required to reverse respiratory depression or coma, [MEDICATION NAME] is the antidote. Record review of the Nursing (YEAR) Drug Handbook, (Wolters Kluwer) page 1610, emergency treatment of [REDACTED]. If there is still no response and additional doses are available, give 0.4 mg IM or subcutaneously or one spray of nasal spray every 2 or 3 minutes until emergency medical assistance arrives. Record review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE], revealed a [AGE] year-old female with a Brief Interview of Mental Status (BIMS) score of 12 out of 15, cognitive impairment. Functional status was assessed as extensive assistance needed with bed mobility, transfers and locomotion on and off unit, dressing and hygiene. Medical [DIAGNOSES REDACTED]. Pain assessment interview noted pain and a frequency of occasionally. Record review of Resident #2's 'Physical Assessment' notes, dated 10/1/18, revealed there to be no nurse documentation, only Certified Nursing Assistance documentation. Record review of Resident #2's Physical Assessment notes, dated 10/2/18 at 00:16 AM, by Licensed Practical Nurse (LPN) night shift noted: Alert & oriented X2 forgetfulness. Able to make needs known. Abdomen is soft and tender. Denies pain or SOB (shortness of breath). Record review of Resident #2's 'Physical Assessment' notes, dated 10/2/18 at 8:20 PM by LPN F, noted: Family reported to CNA that resident was not acting like herself, appeared to be jerking and not wanting to eat. Vitals taken and assessment done. Resident was jerking and responding to commands son commands but did not appear to be understanding, eyes were reactive to light, grips were equal and strong, resident was not acting like herself. Physician notified, new orders obtained for [MEDICATION NAME] 1 mg dose. Resident given dose, and reassessed. Resident was more awake and could follow simple commands and was alert to where she was and who was in her room. Resident will be continuously monitored through the night. Record review of Resident #2's medication record page 1-4, revealed [MEDICATION NAME] Sulf- ER (MS Contin) 30,mg tab every 12 hours oral, started on 9/19/18. Record review of the medication record revealed that on (MONTH) 1, (YEAR) at 10:05 AM the day shift Licensed Practical Nurse (LPN) I was noted to give 30 mg dose of [MEDICATION NAME]. That same day 10/1/18 at 8:38 PM, the night shift LPN gave another [MEDICATION NAME] 30 mg dose. The next day on 10/2/18 at 9:43 AM, LPN F gave another [MEDICATION NAME] 30 mg dose. Record review of Resident #2's [MEDICATION NAME] (MS Contin) narcotic count sign out sheet revealed on the date of 10/1/2018 Licensed Practical Nurse (LPN) I, signed out three (3) tablets of [MEDICATION NAME] 30 mg at 9:50 AM. (90 mg dose) On 10/1/18 at 8:30 PM the night shift LPN signed out one [MEDICATION NAME] 30 mg tablet. (Did not notice a discrepancy in the narcotic sign-out log) On 10/2/18 at 9:00 AM, LPN F signed out one [MEDICATION NAME] 30 mg tablet. In a phone interview on 3/21/19 at 3:08 PM, Licensed Practical Nurse (LPN) F, stated she was going through the end of her shift to check her narcotic count on 10/2/18. LPN F explained that day shift documents in blue or black ink and that night shift documents in red ink in the narcotic sign-out logs. LPN F stated that she saw blue ink signed out three times in a row for same day and same time. That alerted LPN F and she called physician H and got and order and gave [MEDICATION NAME] 0.4 mg. I expected her to come out it right away, she didn't, she was still lethargic. LPN F stated that she did not think that the Resident #2 was overdosed because there were no changes after the [MEDICATION NAME] was given. LPN F stated that Resident #2 had a standing order for oxygen and that she did not call the physician back for more [MEDICATION NAME] or to send the resident out to the hospital. Record review of Resident #2's 'Physical Assessment' note dated 10/2/18 at 8:35 PM by the night shift LPN, revealed: Telephone order given to (LPN F) to hold HS (bedtime) dose of [MEDICATION NAME] mg tab tonight. Record review of Resident #2's 'Physical Assessment' note dated 10/2/18 at 9:30 PM by the night shift LPN, revealed: Lethargy/movements jerky/restless. Vital signs stable. Taking medications orally without difficulty. Record review of Resident #2's 'Physical Assessment' note dated 10/2/18 at 4:07 AM by the night shift LPN, revealed: Doctor notified of elevated blood pressure and heart rate. no orders received. Record review of Resident #2's 'Physical Assessment' note dated 10/3/18 at 9:23 AM by the day shift Registered Nurse, revealed: Resident lying in bed, difficult to arouse, responds to pain, speech slurred assessment completed. Bilateral Breath sounds crackles thru out. Jerky movements observed with arms and upper body. Vital signs blood pressure 90/50, (pulse) 62-45, (respirations) 22, oxygen at 3 liters, oxygen saturation level 91-95%, 98.6. Unable to eat or drink. Doctor notified, order to send to the emergency room foe evaluation and treatment. Daughters notified. Record review of Resident #2's 'Patient Transfer Form', dated 10/3/18 at 8:56 AM, noted blood pressure of 90/50, pulse 62, Respiratory rate 22, temperature 98.6. Reason for transfer: Slow to respond. Received 90 mg of [MEDICATION NAME] AM (10/1/18) and 30 mg at bedtime. [MEDICATION NAME] on 10/2/18 AM. Jerking, abnormal vital signs, bilateral crackles, unable to eat or drink today. Record review of facility 'Medication Improvement Report' for Resident #2 dated 10/3/18, revealed resident received 90 mg [MEDICATION NAME] 10/1/18 at 9:50 AM, order is to be given 30 mg dose. (Discovered on 10/2/18 in the afternoon). Medication error event of wrong dose. Reason for medication error event gave wrong dosage- did not follow 5 rights of medication administration. Treatment needed was sent to hospital on [DATE]. Outcome of medication error event category F- An error occurred that resulted in initial/prolonged hospitalization and/or caused temporary patient harm. Record review of Resident #2's physician progress notes [REDACTED]. The physician assessment and plan: Continue the current program. Labs and medications reviewed. Resident is medically stable. Seems to be doing well given her advanced age and multiple medical comorbidities. Record review of Resident #2's emergency room hospital record, dated 10/3/18, revealed while waiting for admission bed placement, it was noted that Resident #2 was not as responsive as when she first arrived at the emergency room . Resident would respond to painful stimuli but would not respond to questions. Resident #2 was given [MEDICATION NAME] 0.1 mg IV and immediately woke up with this. It appears that resident was still under the influence of the [MEDICATION NAME] sulfate. Resident has suffered aspiration pneumonitis.

Based on interview and record review, the facility failed to prevent pressure ulcer development for 1 resident (#1) of 2 Residents reviewed for pressure ulcers, resulting in Resident #1 developing a stage III pressure ulcer of the coccyx/sacral region. Findings include: Record review of facility 'Assessment: Nursing' policy No. 102.11, revised date of 1/2017, revealed all residents will receive nursing care based on documented assessments of individual needs/problems. purpose (4.) to provide for monitoring and evaluation of care. Procedure: (4.) Resident needs will be reassessed when condition changes, but no less then every shift and quarterly. (5.) Assessments will include biophysical (biological structure and processes) . (7.) Residents nursing care will be based on identified nursing [DIAGNOSES REDACTED]. (10.) Nursing will collaborate with the Treatment Team/other disciplines to the resident needs and to promote positive outcomes. Record review of resident #1's Minimum Data Set (MDS) quarterly, dated 6/18/18, revealed an elderly female resident bed/wheelchair bound with bilateral lower extremity impairment. MDS section G- Functional Status noted the resident was total dependence with assist of one person for bed mobility, transfers, locomotion on and off the unit, and personal hygiene. MDS section J- Skin Conditions noted no unhealed pressure ulcers at stage I or higher noted and no venous or arterial ulcers noted. Medical [DIAGNOSES REDACTED]. Record review of Resident #1's 'Actual Pressure Area' care plan, dated 3/16/18, noted various treatments till 5/17/18 when resolved. Interventions in place (not Yellowed out or crossed out) included: air mattress to bed, profo boot right heel while in bed and therapy. Record review of Resident #1's 'Physical Assessment' notes, dated 8/15/18 through 9/1/18, revealed: 8/15/18 incontinent of bladder (would require observation of peri area and coccyx with clean area). 8/17/18 incontinent of bladder and bowel. Resident was noted to state that her right heel was sore, was hard and had a dark coloring to it. Boots were on. Added pillow under leg. Notified nurse of pain. 8/20/18 Injury risk assessment: No irregularities- chart review completed, no recommendations at this time. 8/22/18 Nursing assessment: Level of conscious- alert, Orientation- person, Speech- Clear, Pupils- equal, reactive, Grips- equal and strong, Emotional status- content, Behavior problems identified- No, Apical pulse-regular, Pacemaker-no, Right radial pulse-strong, left radial pulse- strong, Capillary refill- less than 3 seconds, Left lower ext.- none, Generalized [MEDICAL CONDITION]- none, ted hose-none, Auscultation- clear, bilateral, diminished, Cough- none, Trach- N/A, Suction- no, Oxygen- room air, GI- assist, Bowel sounds- WNL (within Normal limits), Last BM- 8/21/18, Voids- incontinent, urine- clear yellow, Note: Resident able to make needs known. Alert & oriented times 1. No complaint of pain at this time (There was no assessment or description of the coccyx area for redness or open areas) Record review of Resident #1's 'Physical Assessment' notes, dated 8/23/18 by Registered Nurse (RN) E, Incontinent of bladder and bowel, small amount of stool, soft, with one person assist. Coccyx wound measuring 1.7 cm (Centimeter) X 1.5 cm X (with depth of) 0.1 cm (open wound) Wound bed pink, surrounding skin red and blanchable. New order to cleanse coccyx with normal saline, apply [MEDICATION NAME] AG, cover with [MEDICATION NAME] foam. Change every 3 days and PRN (as needed). Continue to turn every 2 hours and get out of bed daily. Family notified. No physician notification documented. Record review of Resident #1's 'Impaired skin Integrity' care plan, dated 8/23/18, revealed open area to coccyx. Record review of Resident #1's 'Physical Assessment' notes, dated 8/27/18 by Registered Nurse (RN) E, Coccyx dressing dry & intact, no sting applied to right heel. Dark area noted to right heel and callused. Blue boots on BLE (Bilateral Lower Extremities), continue to reposition every 2 hours, encourage to get OOB (out of Bed) daily. Family at bedside. No physician notification documented. Record review of Resident #1's 'Physical Assessment' notes, dated 8/29/18, revealed coccyx wound changed per protocol with assistance. Length 1-inch X width 1-inch X depth 3 mm (Millimeter). Eschar (dark dead tissue) in center with pink edges. No odor or discharge. Brief changed, Sensicare (lotion) applied. Patient tolerated well. Patient repositioned, legs elevated, blue boots on. Daughter visiting. An interview on 3/21/19 at 3:45 PM with Registered Nurse (RN) E, while record reviewing wound flow sheets for Resident #1's coccyx wound, revealed that on 8/23/18 wound measurements 1.7 cm (Centimeter) X 1.5 cm X (with depth of) 0.1 cm it's an open wound and would be stage II/III. RN E stated that the wound was found on 8/23/18 already open. Record review of Resident #1's 'Wound Assessment Flowsheet' undated but authored by RN E (she stated it was done on 8/23/18), revealed that the treatment nurse was not notified of wound. Record review of Resident #1's 'Wound Assessment Flowsheet' undated but authored by RN E (she stated it was done 8/27/18), revealed that the treatment nurse was not notified of wound. Record review of Resident #1's 'Wound Assessment Flowsheet' undated but authored by RN E (she stated it was done on 8/28/18), revealed that the treatment nurse was not notified of wound. Record review of Resident #1's 'Physical Assessment' dated 9/1/18 by the day shift nurse, revealed: Resident currently resting in bed. No complaints of pain. No signs/symptoms of distress. Call light within reach. Resident able to make needs known. Treatment to coccyx completed as per order. Wound bed is largely eschar with red edges. Will continue to monitor. Record review of Resident #1's 'Physical Assessment', dated 9/1/18 by the afternoon/night shift nurse, revealed: Resident has been lethargic during this shift. Residents oxygen level was 84% at 7:20 PM and put on 2.5 liters (oxygen) and came up to 97%. Her apical pulse (heart rate) was 41 (bradycardic). Doctor ordered to send to emergency room for evaluation and treatment. Daughter contacted by desk nurse. Awaiting MMR (ambulance) now. Record review of resident #1's physician progress notes [REDACTED]. Physical exam: skin- wound to lower extremity. There was no assessment of the coccyx wound identified on 8/23/18 and its increase in size on 8/29/18. Late chart entry dated 9/5/18 (4 days post event) at 8:26 am by RN E (day shift nurse), noted doctor notified about resident being lethargic, not eating, minimal amount of fluid intake, apical pulse (heart rate) 41 (bradycardic) respiratory rate 22, oxygen level 84% on room air, 02 (oxygen) 97% 2 liters via NC (nasal cannula), blood pressure 105/67. New order send to hospital ER for eval and treat. Family notified Record review of Resident #1's hospital emergency room record, dated 9/1/18, revealed decubitus ulcer that is grade 2-3. emergency room Diagnosis: [REDACTED]. Heart rate noted in the 40's.

This citation pertains to intake MI 325. Based on observation, interview and record review, the facility failed to 1) ensure the proper supervision of 1 resident (sampled Resident #1), who had a known history of falls at the facility and who had been assessed to be impulsive, fell from her wheelchair to the floor, fracturing her left hip and 2) ensure safety devices (alarms) were functioning properly for supplemental Residents #5 and #6, of 4 residents reviewed for falls of a total of 4 sampled residents resulting in, the potential for falls, a fracture of the left hip, hospitalization , pain, and hip surgery with post surgical incision wound care. Findings Include: Due to the requirements of the Health Insurance Portability and Accountability Act (HIPPA), the findings in this report are limited. Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 4/27/17, physician note's dated 3/12/17, 3/23/17 and 3/31/17, nurses and social worker note's, dated 3/10/17 through 5/13/17, and hospital records, dated 3/10/17 through 5/11/17, revealed Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE], alert and able to make her own healthcare decisions, required staff assistance for care and transfers and had a history of [REDACTED]. Review of the hospital records, dated 4/8/17, revealed Resident #1 fell on [DATE] at the facility, was transferred to the hospital, fractured her left hip, had surgical repair of the hip on 4/5/17 and was transferred back to the facility on [DATE]. Review of the facilities Statement of Capacity, dated 3/12/17, revealed Resident #1 was her own person and made her own healthcare decisions. Review of Resident #1's Fall Risk Assessment, dated 3/15/17 (prior to her fall with hip fracture), revealed documentation that the resident was a 10 (10 or more score=high risk for falls). Review of Resident #1's Alteration in self-care care plan, dated 3/10/17, revealed she was a one-person assist for transfers prior to 4/8/17 (the day she returned from the hospital after her hip repair surgery). Review of the facility Fall Occurrence Report, dated 3/20/17, stated Resident was observed sitting on the floor in her room between the w/c (wheelchair) and bed. The resident stated she was trying to get into the bed without assistance, no injury. Internal risk factors, anxiety/attention seeking and stated that the Resident #1 was impulsive. Review of the Fall Occurrence Report (dated 3/20/17) revealed the resident was identified as being potential high risk for falls. Review of the facility Fall Occurrence Report, dated 3/26/17, stated The CENA (Nursing Assistant/CNA) was still in the room straightening; the resident leaned forward to reach for the bag in her closet and fell forward. The resident scraped her L (left) chin on the door of the closet, anxiety/attention seeking. Review of the Fall Occurrence Report (dated 3/20/17) revealed the resident was identified as being potential high risk for falls. Review of the facility Fall Occurrence Report dated, 4/3/17, stated The CENA (CNA, staff member F) was positioning the resident, getting ready to transfer. The resident stood without assistance and fell to the floor between the bed and wheelchair. The CENA was not in the transferring position with the gait belt yet, the resident abruptly stood unassisted. Resident is impulsive, does not always wait for assistance. Review of the nurses' notes, dated 4/4/17 (error in dating, was 4/3/17), stated called this nurse to room for assistance. Noted res. (Resident #1) lying on the floor with a pillow under her head. Res. put back to bed and this nurse assessed for injury. Res. complaining of left hip hurting, PCP (primary care practitioner, physician) called, orders received. Pelvic X-ray and B/L (bilateral) hip ordered. Medicated Res. with ordered pain meds. Review of the x-ray, dated 4/3/17, stated There is a left intertrochanteric fracture with modest angulation and displacement. The joint shows no dislocation. Review of the hospital Discharge Summary, dated 4/8/17, revealed Resident #1 fell at the facility on 4/3/17, was admitted to the hospital due to a fractured left hip, underwent hip surgery on 4/5/17 and was transferred back to the facility on [DATE]. During an interview done on 5/17/17 at 9:30 a.m., Resident #1 stated I can't tell you how it happened (her fall on 4/3/17), I never used a Hoyer (a mechanical lift). I was dropped by a couple of CNA's (Nursing Assistant's), they said they had me, they didn't have a gait belt on me. The resident was in her room in bed and did not want to get up. She was alert with confusion at the time of the interview and verbalized she was unable to completely recall her fall on 4/3/17. During an interview done on 5/17/17 at 8:40 a.m., staff member J (Nurse Manager, RN) revealed Resident #1 was a one-person assist prior to her fall on 4/3/17, and stated she (the resident) was never a lift (mechanical lift), she was a one-person transfer and now after her fall (on 4/3/17), she is a two-person transfer. No one ever dropped her. During an interview done on 5/17/17 at 1:20 p.m., staff member B (Director of Nursing/DON) stated she was a one-person transfer and she stood up from her wheelchair and fell , the aide (staff member F) was with her behind her. An interview was done on 5/17/17 at 10:36 a.m., with staff member F (Nursing Assistant/CNA), accompanied by staff member J (Nurse Manager, RN). During the interview, staff member F stated she (Resident #1) was a one assist, she was weak on the left side. She was really ready to get up, she tried to get up and I told her not yet and I sat her back down. I got in front of her and put her in her wheelchair, I took her to the bathroom. I took the gait belt off, then she said she wanted to go back to bed. I had her by the bed positional bar (the resident was sitting in her wheelchair next to the head of her bed near the bed positional bar), she started to get up, I was standing behind her. She stood up and I put my hand up and she feel flat on her butt. I put her (the resident) in the corner (in the corner of the residents room, near the front of the bed) because I thought it would make her feel safe and she would not fall out of her wheelchair (if the resident started to slip out of her wheelchair, the wall would prevent her from falling). I was not checked off by a nurse for transfers before working the floor. I was written up because she was positioned wrong and the gait belt was not on her. Staff member F put the resident who was sitting in her wheelchair without a gait belt on, in the corner of her room and was standing behind her wheelchair when she stood up and feel to the floor, fracturing her left hip. Resident #1 was put in an unsafe position (in the corner of her room), had a known history of falls at the facility and of being impulsive when she stood up and fell . Staff member F was unable to prevent the fall because she was behind the resident's wheelchair. Review of staff member F's Performance Improvement Plan, dated 4/27/17, stated failed to follow the care card on proper transfer of a resident and revealed she was educated by staff member K (Nurse Manager, RN) on proper resident transfer techniques. Review of Review of staff member F's facility orientation documentation, dated 3/10/17, revealed no documentation of being educated on or of a return demonstration of resident transfers (other then mechanical lifts). During an interview done on 5/17/17 at 12:03 p.m., staff member D (Nurse Educator, RN) informed this surveyor that during new CNA employee's orientation she did not educate nor observe return demonstrations of resident transfer techniques and stated I use to do competencies (return demonstrations of resident transfer techniques) on them (new CNA employees) on gait belt transfers myself. When this surveyor asked staff member D why she did not include education with a return demonstration of resident transfer techniques in her orientation of new CNA's, she had no answer. During an interview done on 5/17/17 at 1:05 p.m., staff member E (Rehab CNA) stated I worked with her (staff member F), we did transfers after, all types of transfers, after the resident fell (on 4/3/17). During the facility tour accompanied by staff members M (Nurse Manager, RN) and J (Nurse Manager, RN) done on 5/17/17, from 7:20 a.m. through 8:15 a.m., the following was observed: -At 7:45 a.m., supplemental Resident #5 was observed in her room laying in bed with his bed alarm disabled. This surveyor found the resident's bed alarm sitting in his room bathroom on the sink. During an interview done on 5/17/17 at 7:45 a.m., staff member M (Nurse Manager, RN) stated it (the residents bed alarm) should have been on (in working condition). During an interview done on 5/17/17 at 7:50 a.m., staff member G (CNA) stated I didn't notice (the resident's alarm was not functional), I didn't make it to that room. Review of supplemental Resident #5's Resident Care Card, dated 2/16/17 and Fall Risk care plan dated 12/6/17, revealed he was to have a wheelchair and bed alarm in place due to being assessed to be a high risk for falls. -At 8:10 a.m., supplemental Resident #6 was observed in the dining room sitting in her wheelchair with her chair alarm not in working condition, the battery door was open, disabling the alarm. During an interview done on 5/17/17 at 8:10 a.m., staff member J (Nurse Manager, RN) revealed the resident's alarm should have been working, immediately closed the alarms battery door and said all the CNA's should check their residents at the beginning of their shift (7:00 a.m.). During an interview done on 5/17/17 at 8:15 a.m., staff member H (CNA) stated I didn't see the resident. Review of supplemental Resident #6's Fall care plan, dated 4/21/17, revealed she was to have bed and wheelchair alarms. Review of the facilities CENA Guidelines # 114.3, dated 11/04, revealed the CNA's is expected to, demonstrate knowledge and use of good body mechanics (including resident transfers) while performing resident care including transfers. Review of the facility Fall Prevention policy #120.16, dated 6/28/17, stated Staff will be inserviced on a regular basis regarding causative factors associated with falls and the Fall Prevention Program will be a regular part of new employee orientation. Review of the facility Fall Prevention policy #120.16, dated 6/28/17, stated It is the policy of (the facility) Extended Care Program to identify and treat the fall risk potential for each individual resident by virtue of implementation of it's Fall Prevention Program. Purpose: To assure that (the facility) meets it's obligation to maintain resident safety to the greatest practicable extent, thus assuring compliance with Michigan Licensing Regulations.

Based on interview and record review, the facility failed to assess and monitor hydration status for 1 (sampled Resident #2) of 4 residents review for hydration of a total sample of 5 residents, resulting in dehydration and hospitalization . Findings Include: Due to the requirements of the Health Insurance Portability and Accountability Act (HIPPA), the findings in this report are limited. Assessment data should be collected if there is a change in a patients condition, a new on-set of symptoms, monitoring existing conditions or if there is if there is complaints of discomfort or pain. A complete data collection results when the nurse has obtained all the information (through an assessment) relevant to the actual or potential health problem. Inaccurate data results if the nurse fails to collect information that is relevant to a specific area (including hydration). (Fundamentals of Nursing Concepts, Process, and Practice, Patricia A. Potter, Anne G. Perry, Mosby 1985) Review of sampled Resident #2's clinical record revealed she was a [AGE] year old female, admitted to the facility on [DATE], cognitively impaired with a BIMS (brief interview of mental status) of 6 (severely cognitively impaired), non-ambulatory and dependent on staff for all activities of daily living (ADL's). The resident's [DIAGNOSES REDACTED]. Resident #2 was transferred to the hospital on [DATE], had surgery and deceased at the hospital on [DATE]. Review of the hospital emergency department records dated [DATE], stated that the resident was diagnosed with [REDACTED]. Review of hospital records dated [DATE], a physician consultation stated The patient is a [AGE] year old female who presented to the ED (emergency department) yesterday ([DATE]) from (the facility), she was noted to be dehydrated, ill appearing and having loose stools. Review of the facility Advance Directives dated [DATE], revealed Resident #2 had checked yes for IV (intravenous) Hydration. The resident had requested IV hydration if needed. Review of Resident #2's Altered Nutrition care plan dated ,[DATE], revealed she required assist with feeding and stated observe for s/s (signs and symptoms) fluid imbalance and report abnormal findings to MD. Signs and symptoms of dehydration are, dry mouth and skin, skin turgor (elastic, non-elastic or tenting-dehydration), sleepiness, increased thirst, decreased urine output, urine color and consistency, decrease fluid intake, decreased blood pressure, increase heart rate, increased breathing and [MEDICAL CONDITION]. ( Oxford Textbook of Palliative Medicine, 1995, The Family Practice Desk Reference, Mosby, 1995) Nursing staff assess and monitor residents for dehydration as indicated by weight changes, skin and oral mucosa status, fluid intake and output, oral intake, increased thirst, cognitive changes, vital sign changes (blood pressure, pulse and respiration) and labs. (Medical Surgical Nursing, Long, Phipps, Second Edition, 1989) Review of the Clinical Nutrition assessment dated [DATE], stated reports appetite/oral intakes been poor since surgery (prior to admission to the facility). The resident required assist and encouragement with her meals. Review of the Clinical Nutrition assessment dated [DATE], stated oral intakes since admission have been fair to poor, needs assistance with meals (including hydration). Review of Resident #2's Patient Progress Note's/Vital Signs, Nursing Assistant/CNA's note's dated [DATE] through [DATE], revealed no intake was documented on [DATE], [DATE], [DATE], [DATE] and on [DATE]. Review of the resident's electronic record and chart, revealed Resident #2 had a Foley catheter in place, no IV or access line for fluids and had her feeding tube removed prior to facility admission, all of her fluid intake was PO (oral). Review of the residents Nutrition assessment dated [DATE] and care plan dated [DATE], revealed the resident required assistance and encouragement with her oral intake which placed her at risk for dehydration and staff were to assess and monitor her for signs/symptoms of dehydration. Accurate and complete oral intake is required to assess and monitor for fluid intake and hydration status. Review of the residents Patient Progress note's/oral intake dated [DATE] through [DATE], revealed missing documentation of meal consumed (% of meals taken) on [DATE], [DATE], [DATE]/16, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the residents facility Bowel Movement Record dated [DATE] through [DATE], revealed she had loose stools on [DATE] M (medium) LO (loose stool), on [DATE], 3 loose stools, on [DATE] Lg (large) LO (loose stool), and on [DATE] S (small) LO (loose stool). A total of 4 days the resident had loose stools which increased the risk of dehydration due to fluid loss. Review of the Patient Progress Notes/Physical Assessment (nurse's notes) dated [DATE] through [DATE], revealed a total of 8 days with no documentation of a complete nursing hydration assessment done to monitor for dehydration. Review of nurse's note dated [DATE], stated small emesis, which increase the risk of dehydration due to fluid loss. Review of Wound Assessment Lowest (nursing wound, skin and hydration assessments) dated [DATE] through [DATE], revealed a total of 6 incomplete hydration assessments on [DATE] (no skin turgor documented and no indication of dry skin or not), on [DATE] (no skin turgor documented), on [DATE] (no skin turgor & no indication of dry skin or not), on [DATE] (no skin turgor documented and no indication of dry skin or not), on [DATE] (no skin turgor documented) and on [DATE] (no skin turgor documented and no indication of dry skin or not). Review of staff member G (Primary facility physician, DO) Progress Note's dated [DATE] (the day the resident was transferred to the hospital) stated (Resident #2) is seen in medical follow-up regarding change in condition. A few days ago, she had few episodes of nausea and vomiting, as I recall. She developed a low-grade fever at that time as well of 100.1, atrophic (wasting syndrome), warm and dry with poor turgor (sign of dehydration). She has significant tenting at the supraclavicular space (return of skin to normal position, sign of dehydration). Impressions included, dehydration and pneumonia. We are going to attempt a peripheral IV and rehydrate her. If we were unable to start the IV, we will transfer her to the hospital for care. During an interview done on [DATE] at 3:05 p.m., staff member G (physician) said the resident was dehydrated and needed IV access (for fluids and antibiotics). Staff member G revealed he had educated the nurse when he saw the resident on [DATE], regarding the resident's skin tenting (a sign of dehydration). Review of the facility Hydration Protocol dated ,[DATE], revealed warning signs for dehydration, poor skin turgor. During an interview done on [DATE] at 3:25 p.m., staff member F (Registered Dietician) stated I didn't get notified by nursing the resident had hydration concerns, usually I would be notified by nursing. Review of the facility Nutrition Services Hydration Requirements policy dated ,[DATE], stated Nursing staff will notify the dietitian for resident at risk of dehydration. During an interview done on [DATE] at 12:55 p.m., staff member E (Nurse Manager, RN) stated there is no documentation of hydration assessments. During a second interview done on [DATE] at 3:11 p.m., staff member E stated they (nursing staff) probably should of called the doctor to let him know (regarding the residents hydration status). During an interview done on [DATE] at 9:15 a.m., staff member B (Director of Nursing/DON) verbally agreed that staff did not document assessing and monitoring for the residents (Resident #2) hydration status. ( )

This citation pertains to intake number MI 946. Based on interviews and record review, the facility failed to provide supervision and prevent falls for 1 of 4 sampled residents (Resident #101), from a total of 4 residents reviewed for fall risk, resulting in Resident #101 experiencing a fall with displaced fracture of the right distal femoral metaphysis (a broken bone in which 2 or more pieces move such that the ends of the fragments do not line up, located in an area above the right knee), pain, and hospitalization . Findings include: The facesheet revealed Resident #101 was an [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #101's room was identified as being in the facility's locked dementia unit. According to the Minimum Data Sets ((MDS) dated [DATE], Resident #101 was severely cognitively impaired, non-verbal, and was dependent on facility staff for activities of daily living (ADL's). The Fall Risk assessment dated [DATE] revealed Resident #101 was at high risk for falls. The facility's Resident Care Card, dated 11/8/2013, specified Resident #101 was to have "staff to accompany resident to beauty shop and stay with her until appointment completed." The Fall Occurrence Report and Post Fall Worksheet dated 11/26/2014 (untimed), revealed Resident #101 experienced a fall on 11/26/2014 at 1:00 PM, while seated in her wheelchair in the facility's salon. The Resident was reported to have entangled her lower extremity in the padded foot rest of her tipped wheelchair. The report included the resident sustained [REDACTED]. The Resident was reported to have remained at the facility for continued care. The report also included an entry that Resident #101 had a "pattern of leaning forward, and out to the sides of her bed and wheelchair," and utilized a pad alarm on her wheelchair. She was documented to have had a "previous history of falls." According to the Nurses Note/Physical assessment dated [DATE] at 2:32 PM, Licensed Practical Nurse (LPN) "G" was summoned to the facility's salon, finding Resident #101 lying on the floor, face down. The entry included Resident #101 had sustained a "contusion/hematoma on left forehead and small bruise on left ear, redness on right knee. Resident is yelling." The Resident's attending physician and family were notified of the fall. According to the physician progress notes [REDACTED].#101 continued with swelling of her right knee, and her attending physician ordered the administration of a short-term, high-dose steroid. According to the facility's "Timeline of Events Post Fall" (document provided to the State Surveyor by the Director of Nursing on 12/29/2014 at 9:25 AM), Resident #101 experienced continued right knee swelling with "tenderness to touch, with moans when right leg is moved" on 12/14/2014, 12/15/2014, and 12/16/2014. The "timeline" included that on 12/16/2014 (untimed), "increased swelling/redness noted; very tender upon palpation . . . Resident's right knee, right thigh, and groin/outside thigh discolored;" the Resident was sent to a local hospital for evaluation. There was no further documentation provided to the State Surveyor during the unannounced, on site investigation dated 12/29/2014 that any other falls/events occurred at the facility after the date of 11/26/2014 that gave account of the right lower extremity injury (displaced fracture of the right distal femoral metaphysis). Review of the hospital Admission Information form dated 12/16/2014, revealed Resident #101 was hosptalized on [DATE] at 10:12 PM for a fracture of her right lower extremity. According to the orthopedic surgeon's History and Physical submitted on 12/17/2014 at 5:34 PM, Resident #101 was diagnosed with [REDACTED]." During an interview on 12/29/2014 at 8:05 AM, LPN "C" said, "Beauticians aren't supposed to watch over our residents from the locked dementia unit; they're too busy. We send someone, a certified nurse aide (CNA) to watch our residents while they're in the salon. The salon is located outside, and a distance from, our locked dementia unit." During a phone interview on 12/29/2014 at 8:55 AM, Beautician "E" said, "I work at the facility. I'm self employed. I provide services for the residents here. I didn't get training from the facility to care for residents while they're in the salon. She (identified as Resident #101) had behaviors. She constantly leaned forward out of her wheelchair like she was cleaning something. She bent so far forward she would grab her shoes. It was dangerous for her. That day (identified as 11/26/2014) her (Resident #101) and 2 other residents were in the salon, no staff members were in the salon. My back was turned to her; I was working with another client. There were 3 residents total in the salon. I went to the other resident to comb her out; my back was turned to her (Resident #101). I heard a thump, and there she (Resident #101) was on the floor. I ran to the activities room and told them to call the nurses (identified as the nurses in the locked dementia unit). I've had no training to supervise residents like her. She fell and it scared me to death." During a phone interview on 12/29/2014 at 9:30 AM, CNA "D" said, "I was assigned to her (Resident #101) on day shift, 11/26/2014 when she fell in the salon. I'd only worked with her once before. Nobody told me they'd taken her to the salon; don't know who took her. Didn't even know she was gone from the floor (identified as the locked dementia unit). She's always reaching way forward when she's in her wheelchair like she's picking something off the floor. She had a pad alarm on her wheelchair that day. Other residents who lean that far forward, like her, usually have a seat belt on; a strap to keep 'em from leaning. I started looking for her, 'cause I couldn't find her. It was time for lunch. I asked people I work with where she was; nobody knew. She was a fall risk; leaned too far forward all the time." During an interview on 12/29/2014 at 10:55 AM, Physical Therapist "F" said, "She (identified as Resident #101) was a fall risk. Not sure she was safe to be alone with a beautician, untrained to care for residents with advanced dementia and safety awareness issues. This resident (Resident #101) should have had a staff member with her in the salon." During an interview on 12/29/2014 at 2:05 PM, LPN "G" said, "The salon is outside our locked dementia unit. She (identified as Resident #101) could be impulsive. We had to keep checking on her; she didn't know what was safe for her and couldn't follow commands." During an interview on 12/29/2014 at 3:20 PM, the Director of Nursing said the beautician had not received training in the care of residents with advanced dementia, including supervision/fall prevention. During an interview on 12/29/2014 at 3:35 PM, the Nursing Home Administrator said, "the Feds and the state do not say that I have to provide salon services at this facility. If I have to provide 1:1 staff for residents going to the salon, I'll just close it down."

This citation pertains to intake number MI 492. Based on observation, interview and record review, the facility failed to assess pain according to facility policy and manage pain for one resident (#102) out of seven residents reviewed for pain management plans, failed to coordinate care with the [MEDICAL TREATMENT] center to protect the [MEDICAL TREATMENT] for one resident (#102) out of one resident reviewed with a [MEDICAL TREATMENT], failed to provide a comfortable wheelchair and positioning necessary to minimize the risk of aspiration for one resident (#105) and failed to provide opportunities for socialization during meals for two residents (#101 and #105) out of three residents observed for positioning during and after meals and location of meals, and failed to provide appropriate positioning with a wrist brace for one resident (#101) out of two residents reviewed who had braces for their arms, in a total sample of seven residents, resulting in pain that caused the resident to cry out loud and interfered with the quality of life (#102), potential complications of the [MEDICAL TREATMENT] (#102), increased risk for aspiration (#105), diminished opportunity for socialization (#101 and #105), and potential worsening discomfort (#101, 102 and 105). Findings include: According to the "Record of Admission", Resident #102 was a [AGE] year old male re-admitted to the facility on [DATE]. The Physician "Progress Note", with an exam date of 9/5/2014, listed the following [DIAGNOSES REDACTED]. On 10/7/2014 at 4:00 pm, Certified Nursing Assistant (CNA) staff "C", was interviewed and observed in Resident #102's room where the resident was laying in bed. As CNA "C" attempted to straighten out Resident #102's right leg which was bent at the knee to place a positioning device under his feet, Resident #102 cried out loudly because of the pain the movement was causing him. CNA "C" stopped trying to move Resident #102's leg and said he would tell the nurse that Resident #102 needed a pain pill. CNA "C" stated that Resident #102 had leg pain any time he was touched or moved. On 10/8/2014 at 9:00 am while standing in the hall outside Resident #102's room, a voice could be heard through the closed door yelling out loudly, "AHHH, AHHH", as if in pain. On 10/8/2014 at 9:15 am, CNA "E" confirmed that Resident #102 had been yelling during the transfer from his bed to his chair because of pain in his legs. At that time Resident #102 was in his wheeled reclining chair in the Arbor Cafe. When Resident #102 was asked how he felt, he just shook his head no and did not answer. On 10/8/2014 at 3:40 pm, CNA "C" was observed as he transferred Resident #102 from his wheeled reclining chair to his bed in his room with a mechanical lift. As Resident #102 was lowered into his bed he cried out "my leg". CNA "C" stated again that Resident #102 had leg pain any time he was touched or moved. CNA "C" further stated that this had been a "good day" for Resident #102 during the transfer because he usually yells out in pain much more than he did this time. On 10/8/2014 at 3:50 pm, Licensed Practical Nurse (LPN) staff "L" was observed in Resident #102's room as she positioned Resident #102's right leg to provide wound care. LPN "L" attempted to straighten Resident #102's bent right leg and he cried out in pain. CNA "C" who was still in the room said that he would ask a nurse to bring a pain pill for Resident #102 and he left the room. LPN "L" said that perhaps she should wait until Resident #102 got a pain pill and then asked Resident #102 if it was all right for her to continue. Resident #102 nodded yes. During observation on 10/8/2014 at 4:03 pm, LPN "H" entered Resident #102's room and gave him some medication that she told him was a pain pill. At that time, LPN "H" did not ask Resident #102 any questions about the location or intensity of his pain. During an interview at the time of observation, when asked by this Surveyor, Resident #102 stated the pain was in his right calf and he rated the pain as the worst, a 10 on a scale of one to ten. At 4:15 pm, LPN "H" was asked what pain medicine Resident #102 had been given and why she had not assessed the location or intensity of the pain. LPN "H" stated that she had given Resident #102 a [MEDICATION NAME] 5/325 (pain medication with an opioid component) milligrams (mg) and she did not ask him any questions because he was having a treatment performed at the time she gave the medication but she would go now and speak with Resident #102. On 10/9/2014 at 8:27 am, Resident #102 was observed in his reclining wheelchair in the Arbor Cafe. At 9:00 am, CNA "E" was interviewed. CNA "E" stated that he was assigned to care for Resident #102 and he had gotten Resident #102 out of bed earlier this morning. CNA "E" further stated that Resident #102 had cried out in pain when he was moved. CNA "E" stated that the nurse aides change assignments on a weekly basis and every six weeks he is assigned to care for Resident #102 for a week. CNA "E" stated that "any little move makes him cry out - every day, every week, whenever I have him". CNA "E" stated that he told the nurses every time when Resident #102 had pain. According to the facility "Pain Management Policy", dated as reviewed April 2008, all residents would "be screened for pain and comprehensively assessed as warranted. When indicated, appropriate interventions will be instituted to relieve pain, and promote comfort and wellbeing." The policy also directed that a resident be reassessed with [REDACTED]. The nurses were also to record the intensity of pain prior to medications or non-pharmacologic pain relief strategies and within one hour after an intervention was administered. According to the "Patient Progress Notes", dated 9/30/2014 at 5:00 pm, the family of Resident #102 was visiting and asked for something for Resident #102's pain. At 5:10 pm, the "Patient Progress Notes" reflected that Resident #102 was laying in bed "exhibiting facial grimaces and moaning" and that the family was "holding and rubbing his legs" saying that Resident #102's legs hurt him and needed to be stretched out. The nurse recorded that the family had requested that Resident #102 be sent to the emergency room for the pain and that Resident #102 left by ambulance for the hospital at 5:50 pm. According to the records from the hospital, dated 10/1/2014 at 12:55 am, Resident #102 had been diagnosed with [REDACTED]. to be given three times a day. According to the Medication Administration Record (MAR) the medication [MEDICATION NAME] was started on 10/2/2014. On 10/8/2014 at 2:00 pm, the unit manager, Registered Nurse (RN) staff "A" was asked for Resident #102's most recent pain assessment. RN "A" provided a "Pain Screening Form", dated 9/30/2014 with no time indicated. The total score of the "Assessment Results" from the eight question form was a 12. The form indicated that a score of 5 or greater indicated a comprehensive pain assessment was needed. The facility's "Pain Management Policy", dated as reviewed April 2008, directed that a "total screening score of five (5) or greater indicates a comprehensive pain assessment is needed". No additional pain assessments were provided. RN "A" stated on 10/9/2014 at 11:00 am that the nurses should have done a pain assessment for Resident #102 when the new medicine, [MEDICATION NAME], was started. The facility's "Pain Management Policy", dated as reviewed April 2008 instructed that each resident was to be assessed for pain "at least twice per day" during the medication pass and was to be "documented on the Medication Administration Record (MAR)". On 10/9/2014 at 11:00 am, while reviewing Resident #102's MARs for 8/1/2014 to 9/14/2014, RN "A" was asked to provide the medication administration records for the "as needed" pain medication [MEDICATION NAME] 5-325 mg. including the nurses assessments of the pain before the medication was given and the assessment of the medication effectiveness after it was given for the dates 9/15/2014 through 10/9/2014. It was noted that these assessments were not on the MARS for 8/1/2014 to 9/14/2014 and RN "A" commented, they are not printing out (from the computer). The RN unit manager, staff "A" was also asked where on the MAR the twice daily pain assessment was recorded. RN "A" shook her head no and stated, we don't follow that policy with the new system. According to Resident #102's MARS printed for 9/15/2014 to 10/9/2014, the physician order [REDACTED]. had been started on 9/26/2014. The [MEDICATION NAME] had been administered to Resident #102 nine times during the time period. The "comment/reason" indicated each time was recorded as "pain". The only comment under "reaction" was on 10/8/2014, the date LPN "H" was interviewed by this surveyor as noted above. The entry read "pain rated at 5 reassess at 0" and was timed at 6:04 pm. In the clinical record, a hospital report for "Pre & Post-Operative Access Surgery Instructions", dated 12/3/2013 was noted for Resident #102. The instructions did not include a description of the type of access surgery that had been performed. Under the section for "Activity" were the instructions to "not lift objects greater than 10 pounds. Do not wear tight clothing or jewelry over the fistula or graft Be cautious when carrying groceries or hanging purse straps over your arm. Do not lie on your fistula." (As previously noted, according to the "physician progress notes [REDACTED].#102 had kidney disease with placement of an atrioventricular fistula in the right arm for [MEDICAL TREATMENT].) On 10/9/2014 at 8:50 am and again at 10:30 am, RN "K" was asked for the facility policy and procedure for care of [MEDICAL TREATMENT]. On 10/9/2014 at 11:25 am, the Director of Nursing was asked for the facility policy and procedure for care of [MEDICAL TREATMENT]. The facility policy and procedure for care of [MEDICAL TREATMENT] was not received by the conclusion of the survey. On 10/9/2014 at 9:15 am, RN "A" and this surveyor observed Resident #102's right upper inner arm in his room. RN "A" confirmed that this was the location of Resident #102's [MEDICAL TREATMENT]. A dark surgical scar about four inches long was observed. RN "A" stated that Resident #102 had not started [MEDICAL TREATMENT] treatment yet so the access site had not been used. A consultation report (dated 4/15/14) from the physician at the [MEDICAL TREATMENT] clinic revealed that Resident #102 had a right brachial-axillary arteriovenous (AV) graft placed on 12/3/2013. According to the US Department of Health and Human services, National Institutes of Health, National Kidney and Urological Diseases Information Clearinghouse website (http://kidney.niddk.nih.gov/kudiseases/pubs/vascularaccess/. Accessed 10/10/2014), vascular access is necessary for [MEDICAL TREATMENT] treatment to be performed. During [MEDICAL TREATMENT], a machine is used to filter the blood in place of the kidneys. Vascular access allows large amounts of blood to be filtered during the treatments. There are two types of vascular access for long-term [MEDICAL TREATMENT] treatments, the AV fistula and the AV graft. The AV fistula is recommended because it provides a good blood flow, lasts longer and is less likely to become infected or clot. An AV fistula is created by surgically connecting an artery to a vein. For an AV graft, a plastic tube is used to surgically connect an artery to a vein. An AV graft is more likely to develop problems with infection or clotting than a fistula, but a well cared for graft can last for several years. The US Department of Health and Human services, National Institutes of Health, National Kidney and Urological Diseases Information Clearinghouse website (http://kidney.niddk.nih.gov/kudiseases/pubs/vascularaccess/. Accessed 10/10/2014) listed instructions to care for and protect the vascular access site. These instructions included being careful not to bump the access site, checking daily for a thrill (a rhythmic vibration that can be felt over the top of the site), watching for signs of infection, not putting a blood pressure cuff over the site, not wearing tight clothes over the access site, not sleeping with the site under the body, and not putting any pressure on the access site. The "Patient Progress Notes" for Resident #102 revealed that his blood pressure had been taken in his right arm, the site of his AV graft, on 8/28/2014, 9/5/2014, 9/8/2014, 9/12/2014, 9/17/2014, and 9/20/2014. When asked about a plan of care for Resident #102's AV access site during an interview on 10/9/2014 at 11:25 am, the Director of Nursing stated that the orders for the care of the access sites come from the physician and that a care plan is only needed if the physician instructed that the blood pressure not be taken on the arm where the access site was located. The Director of Nursing further stated that a call had been placed to the [MEDICAL TREATMENT] clinic for clarification but they had not yet returned the call. According to the nursing textbook "Medical-Surgical Nursing; Assessment and Management of Clinical Problems", Seventh Edition published by Mosby Elsevier, page 1221, "Blood pressure measurements, insertion of IVs (intravenous needles), and venipuncture should never be performed on the affected extremity. These special precautions are taken to prevent infection and clotting of the vascular access." These interventions are the expected standards of care within the scope of nursing practice. During an interview with the Unit Manager, RN "A" on 10/9/2014 at 12:20 pm, she stated that a care plan had been initiated after the [MEDICAL TREATMENT] had been placed, but the care plan had been discontinued and it should not have been. According to the undated "Record of Admission", Resident #105 was a [AGE] year old male admitted to the facility on [DATE]. According to the "Minimum Data Set Assessment", dated 9/8/2014, Resident #105's [DIAGNOSES REDACTED]. A "Clinical Swallow Evaluation", dated 9/26/2014, reflected that Resident #105 was "pocketing" on the left side of his mouth with eating and coughed when he drank thin liquids. Pocketing means that he did not swallow all of the food from the left side of his mouth. Therefore, Resident #105 was to be upright in his wheelchair for all meals, and was to remain upright for 25 minutes after he ate, to minimize choking and aspiration risks. According to the "Extended Care Center Resident Care Card", dated 7/22/2014, Resident #105 was to be up for meals and his wheelchair was to have an arm rest. On 10/9/2014 at 8:20 am, Resident #105 was observed in his bed in his room. Certified Nursing Assistant (CNA) staff "F" was also in the room and said she had just finished feeding Resident #105 his breakfast. CNA "F" stated that she had cared for Resident #105 since this last Sunday. CNA "F" stated that she had not gotten Resident #105 out of bed at all because of his wheelchair. CNA "F" explained that Resident #105 leaned in his wheelchair and his arm rest tray was not fitting the wheelchair well. She said Resident #105 leaned to the left and he could fall and he did not look comfortable when he was in his wheelchair. The bracket on the bottom of the arm rest tray was loose and jiggly. CNA "F" was asked if she had told the nurse. CNA "F" replied "it has been discussed. They know." During an interview with the Unit Manager, RN "A" on 10/9/2014 at 12:20 pm, she stated that she was not aware that Resident #105 had been leaning in his wheelchair and that the CNA was not getting him out of bed. RN "A" stated that Resident #105 had last been evaluated for seating in his wheelchair in June 2014. ( ) According to the electronic "Record of Admission", undated, Resident #101 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #101's "History & Physical", dated 4/8/14, revealed medical history for Resident #101 included hypertension [MEDICAL CONDITION]([MEDICAL CONDITION]- stroke). On 10-6-14 at 11:40 a.m. Resident #101 was observed sitting in his geri chair (recliner chair) in the Arbor Cafe (activity/dining room). Resident #101 was observed to not have a wrist/arm brace on. On 10-6-14 at 11:55 a.m. LPN (Licensed Practical Nurse) "I" was asked who Resident #101's nurse and aide were. Nurse "I" said she was his nurse and his aide was on a break. Nurse "I" was asked where Resident #101's safety alarm was for his chair. Nurse "I" proceeded to check with Resident #101's aide and then go to the resident's room and obtain the alarm box. After nurse "I" connected the alarm box, she went back to the resident's room and returned with Resident #101's left wrist/arm brace and applied it. Resident #101's "Treatment Log" dated October 2014 states, "(Left) wrist brace on at all times-off for care only." Resident #101's "Extended care center resident care card", undated, states "Braces/Prothesis/Splints" "Brace" marked with an "X", "Wearing Schedule: (Left) wrist off hygiene (every shift)". "Physician's Nursing Orders Report", dated "Printed 10/09/14", states, "left wrist brace on at all times except for hygiene." "Clinical Nursing Skills & Techniques", 6 th Edition, Perry and Potter, 2006, page 304, states, "Slings, splints, and braces are treatment devices used with musculoskeletal injury or disorder. These devices immobilize a body part, prevent deformity, protect against injury, relieve pain and muscle spasm, maintain position until healing is complete, or assist with function." On 10-7-14 at 12:17 p.m. Resident #101 was observed sitting in his geri chair (reclining chair) in his room. On 10-7-14 at 12:30 p.m. Resident #101 was observed sitting in his room in his geri chair being fed his lunch by CNA (certified nurse assistant) "D". CNA "D" was asked why the resident was eating in his room. CNA "D" said, she does that sometimes. Review of Resident #101's electronic "Physician's Nursing Orders Report" dated "printed 10/09/14" states, "Up in cafe for meals/must be fed". CNA "D" failed to follow Physician orders [REDACTED].#101 to eat in the cafe with other residents. ( )

This citation pertains to intake number MI 492. Based on observation, interview, and record review, the facility failed to follow the plan of care to promote healing of an unstageable pressure ulcer for one resident (#102) out of one resident reviewed for pressure ulcers in a sample of seven residents, resulting in wound-related pain, infection, and slowed healing of the wound. Findings include: According to the "Record of Admission", Resident #102 was a [AGE] year-old male re-admitted to the facility on [DATE]. The Physician "Progress Note", with an exam date of 9/5/2014, listed the following [DIAGNOSES REDACTED]. On 10/6/2014 at 11:40 am, Resident #102 was observed in his reclining wheelchair in the Arbor Cafe. Resident #102 was fully dressed and wearing black tie-up shoes. According to the Resident Care Card, up-dated 8/29/2014, the resident was to have "No Shoes" and this was underlined three times. Resident #102 had a care plan in place for impaired skin integrity dated 5/9/2014 that listed "No shoes, use slippers or gripper socks" as an intervention. On 10/8/2014 at 3:50 pm, LPN "L" was observed as she performed wound care to the ulcer on Resident #102's right great toe. The toe was slightly reddened from the knuckle down. A large, moist looking blackened area was present from just under the short toenail covering the tip of the toe. The black area was loose at the edges. There was a small loose flap of the black tissue hanging from the one edge of the black area at the end of the toe. There was a small yellowish area at the edge of the black area, near the toenail. There was reddish-brownish drainage in the dressing that LPN "L" removed. LPN "L" stated that there had been redness extending up Resident #102's leg and he had been prescribed an antibiotic. LPN "L" stated that there was less redness now. At that time, LPN "L" stated that the area was the result of the podiatrist filing down mycotic toenails with an electric nail file and filing the skin on the end of the toe by mistake. On 10/9/2014 at 1:00 pm, an incident and accident report regarding Resident #102's toe injury caused by the podiatrist, nurses notes, and wound documentation was requested from the Assistant Director of Nursing, Registered Nurse (RN) "N". The Unit Manager, RN "A", delivered the requested notes and wound documentation and was interviewed on 10/9/2014 at 2:30 pm. RN "A" stated that when the area on Resident #102's toe first appeared in May 2014 as a blister, it was thought that the pressure from his shoes had caused the area to blister and the plan at that time was initiated for him to not wear shoes. RN "A" insisted the area had not been the result of the podiatrist grinding down his toenails but from his shoes and, therefore, there was no incident report regarding the blister on Resident #102's toe. According to the "Weekly Pressure Ulcer Assessment Flow Sheet" for Resident #102, dated 5/12/2014, the area was classified as a stage II ulcer on the right great toe. No measurements were recorded and the area was said to be tender with pink surrounding the wound. The note for the same date revealed, "found to have a red area on the tip of the great toe and looks like the nails were just groud (sic) down, pt (patient) has thick mycotic nails and this is done by the podiatrist." According to the "Weekly Pressure Ulcer Assessment Flow Sheet" for Resident #102, dated 5/27/2014, the area was classified as a stage II ulcer on the right great toe that measured 0.6 centimeters (cm) by 0.7 cm. and was "dry/turning to scab". The "Weekly Pressure Ulcer Assessment Flow Sheet" for Resident #102, dated 8/8/2014, revealed the area was now classified as an unstageable ulcer on the right great toe with necrotic tissue present in the form of escher (sic) that measured 0.8 cm. by 1 cm. According to the "European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. treatment of [REDACTED]. Washington DC: National Pressure Ulcer Advisory Panel; 2009", the depth of an unstageable ulcer is unknown because the wound base cannot be visualized due to the presence of slough tissue that can be yellow and/or eschar tissue that can be black. Furthermore, even though the true depth cannot be seen, there is a full thickness tissue loss that will be either a stage III or IV once the base of the wound is exposed. According to the "Weekly Pressure Ulcer Assessment Flow Sheet" for Resident #102, dated 9/2/2014, the area on the right great toe was classified as an unstageable ulcer that now measured 1.2 cm. by 1.4 cm. The form revealed that Resident #102 complained that the area was tender and that the toe was red. According to the "Weekly Pressure Ulcer Assessment Flow Sheet" for Resident #102, dated 9/8/2014, the area on the right great toe was classified as an unstageable ulcer that measured 1.2 cm. by 1.5 cm. The form documented an increase in pain. The note for that date reflected that Resident #102 had "an increase in redness that is trailing up the foot also pt is c/o (complaining) a lot (sic) more pain to the area." The note continued on to document that the physician had started Resident #102 on an antibiotic for the next 10 days. According to the Medication Administration Record [REDACTED]. According to the "Weekly Pressure Ulcer Assessment Flow Sheet" for Resident #102, dated 9/24/2014, the area on the right great toe was classified as an unstageable ulcer that now measured 2 cm. by 2 cm. The area continued to have necrotic tissue, eschar, with redness and pain present. The nursing "Patient Progress Notes" for 9/26/2014 revealed that the toe remained red with a blackened scab that "isn't healing" and that Resident #102 had finished the course of antibiotic "with little improvement." According to the note, the physician had been notified and had ordered an arterial doppler to both legs (to assess the circulation) and had ordered the narcotic pain medicine [MEDICATION NAME] 5/325 mg. to be given every six hours as needed for pain. A report from a local hospital revealed that a "venous ultrasound" had been performed on Resident #102 on 10/1/2014 for an "evaluation for [MEDICAL CONDITION]" ([MEDICAL CONDITION] or blood clot). The results were normal with no abnormal masses or fluid collections and negative for a [MEDICAL CONDITION] in both legs. No additional testing was found in the clinical record. According to the "European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. treatment of [REDACTED]. Washington DC: National Pressure Ulcer Advisory Panel; 2009", one of the basic principles of treatment for [REDACTED]. Resident #102's care plan initiated on 5/9/2014 that initiated the intervention for him to not wear shoes reflected this principle. During the interview with the Unit Manager RN "A" on 10/9/2014 at 2:30 pm, she stated that the staff had implemented the measure of Resident #102 not wearing shoes because the staff had believed the blister had developed because of pressure from the shoes. However, as noted above, Resident #102 was wearing his shoes on 10/6/2014 at 11:40 am. ( )

This citation pertains to MI 961. Based on interview and record review, the facility failed to safely transfer and prevent injury (transferred resident without using mechanical lift and without assistance as per plan of care) for 1 (Resident #501) of 7 sampled residents, from a total sample of 7 residents, resulting in a skin tear of the right arm, a fractured left femur (the long bone of the thigh) and being transferred to the hospital. Findings Include: Review of the face sheet, minimum data set (MDS, resident assessment tool) dated 11/24/12, physician progress notes [REDACTED].#501 was admitted to the facility on [DATE], alert with confusion and communication deficits and dependent on staff for her activities of daily living (ADL's). The residents [DIAGNOSES REDACTED]. Review of the quarterly progress note dated 2/21/13, stated "(Resident #501) has a [DIAGNOSES REDACTED]. She also has communication deficits with the staff due to her primary mode of communication being Spanish". Review of the statement of capacity dated 10/5/12, revealed resident #501 was "unable to participate in and understand medical treatment decision making and rights and responsibilities". Observation of resident #501 was done on 2/28/13 at 9:02 a.m. The resident was in her bed and spoke Spanish; staff was unable to understand most of what she was telling them. Review of the Alteration in self-care/ADL care plan dated 10/23/12, stated "Maxi-lift (mechanical lift)". Review of the care conference summary dated 11/21/12 stated "Maxi-lift for transfers". Review of the Skin Impairment care plan dated 7/8/12, stated "2 assist with Maxi-lift for toileting". Review of the mobility assessments dated 2/20/12, 3/6/12 and 5/28/12, revealed resident #501 was non-ambulatory, non-weight bearing, poor gait control, required assistant with transfers and had poor trunk control. Review of the facility investigation summary dated 1/27/13, revealed on 1/26/13 at approximately 6:00 p.m., Resident #501 complained about "pain in her left knee" and she had a small skin tear resulting from an improper transfer. Family felt there was something out of the ordinary with the transfer and the Unit Manager Registered Nurse (RN) #1 started an investigation. The Certified Nursing Assistant (CNA) #1, who was involved, was suspended pending the investigation. On 1/27/13, (family member #1) informed the Director of Nursing (DON) and Unit Manager RN #1 that the resident told her (CNA #1) had picked her up and bumped her leg on the bed frame". Review of the nurses notes dated 1/26/13 at 6:00 p.m., stated "Pt. (patient) sustained R (right) top arm skin tear and L (left) knee pain after being toileted by CENA (CNA), occurrence report completed, staff statements collected. Physician (Physician named) order L knee stat x-ray of knee". Review of nurses notes dated 1/26/13 at 9:40 p.m., stated "X-ray results received via fax, L femoral fracture". Review of nurses notes dated 1/27/13 at 12:20 a.m., stated "Instructed to send to ER (emergency room ) for evaluation". Review of the radiology report dated 1/26/13, stated "distal left femoral fracture". Review of the Physician order [REDACTED]. Review of the hospital records dated 1/31/13, stated "This lady is [AGE] years old, is non-ambulatory, injured her left femur. X-ray report shows a fracture through the distal femur and again, she is non-ambulatory". Review of the facility annual history and physical dated 1/28/13, stated "Patient did have an episode in which the patient's left leg bumped against the side rails and the patient started to have severe pain. An X-ray was done at the facility which showed a distal left femur fracture with displacement of the patella (in the knee area) that was on 1/26/2013". Review of the 24 hour patient condition report dated 1/26/13, stated "R (right) arm skin tear during care, L (left), stat x-ray due to pain, R/O (rule out) twisting of knee". Review of the outpatient consultation visit dated 1/31/13, stated "Distal L (left) femoral FX, wear knee immobilizer". A phone interview was done on 3/1/13 at 11:56 a.m., with CNA #1. CNA #1 stated "I got her (resident #501) out of bed (on 1/26/13), I used my gait belt and I transferred her into her wheelchair and to the toilet. Another CNA (CNA #2) helped me and told me we use a lift (mechanical lift) with her. I was a float; I floated all over the building. I did not look at her care guide, the care guides are never correct, the nurse told me I could get her up, she did not fall, she did not slide down on the floor. The resident never said she was hurt. I asked her if she was in pain and she said "ya, ya, ya" and pointed to her leg. I toileted her before lunch, approximately 3:45 p.m. to 4:10 p.m. (CNA #2) did not tell me anything; she helped me get her out of the wheelchair and onto the toilet. She was rubbing her thigh area, left leg, I told the nurse at 4:30 p.m. (Charge Nurse Licensed Practical Nurse (LPN) #1) never informed me until 5:15 p.m. and said "we have a problem "and asked me why I did not use the sling, I don't know how (family member #1) found out. There was no sling in her bathroom, (CNA #2) went and got the sling". During a second phone interview with CNA #1, done on 3/4/12 at 9:50 a.m., CNA #1 stated "my knee just touched her knee, I slid her over with the puddle pad (positional pad under the resident), at that time I didn't have my hands on her gait belt. I know I was wrong, this happened at 4:00 p.m. and they sent me home at 10:00 p.m.". A third phone interview was done with CNA #1 done on 3/5/13 at 8:45 a.m. When the surveyor asked CNA #1 how she had put the resident back into bed after she had toileted her on 1/26/13, CNA #1 stated "with the lift, there was no body I could get to help me". Resident #501 was a maxi-lift (mechanical lift) and a 2 person assist. An interview was done on 3/4/13 at 11:15 a.m., with CNA #2. CNA #2 stated "When I went into the room, the resident was in her wheelchair in the bathroom. I told (CNA #1); she (the resident) uses the maxi and is a 2 person transfer. She (CNA #1) said she knew she was a 2 person transfer. The sling was on the floor in the shower (of the resident's room). She (CNA #1) was up-set because she had to work that unit; she thought staff was picking on her. (Charge Nurse LPN #1) told me that she had told her about the resident being a maxi-lift and a 2 person transfer. She (CNA #1) transferred her under the arms, she did not use a gait belt, she did not have a gait belt on her. I told her the resident (#501) uses the maxi-lift and put the sling under her and I walked out. I walked out to break; the resident was still on the toilet. (CNA #1) walked out behind me with the resident on the toilet". CNA #2 said the facility policy is to stay with the resident while they are on the toilet and not to leave them alone, especially resident #501 who was total assist. Review of CNA #2's facility educational opportunity dated 2/5/13, stated "failure to complete task according to the care guide resulting in injury". Observation of the facility video of the hall the resident was on dated 1/26/13 on second shift, revealed CNA #1 and CNA #2 both left the resident's room at "4:09 p.m." and went down the hallway (leaving Resident #501 alone in the room on the toilet). At "4:15 p.m." CNA #1 returned to the resident's room alone, this is when she transferred the resident back into bed by herself. An interview was done on 2/28/13 at 1:10 p.m., with Charge Nurse LPN #1. Charge Nurse LPN #1 stated "(CNA #1) came to me about 4:30 p.m. to 5:00 p.m. (on 1/26/13) to tell me while she was transferring the resident, she bumped her knee against her (Resident #501's) right knee. I went in and she had pointed to her left knee, I assessed the knee, the knee looked ok with no bruising, no redness, then approximately 30 minutes later (family member #1) told me that (the resident #501) had told her the aide (CNA #1) had carried her to the toilet and almost had dropped her. Then (family member #1) said she had a skin tear, approximately 1 inch with slight bleeding. She (CNA #1) got up-set when I started questioning her. I gave (CNA #1) report, I told her she (Resident #501) was a 2 person assist with a maxi-lift, I told her to look at the care card". An interview was done on 3/4/13 at 8:25 a.m., with Nurse Manager RN #1. Nurse Manager RN #1 stated "(CNA #1) told me she looked at the care guide and she knew the person was a Hoyer (another name for a mechanical lift) and a 2 person transfer, she (CNA #1) said she knew. She said she used the gait belt with her, her knees both were contracted and she was non-weight bearing and has not been weight bearing since she's been here. She got a displaced patella and fractured femur. She (CNA #1) had turned the bed alarm off about 2 weeks ago (prior to 1/26/13), it was wrote up (by Charge Nurse LPN #3)". An interview was done on 2/28/13 at 2:20 p.m., with Charge Nurse RN #2. Charge Nurse RN #2 stated "(Charge Nurse LPN #1) had come to me and told me she was giving Tylenol because (Resident #501) had bumped her knee. I assessed her leg (left) and the only thing is her left leg hurt the resident. When I asked her CNA (CNA #1), the aide freaked out and said she would not take care of that resident. I do know she (CNA #1) turned the alarms off another day and another time. The CNA (CNA #1) said she transferred the resident and she (the resident) slipped and she grabbed her arm and she hit her knee with the resident's knee". An interview was done on 3/4/13 at 8:40 a.m., with Charge Nurse LPN #3. Charge Nurse LPN #3 stated "I was in (sampled resident #103's) room and giving care and I happened to look at the bed alarm and the battery was disengaged, the battery door was open, so the batteries did not work. I wrote it up and gave it to her (CNA #1)". Review of CNA #1's facility variance/concern report dated 1/21/13, stated "Nurse during routine rounds at 1630 (4:30 p.m.) noted that chair alarm for resident (room number given) was popped (battery door open) also resident in (room number given) bed alarm battery door was open. This doesn't allow alarms to sound or work. Both residents' CNA is (CNA #1), alarm in (room number given) also noted by unit manager". CNA #1 had a resident "safety/quality" concern pending on her at the time of resident #501's fracture (on 1/26/13). During an interview with the Director of Nursing (DON) on 3/5/13 at 10:05 a.m., the DON said she was aware of CNA #1's written concern report dated 1/21/13. When the surveyor requested CNA #1's personnel record "in complete", the written concern dated 1/21/13, was not part of her personnel record. A phone interview was done on 3/5/13 at 4:06 p.m., with family member #1. Family member #1 revealed she was at the facility on 1/26/13, had gone to get something to eat and when she got back the resident was complaining of pain. Family member #1 stated "the first thing she (Resident #501) said is "I am in a lot of pain and I fell ". "I asked (Charge Nurse LPN #1) did she fall, she's complaining of a fall and pain. I saw blood on her arm (the skin tear), (Resident #501) said she (CNA #1) tried to pick her up and she realized she was slipping and she threw her back on the bed, I was very up-set". Review of the physician progress notes [REDACTED]. Review of the physician progress notes [REDACTED]. Review of the Therapy notes dated 1/28/13, stated "R (right) ROM (range of motion) significantly limited 2nd (secondary) to contracture, Pt. c/o (complained) significant pain in L LE (lower extremity) with any movement activity or passively. Pt. D.A. (total assist) for bed mobility 2nd to pain, (family member) reported that the pt. has not been using the Maxi-lift since L LE FX (left lower extremity fracture) and has been using the bed pan and that the pt. has lost her "independence" to be able to be in the W/C (wheelchair) and be pushed in the halls and go to the cafeteria for lunch". Observation made by the surveyor and DON on 3/5/13 at 11:00 a.m., revealed sampled resident #504 was in his bed unsupervised and his bed alarm was sitting in a chair in his room. The resident's care guide dated 11/7/12 and his fall care plan dated 7/12, revealed documentation he had generalized debility, weakness and dementia and was to have a "bed alarm" on. An interview was done on 3/5/13 at 11:00 a.m., with CNA #3 (assigned to the hall the resident was on). CNA #3 stated "I just looked at one part of his care guide". Review of the facility resident care cards policy (#108.30) dated 3/2000 and reviewed 5/2006, stated "A resident care card shall be used by nursing personnel every shift to provide a guide to ensure consistent individualized care, the CENA (CNA) is responsible to follow the resident care card and to review it daily for any changes". ( )

BASED ON OBSERVATION , INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO SUPERVISE, AND IMPLEMENT APPROPRIATE INTERVENTIONS FOR ONE RESIDENT (#510) AFTER 3 FALLS IN A 6 DAY PERIOD FROM A TOTAL SAMPLE OF SEVEN RESIDENTS REVIEWED FOR FALLS, RESULTING IN MINOR INJURIES AND THE POTENTIAL FOR ADDITIONAL INJURIES AND HARM. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION INFORMATION SHEET DATED 4/12/13, RESIDENT #501 WAS admitted to the facility on [DATE] AFTER AN ACUTE HOSPITAL STAY WITH [DIAGNOSES REDACTED]. REVIEW OF THE CLINICAL RECORD PSYCHOSOCIAL HISTORY DATED 4/16/13 DOCUMENTED THAT RESIDENT #510 HAD A FALL AT HOME IN HIS GARAGE WHILE INTOXICATED AND WAS NOT ABLE TO GET UP. HE ALSO HAS A SIGNIFICANT HISTORY OF ALCOHOL ABUSE. THE [AGE] year OLD RESIDENT WAS admitted TO THE FACILITY FOR MEDICAL MANAGEMENT, PHYSICAL, OCCUPATIONAL AND SUPPORTIVE NURSING CARE WITH THE INTENTION OF LONG TERM CARE PLACEMENT AND SERVICES. REVIEW OF RESIDENT #510'S HOSPITAL RECONCILIATION RECORD DATED 4/10/13 NOTED THE FOLLOWING PSYCHOTROPIC MEDICATION THE RESIDENT WAS RECEIVING UPON ADMISSION: QUETIAPINE FUMARATE (SEROQUEL) 25 MILLIGRAM TAB ORALLY TWO TIMES A DAY AND QUETIAPINE FUMARATE (SEROQUEL) 75 MILLIGRAMS EVERY EVENING (ANTIPSYCHOTIC MEDICATIONS); MIRTAZEPINE (REMERON) 7.5 MILLIGRAMS TAB AT BED TIME (ANTIDEPRESSANT); AND LORAZEPAM (ATIVAN) 0.5 MILLIGRAM TAB THREE TIMES DAILY (ANTIANXIETY). UPON ADMISSION TO THE FACILITY RESIDENT #510 WAS PRESCRIBED RISPERDAL 0.5 MILLIGRAM EVERY 12 HOURS DATED 4/12/13 ( ANTIPSYCHOTIC). ACCORDING TO THE MANUFACTURER'S RECOMMENDATIONS, IT STATED MONITORING OF ORTHOSTATIC BLOOD PRESSURE SHOULD BE DONE FOR SEROQUEL, RISPERDAL, AND ATIVAN; FOR SEROQUEL, THE MONITORING OF HEMOGLOBIN A 1 C, OBSERVATION OF NEW OR WORSENING DEPRESSION, ANXIETY, IRRITABILITY, AGGRESSION, OR OTHER SYMPTOMS OF UNUSUAL BEHAVIOR; FOR ATIVAN, THE MONITORING OF RESPIRATORY AND CARDIOVASCULAR STATUS, AND SIGN AND SYMPTOMS OF ANXIETY; FOR RISPERDAL, THE MONITORING OF TRIGLYCERIDES, CHOLESTEROL, GLUCOSE, AND SERUM AMYLASE AND LIPASE ( LABORATORY VALUES FROM BLOOD TESTS ); AND FOR REMERON, THE MONITORING OF A SORE THROAT AND ANY OTHER SYMPTOMS OF INFECTION. ACCORDING TO THE NURSES NOTES FOR THE BEHAVIOR DOCUMENTATION DATED 4/17/13 ON 7 AM TO 7 PM SHIFT, RESIDENT #510 WAS HITTING THE WALLS, ATTEMPTING TO GRAB THE OTHER RESIDENTS, COMBATIVE WITH STAFF, ATTEMPTING TO TAKE OTHER RESIDENT'S FOOD AND ATTEMPTING TO GET INTO THE REFRIGERATOR. ON 4/18/13 THE BEHAVIOR NOTES STATED THE RESIDENT WAS COMBATIVE WITH CARE, HITTING , KICKING, PUNCHING, YELLING AT STAFF, ATTEMPTING TO GET UP WITHOUT ASSISTANCE, GRABBING AT FEMALE STAFF, HITTING HAND ON THE TABLE IN THE DAY ROOM AND UNABLE TO BE REDIRECTED. ON 4/19/13 AT 0600 DOCUMENTATION FROM NURSES NOTES BEHAVIOR SHEET STATED THAT RESIDENT WAS RESTLESS, COMBATIVE WITH CARE THROUGH MOST OF THE NIGHT AND DIFFICULT TO REDIRECT. ACCORDING THE PSYCHOSOCIAL HISTORY NOTES AND SOCIAL WORK assessment dated [DATE], THE GOAL ESTABLISHED WAS TO STABILIZE RESIDENT'S BEHAVIOR, TO DO A GRADUAL DOSE REDUCTION OF THE ATIVAN AND ATTEMPT TO REDUCE THE RISPERDAL TO ZERO USE. ON 4/18/13 A REVIEW OF THE INCIDENT REPORTS FOR FALLS FOR RESIDENT #510 SHOWED 2 FALLS OCCURRED. FIRST ONE DATED 4/15/13 AT 1710 PM., DOCUMENTED THAT RESIDENT #510 WAS OBSERVED SITTING ON THE FLOOR ON HIS BOTTOM IN FRONT OF HIS WHEEL CHAIR BY WATER FRONT GRILL AFTER ATTEMPTING TO STAND, RESULTING IN SKIN TEAR TO RIGHT ELBOW. A REVIEW OF THE INCIDENT REPORT DATED 4/15/13 STATED THE CORRECTIVE ACTION WAS TO OFFER TOILETING TO THE RESIDENT EVERY HOUR FOR SEVEN DAYS. THE CARE PLAN REFLECTED THIS CORRECTIVE ACTION. THE DOCUMENT TITLED ECC FALL CHARTING RATED THIS RESIDENT TO BE A FALL RISK WITH A SCORE OF 12 (REPRESENTING HIGH RISK, ANY NUMBER GREATER THAN 10 OR MORE REPRESENTS HIGH RISK). A REVIEW OF THE SECOND INCIDENT REPORT DATED 4/17/13 DOCUMENTED THAT RESIDENT fell ASLEEP, LEANED AND fell FORWARD TO THE FLOOR HITTING THE TOP OF HIS HEAD AND RECEIVED A PURPLE HEMATOMA TO THE TOP OF HIS HEAD. REVIEW OF THE INCIDENT REPORT DATED 4/17/13 HAD A CORRECTIVE ACTION TO PLACE RESIDENT #510 BY THE NURSES STATION WHILE UP IN WHEEL CHAIR. THE CARE PLAN AND CARE GUIDE REFLECTED THE INTERVENTIONS OF TOILETING THE RESIDENT EVERY HOUR AND PLACING THE RESIDENT BY THE NURSES STATION WHILE UP IN HIS WHEEL CHAIR. THE DOCUMENT TITLED ECC FALL CHARTING RATED THIS RESIDENT A SCORE OF 16 (ANY NUMBER GREATER THAN 10 OR MORE REPRESENTS HIGH RISK). THIS WAS AN INCREASE FOR HIS RISK OF FALLS ROM A SCORE OF 12 TO 16. ON 4/19/13 AT 9 10 AM. TWO SURVEYORS WERE AT THE NURSES STATION AND WITNESSED RESIDENT #510 FALLING FORWARD FROM HIS WHEEL CHAIR. RESIDENT #510 WAS SEATED ACROSS THE HALL IN FRONT OF THE NURSES STATION. RESIDENT #510 fell OUT OF WHEEL CHAIR, HIT HIS HEAD ON THE FLOOR RESULTING IN AN ABRASION MEASURED AT 2.0 CENTIMETERS BY 0.5 CENTIMETERS. NURSING STAFF ASSESSED RESIDENT #510, ASSISTED HIM TO HIS WHEEL CHAIR AND WHEELED HIM BACK TO HIS ROOM TO TREAT THE ABRASION ON THE RESIDENT'S LEFT FOREHEAD. VITAL SIGNS TAKEN DOCUMENTED BLOOD PRESSURE OF 102/60, PULSE OF 78, RESPIRATIONS OF 18, AND OXYGEN SATURATION OF 96 %. OBSERVATION AT THE TIME OF THE FALL REVEALED THERE WERE NO ALARMS PRESENT AND SOUNDING FROM THE WHEEL CHAIR. AN INTERVIEW WAS CONDUCTED WITH THE UNIT MANAGER, STAFF "A" ON 4/19/13 AT 9: 30 AM. TO EXPLORE IF OTHER INTERVENTIONS WERE INSTITUTED FOR RESIDENT #510 AFTER THE TWO FALLS. STAFF "A" STATED THAT SHE WAS AWARE OF HIS FALL HISTORY BUT DID NOT WANT TO USE A SEAT BELT; THIS WAS THE LAST RESORT BUT PROBABLY WOULD PUT ONE ON HIM NOW IN LIGHT OF THE THIRD FALL. STAFF "A" ALSO SAID THAT SHE DID NOT WANT A SEAT BELT ON HIM SINCE TOILETING WAS OFFERED EVERY HOUR. SHE ADDED THAT SHE DID NOT PUT ANY OTHER INTERVENTION IN PLACE AS SHE NEEDED TIME TO FIGURE OUT RESIDENT #510'S PATTERNS, WHAT HE DOES AND HAD NOT HAD ENOUGH TIME TO ASSESS THESE FACTORS. STAFF "A" WAS ASKED WHY RESIDENT #510 WAS PLACED ON RISPERDAL UPON ADMISSION TO THE FACILITY. STAFF "A" STATED THAT THEY WERE HAVING A HARD TIME DEALING WITH HIS BEHAVIORS ON THE GARDEN UNIT WHERE HE ORIGINALLY WAS admitted . IT WAS ADDED THAT THE PSYCHOLOGIST STARTED HIM ON RISPERDAL. SHE ALSO EXPLAINED THAT SHE TOLD THE PSYCHOLOGIST SHE THOUGHT THE PSYCHOTROPICS WHERE TOO MUCH. THE PSYCHOLOGIST REPLIED THAT SHE WOULD LOOK AT THE MEDICATIONS AND SEE HIM THIS WEEKEND. RESIDENT #510 WAS MOVED FROM THE GARDEN UNIT TO THE CLOSED UNIT. STAFF "A" WAS ASKED IF THEY WERE MONITORING ORTHOSTATIC BLOOD PRESSURES ON ALL THE RESIDENTS ON PSYCHOTROPICS. SHE SAID, "YES"; THEY ARE DONE WEEKLY AND THEN REDUCED TO MONTHLY. SHE WAS ALSO ASKED IF THE STAFF WAS OFFERING RESIDENT #510 HIS HOURLY TOILETING. SHE SAID, "YES". A REVIEW OF THE SKILLED NURSES NOTES SHOWED RESIDENT #510'S BLOOD PRESSURES: ON 4/12/13, AT 116/58; ON 4/13/13 , 7 AM TO 7 PM SHIFT, BLOOD PRESSURE AT 81/46 AND 7 PM TO 7 AM SHIFT BLOOD PRESSURE AT 108/64; ON 4/14/13 7 AM TO 7 PM SHIFT, BLOOD PRESSURE AT 92/49 AND 7 PM TO 7 AM SHIFT AT 102/60; ON 4/15/13 7 AM TO 7 PM SHIFT BLOOD PRESSURE AT 102/60 AND ON 7 PM TO 7 AM SHIFT, BLOOD PRESSURE AT 87/42; ON 4/16/13 7 AM TO 7 PM SHIFT BLOOD PRESSURE AT 106/55; ON 4/17/13 7 AM TO 7 PM SHIFT, BLOOD PRESSURE AT 99/56; ON 4/18/13 7 AM TO 7 PM SHIFT BLOOD PRESSURE AT 92/53. AND 7 PM TO 7 AM SHIFT, BLOOD PRESSURE AT 101/58. LIPPINCOTT'S MANUAL OF NURSING PRACTICE, 9 TH EDITION, PAGE 466, STATED THE NORMAL BLOOD PRESSURE RANGE IS 120/80. RESIDENT #510'S BLOOD PRESSURES WERE BELOW THE NORMAL RANGE. THE FACILITY IDENTIFIED RESIDENT #510 TO BE AT HIGH RISK FOR FALLS, LISTED HIS MEDICAL AND PHYSICAL CONDITION, WAS AWARE OF HIS MULTIPLE PSYCHOACTIVE MEDICATIONS AND LISTED HIS MALADAPTIVE BEHAVIORS. HOWEVER, THERE WERE MISSED OPPORTUNITIES TO LOOK AT EACH FALL FOR A ROOT CAUSE, CORRELATE THE CAUSAL FACTORS FOR ADEQUATE AND AGGRESSIVE INTERVENTIONS TO PREVENT FALLS, INTEGRATE THE IMPACT OF THE SIDE-EFFECTS AND ADVERSE INTERACTIONS OF HIS MULTIPLE PSYCHOACTIVE MEDICATIONS AS A CONTRIBUTING FACTOR TO HIS FALLS AND FAILURE TO MONITOR FOR HIS ORTHOSTATIC BLOOD PRESSURE. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 560. BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ORAL HYGIENE) IN 1 OF 5 SAMPLED RESIDENTS (#101), FROM A TOTAL SAMPLE OF 5 RESIDENTS, RESULTING IN RESIDENT #101 EXPERIENCING DENTAL ABSCESS, hospitalization , SURGICAL INTERVENTION, ADMISSION TO INTENSIVE CARE, AND SUBSEQUENT DEATH. FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #101 WAS AN [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS ((MDS) dated [DATE] REVEALED RESIDENT #101 WAS SEVERELY COGNITIVELY IMPAIRED, EXPERIENCED DIFFICULTY EXPRESSING HER (RESIDENT 101'S) NEEDS AND UNDERSTANDING OTHERS, REQUIRED A MECHANICALLY ALTERED DIET, HAD DIFFICULTY CHEWING, AND WAS TOTALLY DEPENDENT ON ASSISTANCE FROM FACILITY STAFF FOR ADL'S, INCLUDING ORAL HYGIENE. THE INTERDISCIPLINARY PROGRESS NOTES DATED [DATE] AT 2:00 P.M., REVEALED RESIDENT #101'S HUSBAND NOTIFIED NURSING STAFF THE RESIDENT WAS "CHEWING ALL THE TIME." DOCUMENTATION REVEALED THE RESIDENT'S MOUTH WAS ASSESSED AND A [MEDICATION NAME] OF FOOD WAS OBSERVED. THE NOTE INDICATED A SWALLOW EVALUATION WAS REQUESTED. THE PHYSICIAN ORDER/SWALLOW INSTRUCTIONS FORM DATED [DATE] AT 12:30 P.M., INDICATED AN EVALUATION HAD BEEN COMPLETED BY A SPEECH-LANGUAGE PATHOLOGIST (SLP #20) WHO ASSESSED RESIDENT #101 WITH SWALLOWING DIFFICULTY, INCLUDING POCKETING FOOD IN HER (RESIDENT #101'S) MOUTH. INSTRUCTIONS TO FACILITY STAFF SPECIFIED RESIDENT #101 WAS TO RECEIVE "ORAL CARE AFTER EACH MEAL." INSTRUCTIONS WERE SIGNED BY RESIDENT #101'S ATTENDING PHYSICIAN (#3). THE RESIDENT CARE CARD (INFORMATION SHEET DETAILING CARE TO BE PROVIDED TO RESIDENTS FROM NURSE AIDES) FOR RESIDENT #101, INITIATED ,[DATE], SPECIFIED FACILITY STAFF WERE TO "BRUSH TEETH GOOD AROUND GUMS AND FLOSS AFTER MEALS WITH A PINK TOOTHETTE." THE ACTIVITIES OF DAILY LIVING (ADL'S) CARE PLAN FOR RESIDENT #101 INITIATED ,[DATE], SPECIFIED RESIDENT #101 REQUIRED TOTAL ASSISTANCE WITH HYGIENE, INCLUDING ORAL CARE, AND FACILITY STAFF WERE TO "USE PINK TOOTHPASTE AFTER EACH MEAL TO REMOVE ANY FOOD LEFT IN ORAL CAVITY." THE ANCILLARY ORDER SHEET DATED [DATE] TO [DATE], FOR RESIDENT #101 SPECIFIED "SHIFT NURSE TO MONITOR THAT TEETH ARE BRUSHED AND FLOSSED." DURING AN INTERVIEW ON [DATE] AT 1:05 P.M., THE UNIT MANAGER #19 SAID, "ORAL CARE WAS EXPECTED TO BE DONE AFTER MEALS AND AT BEDTIME FOR RESIDENT #101. AROUND [DATE] SHE (RESIDENT #101) DECLINED. WE HAD A SPEECH EVALUATION DONE. SHE WAS PUT ON GROUND MEATS. SHE ALSO COUGHED WITH FLUIDS. SHE WAS KNOWN TO POCKET FOODS. SHE RESISTED CARE. I TALKED WITH HER (RESIDENT #101) HUSBAND DAILY. HE VOICED CONCERN THAT THE AIDES WEREN'T CLEANING HER MOUTH AS THEY SHOULD. HE LEFT ME A NOTE WITH A LIST OF HIS CONCERNS ON [DATE] THAT INCLUDED DENTAL CARE; THIS WAS REVIEWED BY HIS WIFE'S DOCTOR (#3)." DURING AN INTERVIEW ON [DATE] AT 9:20 A.M., RESIDENT #101'S ATTENDING PHYSICIAN SAID, "SHE (RESIDENT #101) WAS ANOTHER DOCTOR'S PATIENT. I PICKED UP HER CARE WITHIN THE PAST 2 YEARS; SHE HAD NO CHRONIC OR ACTIVE DENTAL ISSUES AT THAT TIME." DURING AN INTERVIEW ON [DATE] AT 10:05 A.M., CERTIFIED NURSE AIDE #14 SAID, "I KNEW HER (RESIDENT #101) VERY WELL. SHE WAS HERE FOR ABOUT 5 YEARS. SHE COULDN'T EVEN WASH HER FACE OR BRUSH HER TEETH. WE WERE SUPPOSED TO DO MOUTH CARE FOR HER AFTER EVERY MEAL AND AFTER SNACKS. I WAS EXPECTED TO DO MOUTH CARE THREE TIMES ON FIRST SHIFT (IDENTIFIED AS 7:00 A.M. TO 3:00 P.M.). SHE DIDN'T GET THAT CARE 'CAUSE SHE WAS COMBATIVE. HER GUMS AND TEETH WERE BAD. I WENT OFF SITE AT LEAST TWICE TO HER DENTAL VISITS. I WAS IN THE ROOM WHEN HER DENTIST TOLD HER HUSBAND HER MOUTH WAS IN BAD SHAPE." DURING AN INTERVIEW ON [DATE] AT 10:30 A.M., CERTIFIED NURSE AIDE #15 SAID, "I'D KNOWN HER (RESIDENT #101) FOR 5 YEARS AND WORKED WITH HER A LOT. SHE WAS VERY CONFUSED. SHE WAS DEPENDENT ON US FOR ADL'S. WE WERE EXPECTED TO CLEAN HER TEETH AFTER BREAKFAST AND LUNCH ON FIRST SHIFT. SHE HAD AN ODOR TO HER MOUTH." DURING AN INTERVIEW ON [DATE] AT 10:45 A.M., CERTIFIED NURSE AIDE #16 SAID, "RESIDENT (#101) WAS VERY CONFUSED. SHE WAS A TOTAL CARE. SHE'D SCRATCH ME. I WAS EXPECTED TO CLEAN HER MOUTH. THERE WERE TIMES WE JUST COULDN'T DO HER MOUTH CARE. I'D TELL A NURSE. SHE WAS COMBATIVE AND IT JUST DIDN'T HAPPEN, HER MOUTH DIDN'T GET DONE. AT THE END OF HER STAY, SHE HAD TOOTH PAIN AND STOPPED EATING. SHE WOULDN'T LET US FEED HER OR NOTHING. WE COULDN'T EVEN DO HER MOUTH CARE FOR ABOUT 2 WEEKS; THE NURSES KNEW, EVERYONE WAS AWARE." DURING AN INTERVIEW ON [DATE] AT 11:05 A.M., REGISTERED NURSE #17 SAID, "SHE (RESIDENT #101) WAS VERY CONFUSED. SHE WAS SUPPOSED TO HAVE MOUTH CARE DONE AFTER EVERY MEAL. NURSE AIDES PROVIDED THIS CARE. SHE OFTEN WAS COMBATIVE AND THE NURSE AIDES REPORTED THEY COULD NOT DO HER ORAL CARE. WE (NURSES) TOLD THE NURSE AIDES TO DOCUMENT IN THE NURSE AIDE BOOK. I DON'T DO ACTUAL CARE ON RESIDENTS. I NEVER DID SEE THE RESIDENT'S ORAL CAVITY, SO I DON'T KNOW WHAT SHAPE IT WAS IN. I DID TELL HER DOCTOR (#3). HE WAS AWARE SHE HAD A PROBLEM WITH EATING AND DRINKING; HE WAS INFORMED SEVERAL TIMES. HE TOLD US TO WATCH HER INTAKE AND OUTPUT. EVENTUALLY RESIDENT #101 WAS SENT TO THE HOSPITAL. I DON'T KNOW IF THE DOCTOR MET WITH HER HUSBAND REGARDING HER PROBLEM WITH EATING AND DRINKING. THE DOCTOR TALKED TO ME ABOUT PUTTING HER ON INTRAVENOUS FLUIDS OR POSSIBLY A FEEDING TUBE; HE SAID WE MAY HAVE TO APPROACH HER HUSBAND WITH THESE POSSIBLE OPTIONS, BUT WE NEVER DID." DURING AN INTERVIEW ON [DATE] AT 11:35 A.M., LICENSED PRACTICAL NURSE #18 SAID, "SHE (RESIDENT #101) WAS VERY QUIET, CONFUSED. SHE WAS DEPENDENT ON STAFF FOR ADL'S. SHE WAS SUPPOSED TO HAVE MOUTH CARE. SHE WAS POCKETING FOOD. I WAS AWARE SHE HAD MOUTH PAIN. I KNEW SHE HAD AN ABSCESSED TOOTH OR TWO. SHE REFUSED TO EAT. I DON'T RECALL IF ANY NURSE AIDES REPORTED AN INABILITY TO DO ORAL CARE. I CARED FOR HER THE LAST WEEK PRIOR TO HER hospitalization . HER CONDITION WAS DECLINING." DURING AN INTERVIEW ON [DATE] AT 1:15 P.M., SPEECH-LANGUAGE PATHOLOGIST #20 SAID, "I DID A SWALLOW EVALUATION ON HER (RESIDENT #101) ON [DATE]. SHE WAS POCKETING FOOD. I HAD HER PLACED ON AN ALTERED DIET WITH GROUND MEATS. STAFF WERE TO CHECK HER MOUTH FOR POCKETED FOOD AFTER EACH MEAL. ORAL CARE WAS ORDERED TO BE DONE AFTER EVERY MEAL TO CHECK THAT NO RESIDUAL FOOD WAS LEFT IN HER MOUTH. RESIDENT #101 WAS ORDERED TO HAVE MOUTH CARE AFTER EVERY MEAL THAT INCLUDED BRUSHING, FLOSSING, AND RINSING WITH WATER. IF MOUTH CARE WASN'T PROVIDED AFTER EVERY MEAL, RESIDUE WOULD RESULT IN BREAK DOWN OF HER TEETH AND GUMS, AND EVENTUALLY TO PAIN WITH CHEWING." DURING AN INTERVIEW ON [DATE] AT 2:35 P.M., THE DIRECTOR OF NURSING SAID, "ORAL CARE WAS BASED ON THE INDIVIDUAL NEEDS OF EACH RESIDENT." DURING A TELEPHONE INTERVIEW ON [DATE] AT 12:00 P.M., DENTIST #25 SAID, "I KNOW THIS RESIDENT (#101) VERY WELL. I FOUND DEBRIS IN HER MOUTH ON ALL VISITS, AND IT WAS EXTENSIVE. THE TISSUES OF HER MOUTH WERE VERY FRAGILE, AND THEY WOULD BLEED. EPISODIC ORAL CARE DONE AFTER MEALS BY STAFF COULD DEVELOP OVER TIME INTO DENTAL ABSCESS." THE INTERDISCIPLINARY PROGRESS NOTE DATED [DATE] AT 12:30 P.M., REVEALED RESIDENT #101 WAS UNABLE TO EAT OR DRINK AND WAS SENT TO A LOCAL HOSPITAL FOR EVALUATION, AFTER HER ATTENDING PHYSICIAN WAS NOTIFIED. ACCORDING TO THE HOSPITAL DISCHARGE SUMMARY DATED [DATE] AT 8:32 A.M., RESIDENT #101 WAS admitted TO THE EMERGENCY DEPARTMENT ON [DATE] FROM THE FACILITY FOR EVALUATION OF SEVERE DENTAL PAIN AND INABILITY TO EAT OR DRINK FOR THE PAST 3 DAYS. RESIDENT #101 WAS assessed with [REDACTED]. SHE WAS TRANSFERRED TO THE INTENSIVE CARE UNIT, WHERE SHE died on [DATE]. THE CERTIFICATE OF DEATH SIGNED [DATE], INCLUDED CAUSE OF DEATH AS DENTAL ABSCESS.

Applies to MI 668 Based on observation, interview, and records review the facility failed to transfer a resident (#101) as indicated in the care plan in 1 of 3 sampled residents from a total sample of 3 residents resulting in Resident #101 sustaining leg fracture. Findings include: Review of the MDS (Minimum Data Set) dated 4/25/11 revealed Resident #101 had [DIAGNOSES REDACTED]. Review of care plan "Fall Risk" dated 4/11 for Resident #101 revealed the following intervention: "Use Maxi Lift (mechanical lift) for all resident transfers, use 2 people..." Review of "Fall Occurrence Report" dated 6/21/11 at 10:30 pm revealed Resident #101 was "lowered to the floor" during a failed transfer. Report revealed the following "resident is a Maxi lift transfer, 0 (no) weight bearing, unable to stand..."(sic). Review of facility investigative report (not dated) revealed the following events: On 6/21/11 at 9:45 pm, during a tornado alert, CNA (Certified Nursing Assistant) #3 and CNA #4 transferred Resident #101 from bed to wheelchair. At 10:30 pm, CNA #3 and CNA #5 attempted to transfer Resident #101 back to bed when Resident #101 "Began to fall forward". CNA #6 assisted CNA #3 and CNA #4 lower Resident #101 to the floor. Review of CNA #3's written statement dated 6/27/11 revealed during Resident #101's transfer back to bed, assisted by CNA #5, Resident #101 began "slipping out of wheelchair" Resident #101 was lowered to floor. CNA #6 came in room and 3 CNA's transferred Resident #101 to bed. Resident #101 "was sitting forward on the foot of the bed" and then Resident #101 "began to fall to the left which caused us (CNA's) to fall forward on the bed". "We (CNA's) straightened (Resident #101) out and laid (Resident) correctly on the bed." Numerous attempts were made to contact CNA #3 by this surveyor, but this surveyor was unsuccessful. The DON (Director of Nursing) said CNA #3 was no longer employed by facility. Review of CNA #5's written statement dated 6/23/11 CNA #5 wrote, "...we attempted to get (Resident #101) into bed. (Resident #101) was sliding down in chair, (CNA #6) walked in, we lowered (Resident #101) down to the floor. I (CNA #5) grabbed one arm, (CNA #6) grabbed other, (CNA #3) had legs and we put Resident #101 into bed. I (CNA #5) was closer to the bed so the side I was on fell softer then other sides." Numerous attempts were made to contact CNA #5 by this surveyor, but this surveyor was unsuccessful. The DON said CNA #5 was no longer employed by facility. Review of CNA #6 written statement dated 6/27/11 CNA #6 wrote, "...I seen (Resident #101) on the floor...(Resident #101) was lifted from the floor using 3 man, I had upper body and (CNA #5) did as well on the other side. (CNA #3) had legs. We lifted Resident #101 from floor and put into the bed, we fell forward with (Resident #101). (Resident #101's) head was at the foot of the bed at first but (Resident #101) was sat up and put into the bed properly." Numerous attempts were made to contact CNA Staff #6 by this surveyor, but this surveyor was unsuccessful. DON (Director of Nurses) said CNA Staff #6 out of country. CNA #4's written statement dated 6/27/11 was reviewed and CNA #4 was interviewed by telephone on 7/18/11 at 9:22 am by telephone. CNA #4 confirmed her written statement. CNA #4 said she helped CNA #3 Transfer Resident #101 out of the bed to wheelchair. CNA #4 said, "...actually we did not use the lift (Maxi lift). We raised the bed high...We lifted (Resident #101) off the bed into the wheelchair...I thought CNA #3 knew what she was doing as far as a correct kind of transfer." CNA #4 did not assist with transfer back to bed. Review of nurse's notes dated 6/22/11 at 6:00 am revealed staff observed that Resident #101 had a swollen right knee. Resident #101 said she "fell yesterday" (6/21/11). An X-ray was ordered. Review of the x-ray reports dated 6/22/11 revealed Resident #101 had a right and left calf bone fracture and left shin bone fracture. Physician #7 was interviewed on 7/8/11 at 3:40 pm in a conference room. Physician #7 reviewed Resident #101 progress note dated 6/24/11 and indicated Resident #101 had "severe osteoporosis". Physician #7 said, "Being transferred that way (on 6/21/11 at 10:30 pm) would have caused the fracture...(Resident #101) hasn't used lower extremities for years." Resident #101 was observed and interviewed on 7/7/11 at 2:45 pm in resident's room. Resident #101 said she fell and then pointed to right side of bed floor. Resident #101 said fall happened "a long time ago".

THIS CITATION PERTAINS TO INTAKE NUMBER MI 263 BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PREVENT FALLS FOR 1 OF 4 RESIDENTS (#101), IN A TOTAL OF 4 SAMPLED RESIDENTS AT RISK FOR FALLS, RESULTING IN THE RESIDENT EXPERIENCING A SPIRAL FRACTURE OF HER RIGHT FEMUR (BROKEN BONE OF THE THIGH), AND SUBSEQUENT SURGICAL PLACEMENT OF AN INTRAMEDULLARY ROD. FINDINGS INCLUDE: THE FACESHEET REVEALED RESIDENT #101 WAS A [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SETS ((MDS) dated [DATE], RESIDENT #101 WAS SEVERELY COGNITIVELY IMPAIRED AND WAS TOTALLY DEPENDENT ON FACILITY STAFF FOR BED MOBILITY (REPOSITIONING SIDE TO SIDE). ACCORDING TO THE SUMMARY FINDINGS REPORT DATED 5/26/2011 (UNTIMED), AND THE VARIANCE/CONCERN REPORT DATED 3/23/2011 (UNTIMED), RESIDENT #101 EXPERIENCED A FALL ON 5/23/2011 AT 2:00 A.M., WHEN SHE ROLLED OUT OF BED AS A CERTIFIED NURSE AIDE (CNA, STAFF MEMBER #5) TURNED THE RESIDENT AWAY FROM HER TO CLEAN HER OF STOOL. THE RESIDENT WAS REPORTED TO HAVE SUSTAINED INJURY TO HER RIGHT LOWER EXTREMITY. THE RESIDENT WAS REPORTED AS SENT TO A LOCAL hospital on [DATE] FOR EVALUATION. THE DISCHARGE SUMMARY OF THE LOCAL HOSPITAL EVALUATING RESIDENT #101 AFTER HER FALL ON 5/23/2011 DOCUMENTED THE RESIDENT HAD EXPERIENCED A "SPIRAL FRACTURE OF THE RIGHT FEMUR WITH INTRAMEDULLARY ROD PLACEMENT." THE RESIDENT WAS REPORTED TO HAVE BEEN discharged FROM THE hospital on [DATE]. DURING AN INTERVIEW ON 6/17/2011 AT 3:25 P.M., THE CERTIFIED NURSE AIDE (STAFF MEMBER #5) SAID, "I KNEW THIS RESIDENT (#101) VERY WELL, I'D CARE FOR HER A LOT BEFORE. SHE DOESN'T MOVE AND IS STIFF. SHE'D HAD A BOWEL MOVEMENT. I PULLED HER BRIEF DOWN WHILE SHE WAS LAYING ON HER BACK. HER BED WAS IN THE HIGH POSITION. I TURNED HER ONTO HER LEFT SIDE, AND TURNED HER AWAY FROM ME TO CLEAN HER. THERE WAS NOTHING TO BLOCK HER FROM ROLLING FORWARD. WHEN I PUT HER ON HER LEFT SIDE, THAT PUT HER WAY TOO FAR OVER TO THE LEFT SIDE OF HER BED. SHE WAS CLOSER TO THE EDGE OF HER BED THAN I'D THOUGHT. MY RIGHT HAND WAS ON HER UPPER RIGHT ARM. SHE JERKED, AND HER BODY WENT OVER THE EDGE OF THE BED; SHE fell . SHE WENT ONTO THE FLOOR ON THE LEFT SIDE OF HER BED. AS SHE fell , I PUT MY LEFT HAND ONTO HER RIGHT LEG AND GRABBED IT TO KEEP HER IN BED, BUT SHE CONTINUED TO FALL. I COULDN'T GET HOLD OF HER RIGHT LEG WELL ENOUGH. I KNOW I'M NOT SUPPOSED TO TURN HER AWAY FROM ME. I WAS TAUGHT TO TURN A PERSON TO ME, NOT AWAY FROM ME BECAUSE A PERSON HAD AN INCREASED FALL RISK AND YOU DON'T HAVE CONTROL OF THE FALL WHEN YOU TURN SOMEONE AWAY FROM YOU. WHAT I DID WAS STUPID AND DIDN'T MAKE SENSE. I SHOULD'VE TURNED HER TOWARD ME. IT WASN'T SAFE." DURING AN INTERVIEW ON 6/17/2011 AT 4:15 P.M., A NURSE (WITNESS #6) SAID, "I DIDN'T OBSERVE THE FALL ON 5/23/2011 AT 2:00 A.M. I RESPONDED TO THE EMERGENCY LIGHT AT THE ROOM. I WENT TO THE ROOM IMMEDIATELY. I FOUND THE RESIDENT (#101) ON HER RIGHT SIDE, ON THE LEFT SIDE OF THE BED. THE BED WAS IN THE HIGH POSITION. I ASSESSED THE RESIDENT, THEN I CALLED THE DOCTOR; HE ORDERED AN X-RAY FOR HER LEG DUE TO THE SWELLING. THE CNA (STAFF MEMBER #5 TOLD ME SHE TURNED THE RESIDENT AWAY FROM HER TO POSITION HER IN BED. I TOLD HER (CNA, STAFF MEMBER #5) IT WASN'T THE RIGHT WAY TO TURN SOMEBODY." DURING AN INTERVIEW ON 6/17/2011 AT 5:05 P.M., THE DIRECTOR OF NURSING SAID, "WHEN CLEANING A RESIDENT, IN BED, THE RESIDENT SHOULD BE TURNED TOWARD THE CARETAKER; IT'S THE ONLY WAY TO MAINTAIN CONTROL AND IT PROVIDES FOR SUPPORT AND SAFETY OF THE RESIDENT."

This citation pertains to intake number MI 566. Based on observation, interview and record review the facility failed to prevent and protect physical abuse in 1 of 4 sampled residents (Resident #102) resulting in the Resident #102 receiving multiple bruise and experiencing pain when she was made to get out of bed against her will. Findings include: Resident #102 was a [AGE] year old female, admitted to the facility on [DATE]. According to her Annual History and Physical she had the following Diagnoses: [REDACTED]. According to her Minim Data Set ((MDS) dated [DATE] Resident #102 was able to make herself understood by others. For Cognitive Patterns Resident #102 scored 12/15 , which means she has a mild memory deficit. For assistance required to transfer and use the toilet Resident #102 scored 3/2, which means she requires extensive assistance of one person. According to the Facility Incident Report - 24 hours, under summary of incident it reads, "2-23-2011, time 4:15 PM, Residents son reported bruising on Resident's hands and right arm. Resident stated that occurred during a transfer with a staff member. Investigation to follow." According to the Resident Care Plan for Alteration in self care/ADL's (activity of daily living) the care plan states, "Bruises easily" and Intervention states, "use gentle touch with care and transfers". According to the Hospital Consultation Report, dated 2-23-2011,"(Resident #102) was transferred from facility because of platelets of 20,000, with petechiae, although she has had no actual bleeding". Resident #102 was treated and returned to the facility the same day. Review of the Occurrence Investigation Report for Resident #102, dated 2-23-2011, at 4:15 PM. revealed "Were there any changes in Resident's behavior prior to occurrence? Resident became combative while transferring her from bed to Sara Lift (Mechanical lift) per CNA (certified nurse aide)". According to the Bath/Shower Worksheet, dated 2-23-2011, revealed a body diagram with bruising and petechiae on Resident #102. The back of the right hand shows a purple/blue area measuring 8 x 8.5 cm. The back of the left hand shows a blue/purple area measuring 9 x 6 cm. The right forward facing arm shows 5 areas, upper arm has 2 areas that were red measuring 2 x 4 cm and 3 x 1.25 cm. The lower arm showed red and pink areas 2.5 x 4.25 cm, 3 x 2 cm and 3 x 1.25 cm. Family member #1 provided pictures taken on 2-23-2011 when Resident #102 was transferred to the hospital. The bruise on the back of both hands match the above description. The bruising on the upper arm showed 4 areas of discoloration that were in alignment and appeared to represent finger pressure if someone pulled on the Residents arm. Review of the written statement by the Director of Nursing on 3-1-2011, revealed, "Interview with CNA #1." CNA #1 stated, "At 4:30 AM went into her (Resident #102's) room and told her it was time to get up. I asked her if she wanted to get up and go to the bathroom first or get weighed first. She didn't answered so I asked her "are you awake". I told her lets get up and go to the bathroom, I reached for her hand and she drew back and started yelling. So I just stopped. Then I took her by the hands and pulled her to the edge of the bed. She, (Resident #102), said if you are going to be that persistent I'll just get up. I checked her a couple times after that. I didn't notice any bruising. Just the "blood vessel", in her right hand that looked like it would pop easy. Knew she should not have transferred, admitted had been trained and in-serviced on proper transfers. Did not use gait belt stated did not fit her. Stated she was too busy. Had a total care Resident that she had to take care of . Stated she had an appointment (personal) so had to stay on time, "I could not stay over." "Normally if they resist I leave them alone and step back. Something changed with her since last time I had her. She wasn't as cooperative. Got her up at 4:30 AM because, I had to weight her." Review of the written interview conducted by Registered Nurse (RN) #1 regarding Resident #102's incident on 2-23-2011, revealed, "I asked the Resident how she got the bruises on her hands? Resident stated when they got me up to weigh me. The Resident stated it felt like nails going into my hand. I then asked the Resident what felt like nails? The Resident then grasped her right hand with her left hand and said it felt like nails were going into my hand when she was getting me up. I then asked when who was getting you up, Resident replied, the girl that weighed me. When the Director of Nursing was present (Resident #102) stated, 'she got the bruises form that girl that got her up this morning at about 4 AM to weigh her. She was sleeping when she came in to weigh her'." Resident stated, "she tried to bite the girl when she tried to get her up. The Resident went on to say she did not want to get up at 4 AM, so I might have tried to bite her." During an interview with Resident #102, on 3-10-2011 at 9:00 AM, Resident #102 was asked how she got the bruises. (Bruises still covered the majority of the surface of the back of both hands and were gray/black in color). Resident #102 said, "I remember nails going into my hands when she tried to get me up, I was so sick of getting up at 4 AM to be weighed". Resident #102 stated, "I told her I did not want to get up and she made me get up." Resident #102 was asked if she felt that the staff that got her out of bed hurt her and she replied, "yes". Resident #102 was asked if she tried to bite the staff member that got her up and she said, "yes, she would not leave me alone." During a telephone interview with CNA #1, on 3-11-201, at 9:20 AM, CNA #1 was asked what happened with Resident #102 that caused bruises. CNA #1 said she had to get Resident #102 up because she had doctors orders for weights and Resident #102 was getting tired of the process and she did not want to get up. CNA #1 went on to say that the Resident smelled wet and she needed to get her to the toilet to change her. CNA #1 said she used the crook of Resident #102's arm to get her to the edge of the bed and then pulled on her hands. When CNA #1 was asked if this was how she was instructed to transfer Residents she said, no but my gait belt was not big enough. CNA #1 was asked if she saw any bruises on Resident #102 she said she had a small one on her right hand like she had lab work done. CNA #1 was asked if she let her supervisor know about the Resident refusing to get up and the bruise on her hand, CNA #1 stated, "no the supervisor was busy". During a telephone interview with RN #2, on 3-11-2011, at 9:45 AM, RN#2 said she was not aware of the situation with CNA #1 and Resident #102 until a few days after the event. RN#2 said she was the supervisor that night. She said if CNA #1 had told her that Resident #102 was refusing care she would have gone to assess Resident #102. RN#2 was asked if there was a problem getting a gait belt to fit Resident #102. RN #2 said she had never heard of any problem getting a gait belt to fit Resident #102 and everyone has access to gait belts, and if there was a problem they are all taught to stop and get help. RN#2 said CNA #1 never reported any problems regarding refusal/difficulty with care or bruises on Resident #102. According to the police report, dated 3-1-2011 at 4:47 PM, under Interview Victim, it stated, "(Resident #102) stated about 4:00 AM every morning she is waken up by nurses to be weighed and go to the bathroom. Resident #102 stated the morning of the incident a nurse woke her up and was standing by her bed telling her to get up. Resident #102 said she did not want to get up that morning but the staff 'came with a hand' and it felt like fingernails on her hand. (Resident #102) said the staff was ugly with words. When I asked Resident #102 what she meant she replied the care giver said, 'We'll see how strong you are and you did it once you can do it again'. While interviewing Resident #102, she was vague about what happened the night of the incident and could not remember because she said she was half asleep and didn't want to get up". According to the police report dated 3-1-2011, at 4:47 PM under interview with the Nursing Home Administrator (NHA), it stated, "(name of NHA) advised, because of the pulling from (CNA #1's name) and (Resident #102's name) the bruising occurred. (Name of NHA) said the care giver was immediately suspended and was going to be terminated for improper transfer. (Name of NHA) said he believed there was no intent to harm (name of Resident #102) on (name of CNA #1), although she used improper technique and should of just let Resident #102 sleep because she did not want to get up that night." According to a copy of a letter dated 3-4-2011, addressed to CNA #1, the 2nd paragraph states, " Upon conclusion of my investigation I have found that you have violated (Name of facility) Group I Work Rules. Specifically Group I, #13, "Failure to fulfill job responsibilities to the extent that such failure has the potential for or does cause injury to a person or substantial damage to equipment or to (name of facility). Therefore, due to the serious nature of this incident your employment with (name of facility) will be terminated effective March 4, 2011.