Every finding on record at Hoyt Nursing & Rehab Centre

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include:On 07/07/2026 at 9:15 AM during the initial kitchen tour, a dirty fan with dust on the surface of the fan was observed blowing directly at clean plates stored on a cart and wrapped silverware near the steam table. On 07/07/2026 at 9:23 AM a yellow discoloration on the interior wall of the ice machine was observed. During this observation, Dietary Manager S acknowledged that she saw the yellow discoloration and stated she will have the ice dumped out and have the machine cleaned. In addition, Dietary Manager S stated the ice machine is cleaned monthly. On 07/07/2026 at 9:31 AM a utility sink with an attached hose and a chemical feeder downstream of an atmospheric vacuum breaker was observed in the janitor's closet. On 07/07/2026 at 11:45 AM during lunch observation, a fly was observed flying around the steam table in the main kitchen. On 07/07/2026 at 11:56 AM the wiping cloth sanitizer bucket stored in a cart near the stove was tested with quaternary ammonium test strips, and the result was at 100 parts per million (ppm). During this observation, Corporate Dietician T was interviewed on the sanitizer range requirement, and she stated 150-200 and that the bucket is changed out every two hours, and it's due to be changed in a few minutes. On 07/07/2026 at 12:03 PM milk was temped using a thermometer probe and the temperature was recorded at 55 F. During this observation, Dietary Manager S was interviewed on the temperature requirement for cold holding, and she stated no higher than 41 F, and proceeded to have the milk tossed out. On 07/07/2026 at 12:10PM a fly was observed flying around the serving area in the east kitchen. According to the 2022 FDA Food Code, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, Except as specified in (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: In a clean, dry location.Where they are not exposed to splash, dust, or other contamination; and.At least 15 cm (6 inches) above the floor.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 State of Michigan's 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).According to the State of Michigan's 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.According to the FDA 2022 Food Code, 6-501.111 Controlling Pests, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by .Routinely inspecting incoming shipments of food and supplies .Routinely inspecting the premises for evidence of pests .Using methods, if pests are found, such as trapping devices or other means of pest control . Eliminating harborage conditions.According to the FDA 2022 Food Code, 3-304.14 Wiping Cloths, Use Limitation, Cloths in-use for wiping counters and other equipment surfaces shall be .Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114 and The sanitizing solution must be changed as needed to minimize the accumulation of organic material and sustain proper concentration. Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit.According to the facility's Sanitation of Kitchen policy, Sanitizing of environmental surfaces must be performed with one of the following solutions: .150-200ppm quaternary ammonia compound (QAC) . and Between uses, cloths and towels used to clean and sanitize kitchen surfaces will be soaked in containers filled with approved sanitizing solution. Sanitizing solution will be changed at least two-three times per shift or if solution becomes cloudy or visibly dirty.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.According to the facility's Food Temperature policy, Cold foods must be maintained at an internal temperature of 41 F or below.

Based on observation, interview and record review, the facility failed to 1) Implement and operationalize processes and procedures to ensure the provision of accurate pharmaceutical services, 2) Ensure narcotic medication reconciliation and disposal in two of three medication carts reviewed and 3) Ensure the appropriate disposal of a fentanyl (narcotic medication) patch for one resident (Resident #16), resulting in the potential for controlled substance diversion and medication errors for all 80 facility residents.Findings include: Resident #16: On 7/07/2026, at 10:09 AM, Resident #16 was sitting upright in their bed. There was a fentanyl patch on their over bed table which was next to the bed. Resident #16 denied being in pain. Nurse E entered the room and was asked what was on the overbed table and Nurse E stated, a Fentanyl patch. I will get that. Nurse E was asked to get their manager. On 7/07/2026, at 10:010 AM, Nurse N entered Resident #16's room and was asked why there would be a Fentanyl patch on the over bed table. Nurse N stated, sometimes they just come off. The patch appeared used and had the date 7/3/26 written on it. Nurse N checked Resident #16's skin and there was a new Fentanyl patch on their right chest wall with the date 7/6/26 and secured with a see-through occlusive dressing. Nurse N removed the used fentanyl patch from the over bed table. A Tour of the 200 Hall Medication Cart was completed on 7/9/26 at 8:07 AM with Licensed Practical Nurse (LPN) G. After reviewing the contents of the medication cart, the narcotic medications were counted for reconciliation with LPN G. The form was signed as having been counted by the night shift nurse and LPN G on 7/9/26 at 6:30 AM. The total number of narcotic medication containers in the cart did not match the total number documented on the Narcotic Count Sheet. The Narcotic Count Sheet specified there were seven narcotic medication containers in the medication cart and there were eight present. LPN G confirmed there were eight narcotic medication containers in the medication cart and seven were documented on the Narcotic Count Sheet. When queried regarding the discrepancy, LPN G went through the narcotic medications and indicated a new narcotic medication must have been delivered during the night but not added to the count sheet. LPN G was asked how the discrepancy was not identified when the medications were counted in the morning, LPN G stated, (LPN H) counted it. LPN G was asked if it was their signature on the Narcotic Count Sheet form, LPN G confirmed it was. When asked why they signed the sheet if they did not complete the medication reconciliation count, LPN G stated, Honestly I didn't want you to see that it wasn't signed and it wasn't signed. At 8:20 AM on 7/9/26, an interview was completed with LPN G and LPN H. LPN H was asked if they completed the narcotic medications on the 200 Hall Medication Cart when they started their shift and responded they did. When asked why the total number of narcotic medication packages in the cart did not match the number on the Narcotic Count form if they counted the narcotics with another nurse, LPN H stated, I probably wasn't quite awake and didn't look at the sheet (Narcotic Count Form). LPN H was shown the Narcotic Count Sheet. When asked why they did not sign the form if they completed the count, LPN H signed the form next to LPN G's signature but did not provide an explanation. A review and count of the 100 Hall Medication Cart narcotics was completed with LPN H on 7/9/26 at 8:27 AM. The total Narcotic Count Sheet was signed by the outgoing night shift nurse on 7/9/26 at 6:30 AM but not signed by the incoming day shift nurse. When queried if they counted the narcotic medications in the cart with the night shift nurse, LPN H verbalized they did. When asked why they did not sign the form, LPN H did not provide an explanation. An interview was completed with the Director of Nursing (DON) on 7/9/26 at 8:47 AM. When queried regarding the facility policy/procedure related to narcotic medication count and reconciliation, the DON revealed the nurse who is leaving counts the narcotics with the nurse who is starting their shift. When queried if the staff who complete the narcotic medication count are supposed to sign the Narcotic Count Sheet, the DON verbalized they are. When asked how the total number of narcotic medication containers could be wrong if staff are counting the medications, the DON did not provide an explanation. The DON was informed of the 100 Hall Medication Cart count inaccuracies as well as the lack of signing the forms. No further explanation was provided. On 7/9/26 at 9:49 AM, a tour of the 400 Hall Medication Cart was completed with LPN I. Two loose, white colored half tablets were present in the narcotic drawer of the medication cart. The tablets were not the same size, and both had been cut in half. When queried, LPN I stated they did not know what the tablets were nor how long they had been in the drawer. Due to the tablets being cut in half, they were unable to be identified. The DON came to the medication cart. When asked, the DON was unable to say how long they had been in the narcotic medication drawer, what the medications were and/or who they belonged to. Review of facility policy/procedure entitled, Medication Storage in the Facility (Dated: 9/1/23) revealed, Policy. controlled substances are subject to special handling, storage, disposal and record keeping. E. At each shift change or when keys are transferred, a physical inventory of all controlled substances. is conducted. and is documented. F. Any discrepancy in controlled substance counts is reported to the Director of Nursing. G. Current controlled substance accountability reports are kept in the. designated binder.

Based on observation, interview and record review, the facility failed to ensure that safe medication storage and labeling procedures were implemented in two of four medication carts resulting in undated, expired, and unlabeled medications. Findings include:A tour of the 400 hall Medication Cart was completed on [DATE] at 2:03 PM with Licensed Practical Nurse (LPN) J and LPN K. The following items were noted in the medication cart:- Open and undated 30 fluid (Fl) ounce (oz) container of ProStat. The bottle specified, Discard 3 months after opening.- Box of Budesonide Inhalation Suspension 0.5 milligrams (mg)/2 milliliter (mL) (nebulizer) solution for Resident #75, Dated as Opened [DATE]. The package specified the package was good for two weeks after opening.- Novolog Flexpen (insulin), Dated as opened [DATE] with no resident name and/or identifier.- Humalog Kwik pen (insulin), Dated as opened [DATE]. The insulin pen had a room number written on it but no resident name.- Open container of Assure Prism control solution for blood glucose monitor dated as opened [DATE]. The package stated, Discard 3 months after opening. When queried regarding the ProStat bottle not being labeled when opened, LPN K revealed they were unaware the medication had to be used within a specific time frame after being opened. LPN K was then shown the date on Budesonide Inhalation Suspension and asked how long the medication is able to be used for after being opened. LPN K revealed they would need to look. LPN K was then asked who the Novolog Flexpen belonged to and responded that they did not know because the pen did not have any resident identification on it. When queried who the Humalog Kwikpen belonged to, LPN K indicated the room number written on the insulin pen and proceeded to look in the Electronic Medical Record (EMR) to locate the resident's name. When queried if residents can change rooms, LPN K replied, Yes. LPN K was then asked if labeling the insulin pen with only a room number was best practice and replied, No. An interview was completed with the Director of Nursing (DON) on [DATE] at 4:29 PM. When queried if insulin pens should be labeled with the resident's name, the DON replied, Yes. The DON was informed about the two open insulin pens in the 400 Hall Medication Cart not being labeled with the Resident name and/or other resident specific identifier, the DON verbalized that was unacceptable. When queried if medications and medical supplies that have shorten expiration dates after being opened should be labeled with the date opened, the DON verbalized they should. After being informed of expired and undated items in the 400 Hall Medication Cart, the DON verbalized understanding but did not provide an explanation. The facility policy/procedure related to medication storage and labeling was requested at this time but not received by the conclusion of the survey. A tour of the 100 Hall Medication Cart was completed with LPN H on [DATE] at 7:26 AM. The following items were present in the cart:- Novolog Flexpen, Dated as opened [DATE] with no resident name and/or identifier.- Lantus Solostar (insulin pen), Dated as opened [DATE] with no resident name and/or identifier.- Open container of Assure Prism control solution for blood glucose monitor dated as opened [DATE]. The package stated, Discard 3 months after opening. - Open and undated 30 fluid (Fl) ounce (oz) container of ProStat.

Based on observation, interview and record review, the facility failed to 1) Properly and safety store 1 E-tank (full oxygen canister), and 2) Store respiratory equipment (nasal cannula attached to concentrator and CPAP mask) when not in use for 4 residents (#3, #9, #13 and #75) of 4 residents reviewed for respiratory equipment, safety, and storage, resulting in the protentional for the oxygen tank to fall. Findings Include: Resident #13: On 7/07/2026, at 11:07 AM, Resident #13 was sitting in their recliner in their room. There was a single oxygen tank standing upright in the corner behind the recliner unsecured. On 7/07/2026, at 11:15 AM, an observation along with the Director of Nursing (DON) of Resident #13's room was conducted. The DON was asked if the oxygen tank was full and the DON stated that it's full and I will go get a holder for it. On 7/08/2026 at 9:00 AM, a record review of Resident #13's electronic medical record revealed an admission on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Hypertension and Dependence on supplemental oxygen. Resident #13 required assistance with Activities of Daily Living and had moderately impaired cognition. A review of the facility provided OXYGEN ADMINISTRATION & SAFETY Date 6/7/17 revealed . Safe Administration of oxygen therapy to the resident . when using oxygen cylinder, secure oxygen cylinder in appropriate holder . Resident #3: Review of the Face Sheet, Physician orders, Physician and Nursing progress notes dated 7/26, and care plans dated 6/26, revealed Resident #3 was [AGE] years old, alert and able to be interviewed, admitted to the facility on [DATE], after a fall with a fracture. The resident's diagnoses included, anxiety, multiple sclerosis, chronic lung disease, diabetes, respiratory failure, fall with fracture, obesity, atrial fibrillation, urinary tract infection with the presence of an automatic cardiac defibrillator. Review of Resident #3's physician orders upon admission [DATE]), revealed an order for oxygen at 3L/3 liters per nasal cannula. Review of the residents Alteration in oxygen exchange care plan dated 6/17/26, revealed oxygen/O2 3L, and stated change tubing and clean filters/devices per protocol. Review of the facility Oxygen Administration policy, dated 6/7/17, stated Oxygen administration will be provided per physician's order observing appropriate safety measures (including preventing cross contamination and illness). Resident #9: Review of the Face Sheet, Physician orders dated 6/10/26, and care plans dated 6/11/26, revealed Resident #9 was [AGE] years old, alert and his own person, admitted to the facility on [DATE] and re-admitted on [DATE]. The residents diagnosis included, obstructive sleep apnea (with use of CPAP), diabetes, attention-deficit, depression and Dementia. The resident had an order dated 6/12/26, for CPAP use at HS (at night) and remove in am. Review of the resident's facility Alteration in oxygen exchange care plan, dated 3/13/26, revealed that the resident use supplemental oxygen and used a CPAP machine and mask at night. Observations were done on 7/7/26 at 9:41 a.m. and on 7/8/26 at 10:21 a.m., of the resident in bed with his CPAP mask and tubing completely dry sitting on top of his bedside dresser; there was no clear plastic bag on his beside table. Review of the facility BI-PAP/CPAP policy, dated 6/7/17, stated BI-PAP/CPAP therapy will be administered by a Respiratory Therapist or Nurse upon order of a physician. The headgear can be hand washed in a mild soap and water solution if soiled, rinse well and air dry. During an interview done on 7/9/26 at 10:40 a.m., the Director of Nursing/DON stated, The masks and tubing (for O2 and CPAP) should be in a clear plastic bag (when not in use). Resident #75: On 7/7/26 at 9:53 AM, Resident #75 was observed in their room. The Resident was in bed with their eyes closed and they did not respond when spoke to. A nebulizer machine was in place on the dresser next to the Resident's bed. The nebulizer was turned on and running with the nebulizer administration mask above the Resident's head, between the headboard and the mattress. An oxygen concentrator was also present next to the Resident's bed. The concentrator was on and delivering supplemental oxygen at 3 liters (L)/minute via nasal cannula (NC). Resident #75 was not receiving the supplemental oxygen. The NC was observed above the Resident's head, between the headboard and mattress, near the nebulizer administrator mask. 6/13 was written on the oxygen tubing in sharpie marker. On 7/7/26 at 1:33 PM, Resident #75 was observed in their room in bed with their eyes closed. An uneaten food tray was observed on the overbed table. The nebulizer machine was turned off, and the administration mask remained in the same place above the Resident's head between the headboard and mattress of the bed. The oxygen concentrator remained on and set at 3L/minute. Resident #75 was not receiving the supplemental oxygen as the NC tubing remained in the same place as prior observation between the headboard and mattress. Record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses which included bone and prostate cancer, Chronic Obstructive Pulmonary Disease (COPD), schizophrenia, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required moderate to substantial assistance to complete Activities of Daily Living (ADLs) with the exception of supervision and set up for oral care and eating. Review of Resident #75's Electronic Medical Record (EMR) revealed a care plan entitled Potential for alteration in oxygen exchange r/t (related to) COPD (Initiated and Revised: 4/9/26). The care plan included the interventions: - Change tubing and clean filters/devices per protocol (Initiated: 4/13/26; Revised: 4/17/26) - O2 (oxygen) @ 2L/NC (Initiated: 4/9/26; Revised: 4/20/26) An interview was completed with the Director of Nursing (DON) on 7/8/26 at 4:18 PM. When queried regarding the frequency in which oxygen tubing is changed at the facility, the DON responded, Weekly. When queried regarding facility policy/procedure related to administration of nebulizer treatments, the DON indicated nursing staff should stay with the resident while the treatment is administered. When asked what the facility policy/procedure is related to nebulizer administration set after a treatment is complete, the DON stated, Take apart, rinse, dry on a towel, and then put in a clear bag after dry. When queried regarding observations of Resident #75's nebulizer, oxygen rate/administration, and oxygen tubing, the DON verbalized that was inappropriate and indicated they would educate staff. Review of facility policy/procedure entitled, Oxygen Administration and Safety (Effective: 6/17/17) revealed, Oxygen administration will be provided per physician's order observing appropriate safety measures. Procedure: 1. Check physician's order for liter flow and method of administration. 4. Oxygen tubing will be changed as needed. 5. The tubing will be stored in a plastic bag or similar storage device when not in use. A facility policy/procedure related to nebulizer/respiratory equipment storage was requested from the facility administrator on 7/8/26 at 12:49 PM but not received by the conclusion of the survey.

Based on interview and record review, the facility failed to ensure advance directives (AD) were executed, and code status was obtained per professional standards for one resident (Resident #48) of one resident reviewed. Findings include: Resident #48:Record review revealed Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia without behavioral disturbance, subdural hemorrhage (collection of blood between the brain and outermost protective membrane layer), subarachnoid hemorrhage (stoke caused by bleeding into the layers surrounding the brain), and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to moderate assistance to complete all Activities of Daily Living (ADLs) with the exception of eating. Review of Resident #48's code status documentation in the Electronic Medical Record (EMR) revealed a signed, Code Status Form dated 3/24/26. The option selected on the form was Do Not Resuscitate (DNR) and was signed by Resident #48's Family Member Witness V. Further review of Resident #48's EMR revealed the Resident had Durable Power of Attorney (DPOA) AD documentation which designated Witness V as their DPOA if they were unable to make medical decisions for themselves. A determination of incompetency was not present in Resident #48's EMR. An interview was completed with Social [NAME] Designee (SSD) W on 7/8/26 at 1:09 PM. When queried regarding Resident #48's AD and code status, SSD W stated, I know (Resident #48) has a DPOA. When asked if the Resident has been deemed incompetent, SSD W indicated they thought the Resident had. A review of Resident #48's EMR was completed with SSD W at this time. SSD W confirmed Resident #48 did not have incompetency documentation in the EMR and not been deemed incompetent. Resident #48's Code Status Form dated 3/24/26 was reviewed with SSD W. SSD W confirmed Witness V signed the form. When queried why Witness V signed the form when Resident #48 had not been deemed incompetent, SSD W stated, Shouldn't have. No further explanation was provided.An interview was completed with the Director of Nursing (DON) on 7/8/26 at 4:04 PM. The DON was asked when a DPOA takes effect and responded when a resident is unable to make their own decisions. When queried if a resident has to be deemed incompetent in order for a DPOA to be activated, the DON confirmed they did. When asked why Witness V signed Resident #48's DNR code status form when the Resident has not been deemed incompetent and responded that they should not have signed the form. The DON verbalized Resident #48 should complete and sign the form. The facility 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 1. Failed to ensure dignity for 6 residents (#3, #8, #18, #20, #89 and #90) of 18 residents reviewed for dignity regarding timely call light response from staff, and 2. Failed to provide snacks at night per confidential residents' group meeting, and resident verbalizations during the initial tour, resulting in anger, frustration, incontinent episodes, embarrassment, protentional isolation and hunger at night. Findings Include:Resident #3: Review of the Face Sheet, Physician orders, Physician and Nursing progress notes, dated 7/26, and care plans, dated 6/26, revealed Resident #3 was [AGE] years old, alert and able to be interviewed, admitted to the facility on [DATE], after a fall with a fracture. The residents diagnosis included, anxiety, multiple sclerosis, chronic lung disease, diabetes, respiratory failure, fall with fracture, obesity, atrial fibrillation, urinary tract infection with the presence of an automatic cardiac defibrillator. Review of the Nutrition care plan dated 6/16/26, revealed the resident was to have snacks/supplement offered daily. During an interview done on 7/7/26 at 10:54 a.m., Resident #3 stated It takes them (staff) over an hour to answer my light (call light); I have peed, I got mad, embarrassed; it's all the time. Resident #8: Review of the Face Sheet, Physician and Nursing progress notes dated 7/26, and care plans dated 12/29/25, revealed Resident #8 was [AGE] years old, alert and able to be interviewed, initially admitted to the facility on [DATE], The resident's diagnoses included, diabetes, end stage renal disease, gastroenteritis and colitis, anemia (low iron), high blood pressure, stroke with left sided weakness, muscle weakness and depression. Review of the Safety care plan dated 12/29/25, revealed the residents call light placement/accessibility. During an interview done on 7/7/26 at 10:29 a.m., Resident #8 stated On the weekends it takes longer (for staff to answer her call light), about an hour; they are working with less people (on the weekends). Resident #18: Review of the Face Sheet, Physician and Nursing progress notes dated 7/26, and care plans dated 3/26, revealed Resident #18 was [AGE] years old, confused and not able to be interviewed, admitted to the facility on [DATE]. The resident's diagnoses included, Dementia, anxiety, depression, history of seizures, heart disease, stroke and diabetes. Review of the residents Nutrition and Falls care plans, dated 3/19/26, revealed he was to be offered snacks, and his call light was to be accessible at all times when in bed. Observation of the resident done on 7/7/26 at 11:10 a.m., revealed him in bed with his call light clipped to the upper left side of his pillow. When asked if he could find his call light, he was unable to locate it and when told it was on his upper part of his pillow, he was not able to reach it. Resident #20: Review of the Face Sheet, Physician and Nursing progress notes dated 7/26, and care plans dated 9/25/25, revealed Resident #20 was [AGE] years old, alert and able to be interviewed, admitted to the facility on [DATE]. The resident's diagnoses included stroke with left sided weakness, seizures, metabolic disease, and adult failure to thrive. Review of the residents Nutrition and Safety care plans dated 9/25, revealed he was to be offered snacks, and his call light was to be accessible at all times when in bed. During an interview done on 7/7/26 at 9:54 a.m., Resident #20 stated Sometimes it takes an hour (to answer his call light), sometimes more than that and sometimes they (staff) don't even come. The resident was upset that staff never came at all at times when he put his call light on. Resident #89: Review of the Face Sheet, Physician and Nursing progress notes dated 7/26, and care plans dated 6/25/26, revealed Resident #89 was [AGE] years old, alert and able to be interviewed, admitted to the facility on [DATE], after cancer treatment and a brain bleed. The resident's diagnoses included cancer with chemotherapy treatments, high blood pressure, vascular disease, brain bleed, anxiety, and depression with history of a fall. Review of the residents Nutrition and Safety care plans dated 6/25/26, revealed she was to be offered snacks, and his call light was to be accusable at all times when in bed. During an interview done on 7/7/26 at 10:19 a.m., Resident #89 expressed it takes staff too long to answer her call light. Resident #90: Review of the Face Sheet, Physician and Nursing progress notes dated 7/26, and care plans dated 7/2/26, revealed Resident #90 was [AGE] years old, alert and able to be interviewed, admitted to the facility on [DATE]. The resident's diagnoses included Atrial Fibrillation, urinary tract infection, chronic kidney disease, diabetes, Parkinson's Disease, anxiety and depression. Review of the residents Nutrition and Safety care plans dated 7/2/26, revealed he was to be offered snacks, and his call light was to be accessible at all times when in bed. During an interview done on 7/7/26 at 10:49 a.m., Resident #90 stated It takes them (staff) an hour sometimes to answer the light (call light); I have wet myself and it's embarrassing. During an interview done ono 7/7/26 at 10:51 a.m., Nurse Manager, RN A stated I got here about March and it was worse with the lights (took even longer to answer residents' call lights); we need to get better, yes it takes a while for the lights to get answered. During an interview done on 7/8/26 at 2:20 p.m., the Administrator stated, 10 minutes to 15 minutes is an appropriate time to answer call lights. Review of the facility Call Report Summary, dated 7/4/26 and 7/5/26, revealed a total of 26 times in two day's that resident call lights were not answered timely (greater then 15-minute response time). Review of the facility Call Light Policy dated 5/1/17, stated Call lights will receive consistent and adequate response in order to best meet the individual needs of each resident. On 7/08/2026, at 1:41 PM, During resident council task, there were multiple complaints regarding call lights and timely staff responses; listed below: My bathroom light was on for 30 minutes before they came in They cancel call lights all the time and don't come back Sometimes they don't clip my call light on my bed at night and I can't reach it Ok, I will get you some Tylenol and then never come back They need to staff more aides at night I was on the floor and had to yell for help They never check on me at night They need to make sure our call lights are in reach The aides don't cross over (they stay on their own hall and don't help the other hall) Yhey come in and shut the light off and go away They don't even go to the other halls to help They will cancel the light and say your aide is giving a shower and not help me They will say she's finishing up with someone else and still cancel the light I will let your aide know but still cancel the light The first thing they do is shut the light off, leave and don't come back They will cancel the light and say I'm doing something else The nighttime nurses can be rude The changing of shifts you can hear them at the nurses' station. We hit the call bell, and you can hear them up there and nobody comes to answer the light A lot of time you can hear them visiting and they don't come answer the light On 7/08/2026, at 1:41 PM, during resident council task, the following complaints were voiced regarding bedtime snacks: You have to ask for snacks at night and then they don't bring you one The last two nights I didn't get it They say there's nothing in the fridge They don't stock the fridge The aides try to blame the kitchen for not stocking the fridge Why can't the aides go to the kitchen and get them (snacks) They keep the door locked (snack room) On 7/09/2026, at 8:57 AM, the Administrator was interviewed regarding call light complaints from the Resident Council and the Administrator stated, I will continue to work on call lights with them and plan to meet with the Resident Council weekly to work on their complaints. The Administrator was alerted regarding bedtime snacks and that the residents don't always get them and the administrator responded, I was told there are several snacks available. A review of the facility provided Resident Council Minutes revealed the following ongoing concerns: Date 7-3-26 . Old Business . Concerns . Call Lights, snacks yes/no . will continue to review weekly . Date 6-24-26 . New Business . Discussion with Admin regarding call lights snacks being offered, customer service . The snack issue has been addressed by ADM (dietary manager), It is a hit or miss, plans to resolve this issues will be discussed + implemented by dietary manager, + staff. Follow up .

Based on interview and record review the facility failed to ensure that psychotropic medications were used with adequate indications for use and for treatment of a diagnosed condition for one resident (Resident #48) of five residents reviewed. Findings include:Findings include:Resident #48:Record review revealed Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Unspecified Dementia, Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, subdural hemorrhage (collection of blood between the brain and outermost protective membrane layer), subarachnoid hemorrhage (stoke caused by bleeding into the layers surrounding the brain), and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to moderate assistance to complete all Activities of Daily Living (ADLs) with the exception of eating. The MDS further specified that the Resident had no signs/symptoms of depression, no indicators of psychosis, and did not display any behaviors. Resident #48 did not have a mental health and/or psychiatric diagnosis present in the facility Electronic Medical Record (EMR). Review of Resident #48's Medication Administration Record (MAR) for July 2026 revealed Resident #48 was receiving Seroquel (antipsychotic medication used to treat schizophrenia and bipolar disorder with a Black Box Warning that it is not approved to treat elderly patients with dementia-related psychosis due to an increased risk of death) 25 milligrams (mg) at bedtime related to Unspecified Dementia, Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (Start Date: 3/26/26). Review of Resident #48's Electronic Medical Record (EMR) revealed a care plan entitled, Behavior- Trauma Assessment is negative (Initiated and Revised: 3/16/26). The care plan included the intervention, Resident assessed on admission for Trauma Care needs and does not have any concerns (Initiated: 3/16/26). A second care plan entitled, I have an alteration in my mood state r/t (related to) insomnia, acute metabolic encephalopathy (sudden onset dysfunction of the brain with a reversable cause) (Initiated: 2/26/26; Revised: 3/25/26) was present in Resident #48's EMR. This care plan included the intervention, Monitor for potential side effects of psychotropic meds. (Initiated: 2/26/26). No further care plans and/or documentation of daily monitoring for signs/symptoms of side effects of psychotropic medications was noted in Resident #48's EMR. An interview was completed with Social Services Designee (SSD) W on 7/8/26 at 1:19 PM. When queried if unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety was an appropriate diagnosis and reason to take Seroquel, SSD W replied, It shouldn't be unspecified. It should be Alzheimer's/dementia. When asked if Alzheimer's/dementia was a reason to take Seroquel, SSD W replied, No. When queried, SSD W reviewed Resident #48's EMR and verbalized the Resident did not have a diagnosis and/or indication for use of Seroquel. An interview was completed with the Director of Nursing (DON) on 7/8/26 at 4:04 PM. When queried if Dementia without behaviors was a reason for a resident to receive Seroquel, the DON responded it was not. When asked why Resident #48 was receiving Seroquel with Unspecified Dementia, Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety listed as the reason, no documentation of behaviors and no non-pharmacological interventions, the DON stated that was not okay. Review of facility policy/procedure entitled, Use of Psychotherapeutic Medications (Revised: 2/1/25) revealed, A resident will not receive psychotherapeutic medications unless such a medication is needed to treat a specific condition as diagnosed and documented in the clinical record with clearly defined target behaviors and non-pharmacological interventions are not effective. Monitor Alternative Interventions: Document non-pharmacological interventions attempted before prescribing psychotropic medications.

This citation pertains to Intake Number 3053493.Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #45) of 19 residents reviewed for care plans had a comprehensive safety care plan (dated 02/24/26 and updated on 05/30/26) in place, resulting in the discontinued use of a non-skid chair mat. Findings Include: Resident #45: Review of the Face Sheet, Nursing and Physician notes dated 5/30/26 through 7/7/26, physician orders dated 2/24/26 through 6/16/26 and Hospital records dated 6/11/26, revealed Resident #45 was 85 years-old, confused, admitted to the facility on [DATE], required assist with all transfers and was a fall risk upon admission due to a recent fall outside of the facility resulting in a fracture of the right upper leg/femur. The residents diagnosis included, difficulty walking, heart disease, Dementia, Alzheimer's disease, end stage kidney disease, diabetes and anemia (low iron). The resident had a fall with a fracture and surgery of the right upper leg just prior to being admitted to the facility. Review of the resident's facility Falls/safety care plan dated 2/24/26, had the non-slip mat placed on the resident's chair discontinued by facility on 5/30/26, 3 days before the resident fell from his chair and fractured his left upper leg which required surgical intervention (05/30- discontinued mat and fell on 06/03). Nurse who discontinued was not working at facility and the surveyor was unable to contact her. During a phone interview done on 7/8/26 at 11:00 a.m., Family Member #1 C said He fell and fractured his leg at the other nursing home so we brought him here and thought they would keep him safe. Observation was made on 7/7/26 at 2:00 p.m., of Resident #45. The resident was in bed, confused and was unable to answer questions on how he fell; his chair was next to his bed with an incontinent pad on the seat, no gripper pad was on the chair. During an interview done on 7/8/26 at 9:45 a.m., Nurse Manager, RN A stated I think we need to re-look at the environment to prevent another fall. Manager A said she was not aware the residents non-slip chair pad had been removed from his safety care plan. During an interview done on 7/8/26 at 10:00 a.m., the Director of Nursing was not aware he did not have the any non-slip chair pad in his chair (he frequently sits in the chair and fell out of the chair on 6/3/26). During an interview done on 7/8/26 at 10:06 a.m., Cooperate Nurse, RN B stated Something else should of been put in the chair; the dycum (name of non-slip pad in chair) was wrinkling up and he did not like it so we took it off. Review of the facility Baseline Care Plans policy, dated 12/8/25, stated The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered and care of the resident that will meet professional standards of quality care.

Based on observation, interview and record review, the facility failed to maintain physician's orders and maintain the head of the bed safely for one resident (Resident 7) of one resident reviewed for enteral feeding, resulting in the likelihood of aspiration and/or illness. Findings include: Resident #7:On 7/07/2026, at 10:42 AM, Resident #7 was lying in their bed with their enteral feeding solution hooked up to their abdomen and infusing. The head of the bed angle appeared to be about 20 degrees elevated. On 7/07/2026, at 10:46 AM, an observation with Nurse N of Resident #7's angle of elevation for their head of the bed revealed she's at 25 degrees. Nurse N elevated the head of the bed to the appropriate elevation for safe enteral feeding infusion. On 7/08/2026, at 9:30 AM, a record review of Resident #7's electronic medical record revealed an admission on [DATE] with diagnoses that included Gastrostomy status, dysphagia and stroke. Resident #7 required extensive assistance with Activities of Daily Living and had moderately impaired cognition. A review of the physician orders revealed Elevate HOB to 30-45 degrees at all times during feeding and for at least 30-40 minutes after the feeding is stopped every shift for tube feeding . Active Start Date 10/31/2025 .

Based on observation, interview and record review, the facility failed to ensure timely management and implementation of updated interventions for pain management for one resident (Resident #5) of one resident reviewed. Findings include: Resident #5:An interview was completed with Resident #5 on 7/7/26 at 4:21 PM. When queried, Resident #5 verbalized they have pain in their back, legs, and arm. When queried regarding interventions to help relieve their pain, Resident #5 responded, They give me something (medication), it helps but don't take it away. When queried regarding their current pain level, Resident #5 indicated it was currently tolerable but would get very bad. When asked to rate their pain on a scale of zero to 10, Resident #5 shrugged their shoulders and indicated they were not sure. Resident #5 was asked if they spoke to staff regarding their pain and their current medications not controlling their pain and responded they did. Resident #5 then stated, The Doctor came in last week and said he was gone get me a brace for my (right) hand and change my meds but ain't got nothing. Review of Resident #5's Electronic Medical Record (EMR) revealed the Resident was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), chronic viral hepatitis C, spinal stenosis, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, used a wheelchair for ambulation, and was able to complete Activities of Daily Living (ADLs) independently. The MDS further detailed the Resident received daily medication for pain. Review of Resident #5's EMR revealed a care plan entitled, Pain Management r/t (related to) -chronic viral hepatitis C -spinal stenosis. -OA (Osteoarthritis) -opioid med (Initiated and Revised: 12/5/25). The care plan included the interventions:- Medications as ordered (Initiated: 12/5/25; Revised: 12/15/25)- Assess for verbal & non-verbal s/sx (signs/symptoms) of distress or pain unrelieved by ordered meds (Initiated: 12/5/25; Revised: 12/15/25)- Discuss concerns regarding pain management with the MD & consulting pharmacist PRN (as needed) (Initiated: 12/5/25; Revised: 12/15/25) Review of documentation in Resident #5's EMR revealed the Resident had been complaining of wrist/arm pain since 6/10/26 and was seen by the Physician on 6/28/26 related to pain. Detailed review revealed the following:- 6/10/26 at 2:45 PM: Nurse's Note. Resident c/o pain in right wrist able to move wrist without difficulty. - 6/12/26 at 1:53 PM: Nurse's Note. Resident reports mild pain to BIL (bilateral) wrist and forearm. - 6/19/26 at 12:00 PM: Nurse's Note. This writer spoke with resident (has) complains of right hand pain with swelling stated ice does not help the pain. This writer reached out DR. x-ray order. - 6/25/26 at 10:35 AM: Nurse's Note. Contacted Dr to inquire about getting a doppler ordered on Pt Right wrist/arm due to the mass and pain (Resident) has been continuously experiencing. Awaiting follow-up - 6/28/26 at 4:39 AM: Physician's Note. Follow-up on presenting issues as well as review of the chronic medical conditions' patient is currently taking active medical treatment for including medications and non-pharmacological interventions. This patient has evidence of osteoarthritis in multiple joints. focus on improving pain in quality of function. Has increased pain. Will increase Neurontin (medication used to treat nerve pain). Review of Resident #5's Health Care Provider (HCP) orders and Medication Administration Record (MAR) on 7/7/26 revealed the Resident was receiving the following medications for pain:- Gabapentin (Neurontin) 300 milligram (mg) twice a day for Degenerative Joint Disease related to spinal stenosis (Start Date: 12/5/25).- Tylenol 650 mg every six hours for pain (Start Date: 12/5/25).- Buprenorphine HCl-Naloxone HCl (Suboxone- medication used to treat opioid dependence) 2/0.5 mg tablet sublingually twice a day with the indication listed as being used for pain (Start Date: 4/1/26).Resident #5 was admitted to the facility on Buprenorphine HCl-Naloxone HCl 2/0.5 mg two tablets three times a day and changed to one tablet sublingually twice a day in April 2026. Resident #5 had no medication changes following Physician documentation on 6/28/26 specifying they were going to increase the Resident's Neurontin dose. An interview was completed with Licensed Practical Nurse (LPN) F on 7/9/26 at 10:11 AM. When queried if there had been any changes in Resident #5's pain medications recently, LPN F reviewed the Resident's EMR and stated there had not been. When asked if the HCP had ordered a splint or brace for the Resident's arm/wrist recently, LPN F reviewed the EMR and stated they had not. An interview was completed with the Director of Nursing (DON) on 7/9/26 at 11:57 AM. When queried regarding Resident #5 verbalizing complaints of pain and lack of implementation of planned pharmacologic and non-pharmacologic interventions per their discussion with the Physician, the DON revealed they were unaware Resident #5 had requested additional interventions related to pain. The DON was then asked why Resident #5's Neurontin dosage had not been increased after the Physician documented they were going to increase in on 6/28/26, the DON revealed they were unsure and would need to review Resident #5's EMR further and speak to the Physician. A follow up interview was conducted with the DON at 12:10 PM on 7/9/26. When asked about Resident #5, the DON stated, We are going to increase it (Neurontin) and get with Therapy (services) about a brace. When asked why the interventions had not been ordered when indicated by the Physician in their note dated 6/28/26, the DON stated, It should have been caught in our morning meeting and note review honestly. No further explanation was provided. The facility pain management policy/procedure was requested from the facility Administrator on 7/9/26 at 12:06 PM but not received by the conclusion of the survey.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan for one resident (Resident #48) of one resident reviewed for dementia, resulting in the potential for lack of services and care. Findings include:Resident #48:On 7/7/26 at 11:24 AM, Resident #48 was observed sitting in their room in a chair. Family Member Y was sitting at their bedside. An interview was completed at this time. When asked questions, Resident #48 was pleasantly confused and did not always respond when asked questions. When queried, Family Member Y revealed the Resident has dementia is confused at times. Record review revealed Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Dementia without behavioral disturbance, subdural hemorrhage (collection of blood between the brain and outermost protective membrane layer), subarachnoid hemorrhage (stoke caused by bleeding into the layers surrounding the brain), and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to moderate assistance to complete all Activities of Daily Living (ADLs) with the exception of eating. Review of Resident #48's care plans in the Electronic Medical Record (EMR) revealed the Resident did not have a care plan in place related to dementia. Review of progress note documentation in Resident #48's EMR revealed the Resident was alert with some confusion. A Physician's Note dated 6/18/26 at 1:35 PM specified, In terms of dementia according to the nursing staff (Resident) has been doing about the same. is directable mostly by the staff. is not fighting with the staff about any care at present. Further review revealed the Resident had falls at the facility and did not consistently call for staff assistance. An interview with Social Services Designee (SSD) W and Social Services Director X was completed on 7/9/26 at 11:40 AM. When queried if Resident #48 had dementia, staff confirmed they did. When queried regarding a care plan and individualized interventions related to the Resident's known dementia, SSD W stated, Should have a care plan for dementia because (Resident #48) has had that a long time. When asked why the Resident did not have a care plan related to dementia and interventions to ensure they receive appropriate/personalized treatment and care, SSD W did not provide an explanation but confirmed the Resident should have a care plan. The staff were then queried regarding the facility procedure related to assessment of needs for residents with dementia to ensure they receive the necessary care to help them achieve their highest possible level of wellbeing and a response was not provided. An interview was completed with the Director of Nursing (DON) on 7/8/26 at 4:04 PM. When queried regarding Resident #48 not having a care plan for dementia, the DON revealed they were unaware of the Resident not having a care plan. When queried regarding individualized care and interventions related to the Resident's dementia, the DON was unable to provide an explanation. A facility policy/procedure related to assessment and management of residents with dementia was requested at this time but not received by the conclusion of the survey.

Based on observation and interview, the facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include:On 07/07/2026 at 9:46AM dirty cups, a plate, napkins, wrappers, gloves, and a plastic lid were observed on the ground surrounding the dumpster area. On 07/08/2026 at 9:40AM during the environmental tour with Maintenance Director U was interviewed on maintaining the dumpster area, and stated that housekeeping checks the area and the dumpster area is checked daily. According to the FDA 2022 Food Code, 5-501.115 Maintaining Refuse Areas and Enclosures A storage area and enclosure for refuse, recyclables, or returnables shall be maintained free of unnecessary items.

Based on observation, interview and record review, the facility failed to 1) Ensure that the Infection Control data was fully analyzed for February 2026, 2) Ensure that clean linen was transported with a cover on it, and 3) Ensure that 1 of 2 urinary catheters reviewed for infection control standards was sanitarily maintained, resulting in the protentional for cross contamination, increased risk for urinary tract infection with antibiotic usage, incorrect infection rate and incorrect data analysis for the month of February 2026. Findings Include: On 7/07/2026, at 10:31 AM, CNA M was observed in the hallway near room [ROOM NUMBER] with multiple bed pads uncovered tucked under their arm. The linen was touching their uniform. CNA M entered an enhanced barrier precautions (EBP) room; 312 and set down half of the bed pads before leaving out of the room with the remaining bed pads under their arm. The bed pads were touching the front of their uniform. CNA M was asked if they normally carry clean linen uncovered and why they entered the EBP room, drop off half the linen and exit with the remaining linen and CNA M stated, I normally only have 1 but I knew she was looking for some. CNA M walked down the hall towards the nurses' station with the remaining two bed pads under their arm. On 7/07/2026, at 10:37 AM, CNA L was observed carrying clean linen/bed sheets tucked under their left arm, uncovered. The linen was touching their uniform. CNA L entered room [ROOM NUMBER] with the linen and then exited the room without the linen. CNA L was asked if they were making the bed in room [ROOM NUMBER] and CNA L stated, not right now, I will come back to do it. On 7/09/2026, at 10:52 AM, Infection Control Nurse (IC) D was alerted of the linen observations from Day 1 of the survey. Resident #75: On 7/7/26 at 9:53 AM, Resident #75 was observed in their room. The Resident was in bed with their eyes closed and they did not respond when spoke to. An indwelling urinary catheter drainage bag was observed directly on the floor on the right side of the bed, towards the hallway door. On 7/7/26 at 1:33 PM, Resident #75 was observed in their room in bed with their eyes closed. An uneaten food tray was observed on the overbed table. A wheelchair was directly next to the right side of the Resident's bed and their indwelling urinary catheter drainage bag was hooked to the bottom of the wheelchair. The catheter drainage tubing was visibly taunt and stretched. Record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses which included bone and prostate cancer, Chronic Obstructive Pulmonary Disease (COPD), schizophrenia, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required moderate to substantial assistance to complete Activities of Daily Living (ADLs) with the exception of supervision and set up for oral care and eating. The MDS further detailed the Resident had an indwelling urinary catheter. Review of Resident #75's Electronic Medical Record (EMR) revealed a care plan entitled Use of indwelling catheter. (Initiated: 4/17/26; Revised: 7/8/26). The care plan included the interventions, - Ensure the foley catheter is anchored q (every) shift (Initiated: 4/17/26) - Assure catheter and drainage bag are below the level of the bladder (Initiated: 4/17/26) - Check catheter system every shift for patency and integrity (Initiated: 4/17/26) - Foley cath care q shift (Initiated: 6/20/26) An interview was completed with the Director of Nursing (DON) on 7/8/26 at 4:18 PM. When queried regarding indwelling urinary catheter drainage bags, the DON verbalized drainage bags should not touch the floor. When queried regarding observations of Resident #75's urinary catheter drainage bag, the DON responded that the Resident does that sometimes and should have a care plan. Resident #75's care plans were reviewed with the DON at this time. After review, the DON confirmed the Resident did not have a care plan in place related to placing the urinary catheter drainage bag on the floor. Review of facility provided policy/procedure entitled Catheter Care. (Revised: 8/17/17) did not include information pertaining to urinary catheter drainage bag placement. On 7/7/26 at 3:28 p.m., this surveyor requested the analyzing data for the month of February 2026; Infection Control Nurse, RN D pulled the fille of monthly analyzing sheets from her Infection Control book for this surveyor. Infection Control Nurse D said the questions were not all filled in for February 26, and she was not at the facility at the time. On 7/8/26 at approximately 8:30 a.m. Cooperate Infection Control Nurse, RN E said Infection Control Nurse D was not supposed to give you (this surveyor) that information (analyzing data from 2/26,) without letting me see it first. Review of the facility Monthly Infection Control Analysis dated 2/26, signed by the previous Director of Nursing, revealed the following: -Page 1: Blank answer for question regarding antibiotics prescribed (yes or no question). -Page 2: Blank answer for questions #1, #2 and #4 (yes or no questions) -Page 5: Blank answer for questions #6 (community risk factors previous month data), #7, #8, and #1, #2 and #3 under question #9 (Influenza Vaccination Rate of 80%, resident and employee data). -Page 6: Blank answers under Pneumonia vaccination rate of 75%, under Interpretation of respiratory Data, all the questions were left blank (yes or no questions). -Page 7: On top under Monthly Infection Control Analysis all the questions were left blank including (yes or no questions). -Page 8: On the bottom, under Interpretation of Skin Infections (data showed x1 skin infection) all the questions were left blank (yes or no questions). -Page 9: On top (continuing from page 8), all the questions were left blank (yes or no questions). -Page's 11 & 12: Under Outcome Surveillance-Other Infection Data, there was data of 1 confirmed other infection; on page 12, the top questions (under Other Infections) and under Interpretation of Other Infection Data all the questions were blank (yes or no questions). -Page 13: At the bottom of the page, under Interpretation of Process Surveillance, all questions were blank (yes or no questions). -Page 14: The question, Were there any trends in knowledge deficit it was blank (yes or no question), under Summary of Trends and Correction Action Plan, no documentation was found, and under QA committee questions, it also was blank. Review of the facility Infection Control Long-Term Care program, dated 2014, stated The duties of an Infection Preventionist include: Collecting and analyzing data. Review of the facility Infection Prevention and Control Program, dated 11/22/19, stated the program must provide ongoing analysis of surveillance data and review of data and documentation of follow-up activity in response.

This Citation pertains to Intake Number 2995609.Based on interview and record review, the facility failed to ensure that quarterly care planning meetings were accomplished and that the resident and resident's representative were included in the care planning allowing them to make informed decisions regarding healthcare and treatment options for one resident (Resident #1) of one resident reviewed for care planning. Findings include:Resident #1 (R1):A review of R1's medical record revealed an admission into the facility on 5/9/24 and a readmission on [DATE] with diagnoses that included fracture of right femur, history of falling, unsteadiness on feet, abnormalities of gait and mobility. A review of the Minimum Data Set assessment, dated 3/4/26, for R1 revealed a Brief Interview of Mental Status score of 14/15 that indicated intact cognition and the Resident needed substantial/maximal assistance to roll left and right and was dependent on helper for transfers. On 5/7/26 at 10:44 AM, an interview was conducted with Resident Representative (RR) B regarding R1's care at the facility. The RR reported that the Resident had a fall in November of 2025 that he complained he was having pain in his leg that they did an x-ray of and the pain continued, they did another x-ray, but it did not show the fracture. The RR said, He kept telling them he was still in pain, and they just gave him pain medication. The RR reported the Resident called the ambulance himself, he was fed up with them not doing anything, he was hurting so bad that day, the hurt was so painful, and they would just give him pain pills and tell him he was getting better, but he wasn't. The RR reported the Resident called 911 to come get him, the Nurse told the RR that they would check him out and send him right back. The RR stated, He told them he was hurting but they didn't believe him. He has not stopped complaining of the pain since November. The RR reported he went to the hospital, and they found the fracture and had surgery. The RR reported that the fall happened in November of 2025 and he called the ambulance himself in April when he couldn't stand to be in pain all the time. The RR was asked if she had attended the care conference and brought up the issue of continued pain. The RR reported she was not familiar with what a care conference was. When asked if she had been invited to attend a meeting regarding R1's care, the RR reported she had not been asked to attend any meetings. When asked if she received a call about results of a care conference, the RR stated, they called when he fell, but did not indicate a call regarding care conferences. When asked if they had talked together with the Resident and staff members regarding his ongoing pain, the RR reported staff had not talked to her about his pain or a plan for care with the extended complaints of pain. On 5/7/26 at 12:58 PM, an observation was made of R1 lying in bed with the head of the bed elevated. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about his fall in November. The Resident reported he was doesn't remember where he fell but he remembered a CNA (Certified Nursing Assistant) helped him into bed and stated, I told the nurse afterwards, and expressed being in a lot of pain in his hip, I laid in the bed hurtin, hurtin, hurtin. The Resident reported that x-rays were done at the facility and stated, I got two sets from here. The Resident reported they said I didn't have anything wrong. The Resident stated, I told them I wanted more done, an MRI or something. The Resident reported calling the ambulance, getting a cat scan, seeing the fracture, got more x-rays that confirmed a fracture, having surgery and returned to the facility. The Resident reported that he had pain from the surgery, but it was getting better and he was finally getting relief from pain.The Resident was asked about care conferences or meetings held to discuss his care with a team at the facility, the Resident reported not knowing what a care conference was and that they had no meetings and stated, They knew I was in pain. When asked if he had a meeting with staff and his Guardian, the Resident reported not having a meeting like that. When asked if they contacted his Guardian or left a note for them to have a meeting, the Resident reported that his Guardian would have come if she could but did not know of her being asked to come to a meeting to discuss his care. On 5/11/26 at 1:12 PM, an interview was conducted with the acting Director of Nursing (DON) regarding R1's care. The DON was asked about care conferences and facility policy on how often they were to be conducted. The DON reported that care conferences were held quarterly and as needed. The DON was asked about when the care conferences were for R1. The DON reviewed the medical record and stated, The last form I see was in September. The DON checked the progress notes for recent care conference notes and stated, It looks like September was the last one. When asked if the Guardian was informed of or attended the care conference, the DON reported she could not tell from the note. The DON confirmed that they should have had a care conference quarterly or every three months and the Guardian would be invited to attend. It was asked that had they had a care conference the concern of the resident's pain could have been a conversation and set a plan of care. The DON stated, I can't fix the past, going forward we are working on the processes. A review of the facility policy titled, Care Plan Conference: Scheduling and Residential/Family Invitation, revealed, Policy: The facility should involve the resident, resident's family or representative in the care planning. Their attendance and participation in the care plan conference must be encouraged through timely invitation. The Care Plan Conference for long term care residents must be scheduled at least seven (7) days after the ARD of scheduled MDS (Minimum Data Set assessment) . 3. The facility designee shall generate the following: a. Care Plan Conference letters addressed to the following recipients (as appropriate): i. Family Member/Responsible Party; ii. Guardian; b. Invitation addressed to the Resident. 5. The facility designee shall receive the phone call or verbal confirmation or regret from the Resident and/or Family Member/Responsible Party. 6. The facility designee shall communicate to the Social Worker if the Family Member/Responsible Party opted for the post-Care Plan Conference phone call and the anticipated date and time of phone call.

Based on observation, interview and record review, the facility failed to prevent the development of a facility-acquired, Stage IV pressure ulcer for one resident (Resident #58) of two residents reviewed, resulting in the development of a new left heel pressure injury, while residing in the facility with the potential for pain /discomfort, prolonged illness, and infections. Findings include: Resident #58: In an interview on 05/20/25 at 08:56 AM Resident #58 stated that she has a new sore to the bottom of her foot that she did not have when she came. Resident #58 was noted to be seated in a reclining position in the bed watching (Detroit) Tiger baseball on TV. Observation of APM air mattress to bed was in place set to 27-minute cycle with #5 comfort level settings. There were no soft boots noted on the resident at that time. Record review of Resident #58's 'Skin & Wound' tab in the electronic medical record revealed that on 1/9/2025 a wound photo noted left heel eschar, a new pressure injury. Measurements of the left heel pressure injury were documented as: new exact date 1/9/2025 length 3.58cm x width 3.25cm with black eschar noted, pressure wound in-house acquired. In an interview and record review on 05/21/25 at 12:52 PM, the Unit manager Registered Nurse L was asked by the state surveyor how the wound got to eschar without anyone noticing. RN L stated that it was the former Assistant Director of Nursing's (ADON) unit at the time the heel wound was discovered. RN L manages units 1 & 2 There is no manager for that 300 unit right now. Record review of Resident #58's Skin assessments documented no skin injuries until 1/9/2025 when eschar was noted . RN L stated skin assessments should be done weekly every 7 days; aides are to notify nurses on shower days. Residents get 2 showers a week. Once reported to the nurse, the nurses establish a treatment, notify the physician, and implement the weekly photos of the progression. There is no wound nurse here in our facility. Floor nurses do the treatments If the treatment is not working, notify physician to get new orders. Record review of Resident #58's pressure ulcer photo on 2/17/2025 by the former Director of Nursing Staging wound- left heel Level 4 on 2/17/2025, cannot backstage a wound. RN L was asked again, how did it get from nothing to eschar with no treatments or documentation. RN L reviewed Resident #58's Skin care plan and stated that there was no pressure relieving devices. a care plan to turn and reposition frequently, observed skin daily and report issues, aides did not follow the care plan. Was the pressure ulcer avoidable? RN L stated yes avoidable, could have used profo/soft boots or repositioning and added skin prep to heels, elevate heels, and wash and dry heels daily. In an observation (of Resident #58's left heel wound) and interview on 05/21/25 at 01:24 PM with Licensed Practical Nurse (LPN) N, Resident #58 stated I don't know how it got there. My foot hurts, I don't know why it hurts, it just does. Resident #58 started to scream when asked to look at her left heel, no, no, no, it hurts when they touch it. Reapproach/re-try tomorrow for observation. In an interview on 05/21/25 at 02:19 PM, the Director of Nursing and Clinical Consultant A notified the state surveyor that there were no nursing policies for: Pressure ulcer staging for skin, nursing documentation policy, physician order policy, and/or standards of care policy. The Clinical Consultant stated, we have standards used by Google. The nurses use their cell phones. Observation and interview on 05/22/25 at 08:12 AM with Licensed Practical Nurse (LPN) C of Resident #58's left heel dressing dated 5/20/2025 drainage was noted on the dressing, wound packing alginate with foam border dressing. LPN C applied gloves and removed the foam dressing to observe the wound site. No measuring device was brought into the room, estimated to be golf ball size wound area with alginate packing noted with serosanginous drainage that fell out of the wound. LPN C then the old dressing was placed back on wound and sock re-applied by the nurse. In an interview and record review on 05/22/25 at 08:22 AM, Registered Nurse (RN)/Infection Control Nurse/Staff education Nurse K reviewed Resident #58's electronic medical record 'Skin & Wound' photos of the 1/9/2025 left heel wound, blackened with eschar. RN K stated that it would first appear as a reddened area, then into a fluid-filled blister within a couple of days, and, if not getting pressure relieved, the blister will turn to eschar/black tissue. The looks of that would take more than a week, but less than a month. Residents do get showers twice weekly and as needed, The Certified Nurse Assistants (CNA) should be completing skin checks with each shower and reporting to the nurse. and the nurse initiates the photos and skin Assessment forms. Record review of facility's 'Wound Management Program' policy, dated 8/17/2017, noted that to ensure that residents who are admitted with, or acquire, wounds, receive treatment and services to promote healing, prevent complications, and prevent new skin conditions from developing Monitor skin changes during routine daily care .

Based on interview and record review the facility to timely update and formulate advance directives for two residents (#37 and #239) of two residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time). Findings Include: Resident #37: On [DATE] at 3:20 PM, a review was conducted of Resident #37's medical record and it indicated she admitted to the facility on [DATE] with diagnoses that included Atherosclerotic Heart Disease, Diabetes, Hypertension, Dementia, Orthopedic aftercare, Anxiety and Depression. Further review of Resident #37's chart showed there had been no discussion with the resident or her daughter regarding formulating advance directives. Social Services Assessment [DATE]: -No mention of advance directives nor is there is section within this assessment to address it. Progress Notes: [DATE] at 02:27: Resident arrived via (ambulance) 2 pa (person assist) resident here for after care of electrical cervical laminectomy, resident can make her needs known .she also have very high anxiety . Scanned Documents: There were no updated advance directives forms uploaded into Resident #37's record from her [DATE] admission. On [DATE] at 11:36 AM, an interview was conducted with Social Worker Q regarding Resident #37's advance directives. Review was conducted of the Social Work assessment, and it was explained there is not a section available in that assessment that prompts them to ask about advance directives. Further review was conducted of the progress notes and scanned documents and there was nothing that was located that indicated it was discussed with the resident upon her admission to gather her wishes. Social Worker 'Q stated advance directive should be reviewed with each resident upon admission and updated as needed. Resident #239: On [DATE] at 12:10 PM, a review was conducted of Resident #239's medical record and it indicated he was admitted to the facility on [DATE] with diagnoses that included, Muscle Disorder, Dysphagia, Dementia, Atrial Fibrillation, Chronic Kidney Disease, Ataxia, Cardiac Murmur, Alzheimer's Disease and Heart Failure. Further review revealed Resident #239's daughter is his responsible party. Physician Orders: CPR (Cardiopulmonary resuscitation) by Default- initiated on [DATE] DNR- Do Not Resuscitate - initiated on [DATE] Resident Dashboard: Code Status: (Advance Directives) CPR by Default, DNR- Do Not Resuscitate DNR Order: Completed with appropriate signatures on [DATE]. On [DATE] at 12:50 PM, Social Worker R stated Resident #239's daughter brought in all his documents, and they updated his code status to DNR. Review was conducted of his medical record and in his orders both CPR and DNR were listed. Social Worker R reported staff must have added the updated code status and not removed the previous one. The social worker explained she is not able to initiate or update the orders sections. Review was completed of facility policy entitled, Resident Code Policy, revised [DATE]. The policy stated, .Upon admission the admission coordination, admission nurse or social worker will review residents' choices related to code status .

Based on observation, interview and record review, the facility failed to update care plans for one resident (#69) of two residents reviewed, resulting in a failure to add interventions for timely reweighs of Resident #69 to prevent weight loss. Findings include. Resident #69: Observation on 05/20/25 at 02:25 PM of Resident #69 was lying in bed with the head of the bed elevated. Resident #69 was noted to have loose skin to neck and upper arm areas. The surveyor questioned possible weight loss. Record review of resident medical record weights log on 04/07/2025, the resident weighed 131.4 lbs. On 05/07/2025, the resident weighed 121.2 pounds which is a -7.76 % Loss in 30 days. Record review of Resident #69's 'Nutritional' care plan date initiated 8/1/2024 and revision date of 2/27/2025 revealed that there were no added interventions to address the new weight loss of 10.2 pounds in 30 days. There were interventions to re-weigh the resident in a timely manner, or when to re-weigh on a regular basis. In an Interview on 05/21/25 at 02:45 PM with the Registered Dietitian (RD) M stated that Resident #69 did have a weight loss. She previously had a weight gain, she wants to level out, I removed one of her supplements, she was on supplement since admission April 2024, due to wound protein needs, she has a wound stage 4. I removed a protein shake that was higher in calories, I removed it last month. Record review of Resident #69's weight log revealed weight on 5/5/25 of 138.1 then on 5/12/2025 125.2 pounds, her weights i cannot tell you what's going on with her. The CNAs do the weights, inconsistent weights from sitting to mechanical weights were documented. Weights from 4/7/2025 through 5/7/2025 were a 10-pound weight loss. I reviewed her weights, wrote notes. Record review of resident care plans- revealed no added interventions for closer monitoring of weight loss. Record review of the facility Weight policy, did not state when to get a re-weight on a resident, there were no specified time frame noted for re-weight expectations of Certified Nurse Assistant in a timely manner. The Registered Dietitian (RD) M stated My expectation would be within 48 hours is what I would expect. The standards of care for dietitians are 48 hours to get a re-weight. Review of the policy tells me that weekly weight x4 weeks from admission and then once monthly, unless an order from doctor, or a weight change of 3/5# plus or minus, then a re-weight is done, then we go to weekly weights. 39059

Based on observation, interview and record review, the facility failed to document and notify the physician of a popped/ruptured boil/skin condition for one resident (Resident #36), resulting in Resident #36 having a right anterior neck boil that was 'popped by a staff member with no physician's order, no documentation of the wound site and drainage, with the potential for infection. Findings include: In an interview on 05/21/25 at 02:19 PM with the Director of Nursing and Clinical Consultant A notified the state surveyor that there were no nursing policies for: Pressure ulcer staging policy for skin, Nursing documentation policy, physician order policy, and/or standards of care policy. The Clinical Consultant stated, we have standards used by goggle, nurses use their phones. Resident #36: Record review of Resident #36's 'Skin assessment' form dated 5/9/2025 noted a boil to right side back of neck, there were no measurements of size of diameter and/or height, color or edema of the boil noted. The nurse practioner was notified and orders of warm compress and monitor were ordered. Record review of Resident #36's progress notes dated 4/1/2025 through 5/22/2025 at 11:00AM revealed there to be no mention of a boil to the back of resident's neck or that the boil had been popped by staff. Record review of Resident #36's physician orders for the month of May 2025 revealed: On 5/10/2025 to apply warm compress to back of residents neck and monitor twice a day for wound care AND one time only for 1 day. Record review of the Treatment Administration Record for May 2025 revealed: On 5/10/2025 to monitor boil on back of neck for signs/symptoms of infection and notify physician every shift. On 5/21/2025 treatment of: cleanse boil on back of neck with normal saline and apply triple antibiotic ointment and cover with a 4x4 gauze dressing one time a day until healed. One time a day for ruptured boil on the back of neck until 6/3/2025. Start 5/21/2025. Observation and interview on 05/22/25 10:15 AM with the Director of Nursing (DON) and of Resident #36 had left back a left neck area with dressing in place, not dated. Observation of Resident #36's room noted no enhanced barrier precautions and no preventive caddie over the door. Observation of Resident #36's right side rear neck dressing noted Blood seeping through dressing onto his navy-blue sweatshirt. The state surveyor Observed the Director of Nursing (DON) with dressing tray with supplies on her way to Resident #36's room. The state surveyor observed DON to close the window blinds and drew the privacy curtain between beds (no enhanced barrier of gown worn). The DON used Hand sanitizer and gloved, removed old dressing, observed a ping pong size lump with bright red bleeding noted, drainage to run down neck. The DON placed triple antibiotic ointment using a swab stick was applied, and boarder gauze dressing was applied. During the dressing change observation Resident #36 stated that the nurse the nurse popped it (boil) yesterday, and the blood hit the wall. Record review of Resident #36's physician orders revealed that the resident was on anticoagulant Eliquis 5mg oral daily and Aspirin 81mg oral daily (both medications inhibit clotting factors). In an interview on 05/22/25 at 11:05 AM with Registered Nurse (RN)/Infection Control nurse/Staff education K what was the Dressing change expectations? RN K stated A saturated dressing should be changed as needed. Enhanced barrier of a gown should be worn. She was not aware that Resident #36 had an open wound, or that there was a need for enhance barrier precautions, or to follow the wound for healing/infection. Record review with RN K of Resident #36's physician orders revealed that there was no order for the popping of the boil to right back neck of resident #36. There were no progress notes, no physician notes and no care for the boil added to the care plans. Record review of the facility 'Assessment, Resident' policy dated 7/1/2008, revealed the purpose to identify the resident's care needs, to develop a comprehensive plan of care for the residents . (9.) Examine the head and neck: (c.) Drainage. (D.) Open areas. (G.) Growths and document assessment. In an Interview and record review on 05/22/25 at 11:11 AM with the Director of (DON) of Resident #36 was notified that Resident #36 stated that the nurse popped (boil) it yesterday. He stated the blood hit the wall. Record review of Resident #36's progress notes revealed there to be no notes regarding the boil, the popping/rupture of the boil as reported by the resident. Record review of resident care plan revealed that there was no mention of the boil or to monitor. In the interview with the DON stated that she did the PRN dressing change and wrote an order for a dressing change scheduled. No, she did not wear a gown for the change. I don't know who popped the boil, no there was not an order to pop it. Not sure if the physician knew about the boil, there is no notes. In an interview on 05/22/25 at 11:47 AM with Resident #36 stated the nurse, she squeezed the boil earlier this week. The nurse (Licensed Practical Nurse B) while they were looking at it, she squeezed it (the boil), and the blood squirted on the wall. It was the Licensed Practical Nurse (LPN) B she got blood on her watch and had to wipe it off. It does feel better, it hurt like the dickens when she squeezed, after it popped it took the pressure off it. It does seem to keep bleeding. When she popped the boil, I thought I'd need a blood transfusion, it seemed like a lot of blood came out. Record review of Resident #36's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental status (BIMS) score of 15 out of 15, cognitively intact. Record review of Licensed Practical Nurse (LPN) Bs 'Nurse skills/competencies assessment' form dated 6/27/2024 as satisfactory for receiving orders/entering orders in electronic record, Communication with physician/Dr. Notification, Wound assessment, measuring, staging. Wound documentation/pressure reducing devise. The competencies form was signed off by the Director of Nursing services on 6/27/2024 In an interview and record review on 05/22/25 at 12:15 PM with the clinical consultant A revealed I wrote the order for the dressing change on 5/21/2025, Record review of resident progress notes revealed that there were no notes regarding the boil on the back of right neck. There was no physician assessment noted of the boil to the right anterior side of the neck and no order to pop/rupture the boil.

Based on observation, interview and record review the facility failed to implement continuation of preventative mobility services for one resident (#37) of one resident reviewed for restorative therapy services. Findings Include: Resident #37: On 5/20/2025 at 2:55 PM, Resident #37 was observed sitting in her wheelchair in her room. She stated she was waiting on a ramp and bathroom handrails to be installed at her daughter's home and then she would be discharged home. Resident #37 expressed concern that since being cut from therapy on 5/13/25, she is scared she will lose the advances she made, which will make the transition back home more difficult. Resident #37 was asked if she is in a restorative program, and she stated she is not. She reported facility staff only get her out of bed, assist with care and help her in /out of the wheelchair. On 5/20/2025 at 3:20 PM, a review was conducted of Resident #37's medical record and it indicated she admitted to the facility on [DATE] with diagnoses that included Atherosclerotic Heart Disease, Diabetes, Hypertension, Dementia, Orthopedic aftercare, Anxiety and Depression. Further review of Resident #37's chart yielded the following: Care Plan: I have actual ADL/MOBILITY deficit R/T (related to) post op cervical laminectomy for cervical spine stenosis, resp failure, acute on chronic neck pain, h/o cervical paraspinal muscle spasms, diabetes with polyneuropathy, dementia with behavior disturbance, OA , h/o rt hip hemiarthroplasty, weakness and reduced mobility . Ambulation: 1PA with 2ww (two wheeled walker) . On 5/21/2025 at approximately 1:00 PM, staff in the therapy gym were asked if Resident #37 is currently on therapy. They stated she is no longer on therapy as she preparing for discharge home but they were uncertain if she was receiving restorative therapy. On 5/21/2025 at 2:20 PM, MDS (Minimum Data Set) Nurse S shared the resident was discharged from therapy services on 5/13/2025 and she is not currently on a restorative program. Nurse S shared she received an email from the Therapy Manager T at 1:16 PM requesting Resident #37 be added to their restorative program. Nurse stated the delay was therapy thought she was being discharged home shortly after therapy services ended and she ended up staying longer than expected. On 5/21/2025 at 4:05 PM, an interview was conducted with Therapy Program Manager T regarding Resident #37. She explained the resident was not discharged off of therapy on a restorative program as at the time there were no plans for long term care. The plan was for Resident #37 to be discharged home with her daughter shortly after. Manager T stated the resident was on an ambulation program (floor staff walking her during their shifts) but stated she did not know if that was occurring. It was expressed it was unknown how it was concluded she was being discharged home went the Case Conference notes contradict that. Manager T shared they were not aware the resident would remain at the facility until appropriate provisions were made for her at her home. Further review was completed of Resident #37's record: Care Conference 5/2/2025: .Resident is wanting a referral to waiver to see if she qualifies for in services in hope of going home with extra help . Physical Therapy Discharge 5/15/2025: .Patient discharged to reside in this LTC facility .D/C location: Family members home .Discharge recommendations: CGA for mobility with 2ww, patient is staying here for a few days and discharging with family . Occupational Therapy Discharge 5/14/2025: .D/C (discharge) location: patient discharged to live with family member, friends or others . D/C reason: Highest practical level achieved .Prognosis to maintain CLOF (current level of functioning): Good with strong family support . Resident was discharged from therapy services on 5/13/2025. It can be noted upon discharge from therapy services on 5/13/2025, the waiver program had just completed their assessment of Resident #37. The process can be lengthy for approval and take additional time for the equipment that needs to be installed at the home. It is unknown why Resident #37 was not referred to the facility restorative program to maintain her current level of functioning as stated in the discharge plan, when it was evident the plan was for her to remain at the facility until appropriate and comprehensive services were in place for her to discharge home. It is unknown where the gap in communication occurred that effected the resident's continuation of mobility services. On 5/22/2025 at 8:20 AM, an interview was conducted with Social Worker R regarding Resident #37's discharge plans. It was explained she will be discharged to her daughters' home once she is approved for the appropriate service. The assessment was completed on 5/12/2025 and if approved they will provide extra chore provider, install the ramp and bathroom handrails that are needed. Social Worker R shared there was a conversation held with therapy regarding keeping her on therapy services with her secondary insurance as she would still be at the facility awaiting the wavier decision and the mobility equipment at the house. They knew at the care conference on 5/2/2025 that she would not be discharging, and it's discussed in morning meetings. On 5/22/2025 at 12:10 PM, CNA U was observed speaking with Resident #37 in the hallway. The CNA stated she was just informed this morning of the resident being added to the restorative nursing program. CNA U was asked what the ambulation in the residents Kardex meant and it was explained it was the residents transfer status. Resident #37 reported prior to today the staff were not walking her with the walker. Review was conducted of the facility policy entitled; Restorative Program dated 2/21/2018. The policy stated, Based on the comprehensive assessment of a resident and consistent with the residents needs and choices, the facility will provide the necessary care and services to ensure that a residents abilities in activities of daily living do no diminish .Candidates for restorative nursing program may be identified in the following ways: .after discharge from a skilled therapy service in conjunction with a therapy service .

Based on observation, interview and record review, the facility failed to ensure the prevention of cross contamination during colostomy care for 2 resident's (Resident's #40 and #69) of 2 resident's reviewed for ostomy care, resulting in the high potential for cross contamination, resident and staff illness with possible hospitalization . Findings Include: Resident #40: Review of the Face Sheet, care plans dated 6/24, and diagnosis list, revealed Resident #40 was [AGE] years old, admitted to the facility on [DATE], had a Guardian in place for medical and finical decisions, and was dependent on staff for all Activities of Daily Living/ADL's. The residents' diagnosis included, Acute kidney failure, carrier or suspected carrier of Methicillin Susceptible Staphylococcus Aures (antibiotic resistant organism), ulcerative pancolitis, chronic kidney disease, anemia, high blood pressure, diabetes, anxiety disorder, ileostomy status (artificial opening in large intestines), Bipolar disorder, Crohn's disease, cognitive communication deficit, and visual hallucinations. Residents' physician order dated 5/16/25 stated, Monitor ostomy appliance and change as needed and report any redness, inflammation or drainage from site. every shift. Review of Resident #40's Alteration in bowel elimination care plan dated 4/10/25, stated Change ostomy appliance as needed and report any redness, inflammation or drainage from site. Interview done with nurse, Unit Manager/Charge Nurse, RN L stated We usually change the colostomy bags every 3 days or so, the aides ask for new bags about daily; every 7 days is not good. During an interview done on 5/22/25 at 9:40 a.m., Infection Control, RN K said usually they (ostomy bag change orders) are changed weekly, every 7 days; it should say that, I'll fix the orders today (on 5/22/25). 5/22/25 at 9:20 am, observation of ostomy care done by Nursing Assistant/CNA J revealed, she (CNA J) had the same soiled gloves throughout the whole procedure, and (with same gloves on) put trash in bags, put bag on floor, picked up bag's and took to residents exit door, then put them both on the floor. She then removed the soiled gloves, washed her hands and was going to take the contaminated bags out of the room with no gloves on (contaminating her washed hands). Infection Control Nurse K saw this and started to take the two soiled bags out herself after gloving her right hand prior to touching the bags. During an interview done on 5/22/25 at 9:35 a.m., CNA J stated I contaminated the bags, I know I should of taken my gloves off (taken the soiled gloves off after doing procedure, prior to tying bags up and removing them from the bedside to the floor. During an interview done on 5/22/25 at 11:00 a.m., Infection Control Nurse, RN K stated She (CNA J) contaminated closed bag with dirty gloves. Before removing the soiled linen bag and the trash bag, she should have washed her hands and then came back and gathered the bags exited the room. I don't have a policy that says that but that's what should be done. Review of the facility All Staff Education, safe handling of linen and trash done on 5/22/25 stated Soiled linen and trash bags should never touch the floor. You should never tie off bags with contaminated gloves on. Review of the facility Routine Care of Your Ostomy policy dated 5/20/25, revealed primarily at home wear time (how long between ostomy bags) is personal preference. A ostomy pouch with a built-in filter will last the longest. The policy also stated, We do not recommend a wear time longer than five to seven days. Review of the facility Hand washing and Hand Hygiene policy dated 4/29/20, stated Purpose: To ensure appropriate hand hygiene which is essential in reducing the risk of transmission of infectious agents. To protect our residents, visitors, and staff, each facility will promote hand hygiene practices during all care activities and working in locations within facility; after contact/potential contact with blood or body fluids. 22927 Resident #69: Observation on 05/20/25 at 09:16 AM during the initial screening process of Resident #69 was lying in bed, with a bump noted under clothing. Surveyor question air bag/colostomy? Record review of Resident #69's Medication Administration Record (MAR) and Treatment Administration Records (TAR) for January 2025 revealed to 'Monitor the resident's colostomy and colostomy collection bag for any bleeding each shift. February 2025 revealed to 'Monitor the resident's colostomy and colostomy collection bag for any bleeding each shift. 3/30/2025 through 5/21/2025 revealed 'Monitor the resident's colostomy/bag for any signs of bleeding'. On 5/22/2025 the facility implemented a new order of: Change ostomy wafer and bag every 7 days and as needed. Every night shift Thursday for care, start date 5/22/2025. Record review on 05/20/25 at 10:20 AM of Resident #69's electronic medical record physician orders revealed that the ostomy was to be monitored, there was no order to change the colostomy bag every 7 days until 5//22/2025. There were no orders noted to change the colostomy bag at least every 7 days as manufacture recommendations.

This Citation pertains to Intake Numbers MI00151907 and MI00152097. Based on observation, interview and record review, the facility failed to prevent resident-to-resident abuse/assault of one resident (Resident #101), resulting in Resident #101, who was totally dependent for all care and had bilateral lower limb amputations and upper extremities contractures, receiving a black eye with facial contusions while residing in the facility. Findings include. Record review of the Health Care Association of Michigan (HCAM) 'Rights or Residents in Michigan Nursing Facilities' 2022 booklet revealed 'You have the right to designate a representative, in accordance with state law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law . Respect & Dignity: The right to receive written notice, including the reason for the change, before your room or roommate in the facility is changed. Safe environment: You have the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living. Record review of facility 'Abuse/neglect and/or Misappropriation of Resident Funds or Property' policy dated 3/15/2023 revealed the purpose was to assure each resident in the center (facility) is free from abuse, neglect and exploitation. (vi) Neglect: is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of goods or services that a resident requires but the facility fails to provide . Physical abuse: includes hitting, slapping, punching and kicking . Resident #102: Observation was made on 4/10/2025 at 8:46 AM of Resident #102 lying in bed asleep with the head of bed elevated. He did not respond to his name. The state surveyor observed a black eye/bruising to the left side of face. Soft touch call light was clipped to gown within reach. No roommate was noted in the room and only one name was on the room door. Observed bilateral hand contractures, and bilateral amputee lower extremities. Record review of Resident #102's electronic medical record (EMR) revealed that the resident had a legal guardian in place and had a medical diagnosis of vascular dementia. Record review of Resident #102's Behavioral Care consult visit notes revealed diagnoses of bipolar disorder, dementia, depression, schizophrenia, encephalopathy and other medical conditions of bilateral lower limb amputations. Record review of the facility incident report, dated 4/4/2025 at 8:30 AM, revealed that Resident #102 stated another resident made contact with his eye. The other resident denies doing so. Record review of the facility-provided timeline on 4/4/25 at 8:30 AM showed that the Nursing Home Administrator was notified that Resident #102 had a swollen eye and bruising. Resident #102 was noted to state he hit me and pointed toward the window (next bed over). The timeline note Resident #102 Brief Interview of Mental Status (BIMS) score was 5 out of 15, indicating severe cognitive impairment. The timeline also noted that Resident #104 had bruising on the right fingers/hand. The timeline noted Resident #104's Brief Interview of Mental Status (BIMS) score of 11 out of 15, indicating slight cognitive impairment. In an observation and interview on 4/10/2025 at 9:24 AM, Resident #104 was observed on the long-term care side of the building, private room with only one bed noted in the room. Resident #104 was observed walking from the therapy gym to his room with therapy staff. Resident #104 stated I was in another room; I had a doctor in to see me yesterday, to look at my right hand. No, I did not hit anyone, the roommate talked so bad, about that when he was in prison and how he would stab white people in the prison. He had his feet cut off. He treated women terrible, and I asked him to please don't talk that way, I asked him if he had any compassion for the human race. I was standing up in the room, and he started talking about how he would stab white mother fuckers like me in prison. The way he talked about women and white people. I told him he was disgusting to the human race. No, I did not hit him. The conversation was bad from him. No, I did not hit him in the eye. I just pushed him away. The Saginaw Police came originally, and he looked at my hand and my hand was all red. My right hand was red from I don't know I was a police officer. Record review of Resident #104's 'Bed Transfer Form', dated 4/2/2025, revealed that Resident #104 was to move to room [ROOM NUMBER]-1 but was placed in room [ROOM NUMBER]-2 instead. An interview on 4/10/2025 at around 10:00 AM with the social services designee K revealed that Resident #102 is pretty much laid back and stays to himself, listens to music, and he will sit out in the common area. Not much to say about Resident #102. Resident #104 is very aggressive and I only seen that when he got very verbally aggressive with his wife, he was addressing his talking to her but approaching me. His demeanor was toward his wife, she was just explaining how he gets upset. I did go into speak with Resident #102 after the incident, and he stated I don't know why, I don't know why he (Resident #104) was hitting him (Resident #102). Resident #102 said that he was yelling out, why are you doing this, why are you doing this man. I don't know why any staff didn't hear him. Resident #104, I did talk to him with his wife, and he did not say anything. Resident #104 is manipulative and will turn the conversation as to what he wants to talk about. Placement for Resident #104 was moved to a private room and staff has been keeping their eyes on him. He only really comes out for meals. We are keeping everybody safe. We did referral him to another facility and they declined him. He does need a secured unit. Because he does threaten to leave, is on a wander guard. My safety thing is to get him placement in a secure memory facility, in the meantime I do know my staff are to watch him and keep him in sight. In an interview on 4/10/2025 at 1:50 PM via phone, Certified Nurse assistant (CNA) G revealed, I was Resident #102's aide that day, I noticed that he had a swollen eye, he began to tell me what happened that he was hit in the eye stating He hit me looking toward the window where the roommate was. Resident #102 has hand contractures, and his Range of motion and arm extension is limited. He does not feed himself; we assisted him with meals. The roommate (Resident #104) was in the room getting dressed. I brought in his breakfast tray and Resident #104 was sitting up on the edge of the bed, but he wanted his meal in the dining room. So, I took the tray to the 500-hallway dining room and the resident was in his wheelchair and went in that direction. No, I did not hear any shouts or yelling come from that room. I start my day at 6:30 AM, we do a walk through with off going staff Certified Nursing Assistance's and then pass trays at 7:00 AM. I took Resident #102's tray into the room and turned on his light and he turned his head and there was a black eye. I told my nurse. In an interview on 4/10/2025 at 1:59 PM via phone, Certified Nurse Assistant (CNA) H revealed, It wasn't my hall, CNA G told me about it. I went to look at the left eye was swollen with dry blood on his nose and on the pillow. Resident #102 kept saying He kept hitting me, I told him to stop. Resident #102 has hand contractures and could not hit back. At the time the roommate was out of the room. The nurse also was in the room and asked him about being hit. The Roommate (Resident #104) was up in Wheelchair in the hallway and was asked if he hit Resident #102 and he shook his head yes. The Nursing Home Administrator took the Roommate #104 to the conference room, and he had a bruised right hand. In an interview on 4/10/2025 at 2:04 PM, Licensed Practical Nurse (LPN) I revealed that The Certified Nurse Assistant (CNA) G came to me ask me if I'd seen Resident #102's black eye. CNA G was going to feed Resident #102 and seen a black eye. She let me know and I went to the room and Resident #102 told me he wants to press charges. I asked him what happened, he stated that man over there, kept hitting me. Resident #102 has bilateral hand/arm contractures, and he can't hit back. I saw his left eye was swollen closed, with a bloody dry nose and blood drops on the pillow. I went and notified the Nursing Home Administrator; the Infection Control nurse D was with me. Resident #102 just said that he wanted to press charges. Resident #102 will talk crap with the staff or to himself. Resident #102 has been to prison for 4 years and talks prison crap and that could have upset the roommate, because he was a police office. Resident #102 does not like the police, he says they killed his brother and he was in prison. I don't know why they moved Resident #102's original roommate out of that room and moved this new guy Resident #104 into the room. On 4/10/2025 at 2:15 PM, the Nursing Home Administrator presented 5-day investigation for resident-to-resident assault on 4/4/2025. Attempt for past non-compliance, which was rejected due to no time of compliance by team manager. In an interview on 4/10/2025 at 2:50 PM, Registered Nurse (RN) Infection Control Preventionist D revealed, I did go to the resident room that morning with Licensed Practical Nurse (LPN) I. We went in and turned on the light and Resident #10 had a left purple, swollen eye with dried blood on the nose and pillow. We did do an ice pack to his eye and assessed it and went told the Nursing Home Administrator. At that time Resident #102 could not tell us what happened at that moment. We went to talk to roommate Resident #104 who was up in his wheelchair in the hallway. We asked him (Resident #104) to come to the conference room to assess his right hand. Resident #104 had a new bruise to his right hand with purple bruising to the 3 outer knuckles of the hand that was purple and warm to touch. Resident #104 stated that he was surprised someone did not do it sooner the way he was talking to people. No, I did not put the assessment in [NAME] medical chart about his purple bruised hand. I was just reviewing it for the Nursing Home Administrator and I just thought that the nurse would do the actual assessment of the resident post altercation and chart it. The Nursing Home Administrator and I went back to Resident #102's room and asked what happened? Resident #102 stated that he got hit by him (Resident #104). Resident #102 could not say when or what time. Resident #104 stated that Resident #102 was being mean to the girls/staff. Registered Nurse/Unit Manager C was also in the resident's room. Record review of police report, dated 4/4/2025, showed that the incident occurred with the victim being Resident #102 and an Assault and Battery by the suspect, Resident #104. Injuries: Resident #104 had a swollen right hand with obvious bruising. Resident #102 had a swollen left eye with obvious bruising. In an observation on 4/11/2025 at 8:12 AM, the state surveyor observed Certified Nursing assistant (CNA) N seated at bedside feeding Resident #102 with his breakfast meal. An interview and record review on 4/11/2025 at 8:15 AM with social services designee K revealed that she had hallways 300/400/500 long-term, right then she had the entire building. All 89 residents, the other social worker left almost 2 weeks ago. Procedure for Bed transfers: The Interdisciplinary team (IDT) bring it to the morning meeting, we discuss who would be a good fit for another room or area in building, who could we put together as a good fit. We then decide and reach out to the family members, both families are notified, I had (unsampled resident) that was in room [ROOM NUMBER]-2 and he was moved down the hall. They said that (unsampled resident) was moved to a doorway bed closer to the nurse station/cart for monitoring, just to make sure he doesn't roll out of bed, history of wanting to do things for himself, and falls. Resident #104 had just come over from the short term hall, the other social worker had him on the 100/200 hallway and transferred him to long-term care stay. The Nursing Home Administrator gives out task for room transfer/moves and the staff member is to notify the family members. The staff member once they notify family members then fill out a bed transfer form so that we know the transfer can happen. Resident #102 doesn't really bother anyone, he normally is asking where his daughter is, or he talks about [NAME], prison or smack/stuff. Resident #102 and Resident #104 were put together, I would say that it was not a good fit for them to be together. It was a team decision and bad choice. Resident #102 and (unsampled resident) had been roommates for a long time and there were no issues between them. It did not warrant a room move. Record review of the 'Job Description' Social Services undated, revealed that the social worker provides social services to residents and their families to assist them in dealing with the impact of illness and extended care placement . (8.) Inform residents and/or responsible parties of change of roommate(s) and room changes. (11.) Follow federal and state skilled nursing facilities regulations and departmental policies and procedures. In an interview on 4/11/2025 at 8:31 AM with Nursing Home Administrator and Nurse Consultant F, the state surveyor requested the Bed Transfer policy, they stated there was none, but had a Pass Non-Compliance for bed transfers. Surveyor will let the manager know of PNC. Surveyor asked for PNC at this time and the NHA stated that she would need to review it before the surveyor could have it. In an interview on 4/11/2025 at 8:46 AM, the Nursing Home Administrator revealed there was no Bed transfer policy we do not have a policy on bed changes, we would follow the regulation guidance. Guidance states that we must notify the family of the moving roommate and the family of the receiving roommate. We kind of go by request, or concerns. We decide in the IDT team meeting and coordinate with resident and family members. We had an Interdisciplinary team (IDT) meeting and decided to move (unsampled resident) out of 411-2, why? He is Hard of hearing, and a resident that is typically louder running his TV and that would not affect (unsampled resident). I asked Registered Nurse/Unit Manager C to arrange Resident #104's transfer, and Resident #102's roommate transfer would by Assistant Director of Nursing/unit manager B notification. Resident #104 was a former policeman and moved him into Resident #102's room, we talked about Resident #102 would exit seek and become very upset and if the wife is present, she will tell him he is stay permanently. He has triggers to his behavior. He is clearly upset about being here. It was a failure to notify the family member of Resident #102, I should have checked that it was done. We do realize that there has not been a time of compliance. In an interview on 4/11/2025 at 9:10 AM on the bed transfer of Resident #104 on 4/2/2025, Registered Nurse/Unit Manager C stated, A bed transfer starts usually the Nursing Home Administrator (NHA) and Director of Nursing (DON) figure out who is going to Long Term Care (LTC) side from rehab, they inform us and we have to contact the family to ask if the room move is ok with them. We can't move them until we get their approval. We can get an email/on the dashboard and in morning meeting Interdisciplinary team (IDT) meeting, The NHA give us task to complete related to the moves. I had Resident #104 to be moved from my unit to the LTC unit. Record review of the bed transfer form dated 4/2/2025, I did fill that form out. room [ROOM NUMBER]-1, that was the room number that they had assigned to him, he did not go their because? I am not sure why he did not go to room [ROOM NUMBER]-1 that would be a housekeeping question? Resident #102's responsible party should have been notified by Unit manager of LTC or Social service designee about a new roommate. The state surveyor inquired about Resident #102 and Resident #104 should be put together. Registered Nurse/Unit Manager C stated I don't know if that would have been a good fit for those to be together. In an interview on 4/11/2025 at 9:43 AM, the Director of Nursing (DON) revealed that room transfers are discussed in morning meeting if a rehab resident is staying and converted to Long Term Care (LTC), we discuss it as a team to see if they are a good fit for the roommate, then it is tasked to the social worker to go and inform the resident and responsible party, the social workers are to notify. There is transfer forms in the electronic record, per our policy there is a form that will state there is a room change. As part of the regulation, we did inform the DPOA/Resident of incoming roommate. Should Resident #102 and Resident #104 be roommates? The DON Stated, I am not sure I was not here that week. I don't know anything about Resident #104. Resident #102 he does talk crap and tells the ladies they look good, and he does have contractures of the arms bilateral, bilateral amputee one BKA and one AKA. He could not defend himself from harm. I don't know why it was not heard by staff, I don't know when it occurred. In an interview on 4/11/2025 at 9:53 AM, the Nursing Home Administrator related the resident-to-resident investigation, it occurred 4/4/2025 and that she was notified at 8:30 AM. The NHA stated that during the investigation the facility narrowed down the time to a check and change at 6;00 AM there was no eye swelling or black eye. Then at 8;30 AM Certified Nursing Assistant (CNA) went into the room to assist with breakfast and turned on the light and noted the swollen eye and reported it to the nurse right away. NHA stated that sometime between 6-8:00 AM. NHA interviewed the staff, and they did not hear or observe any yelling or occurrence. The staff do go to the nurse station and then go out to the unit and do a room-to-room review, they should be laying eyes on each resident. Resident #102 was noted to be sleeping. The CNA stated that she did peek in and laid eyes on Resident #102, but she did not turn the light on before 830 AM. A resident-to-resident interaction there appears to be physical contact between the residents involved. Resident #104 had bruised knuckles to the right hand and had the ICP nurse do an assessment in the conference room. Resident #102 was sent out to the hospital and came back to us, there were no fractures, just broken blood vessels, we did Tylenol and ice pack prior to hospitalization , he left at 11:30 AM via ambulance to hospital. Record review of Resident #102's hospital record, dated 4/4/2025, revealed significant periorbital edema, ecchymosis (bruising) over the left eye. Atrophy of the hand muscles bilaterally. Below-the-knee amputation on the left,and above-the-knee amputation on the right. Left arm held in flexion and adduction had has clenched fist. Claw hand of the right hand. Diagnosis: (1.) Periorbital hematoma of left eye. (2.) Assault. (3.) subconjunctival hemorrhage of left eye. In an interview on 4/11/2025 at 10:41 AM, Nursing Home Administrator revealed the facility did not have a supervision policy for the monitoring of resident safety.

This Citation pertains to Intake Number MI00151904. Based on interview and record review, the facility failed to 1) Ensure that a timely, complete and accurate resident assessment was done for a change of condition and 2) Transfer a resident to the hospital in a timely manner for 1 resident (Resident #101) of 5 residents reviewed for quality of resident care, resulting in a failure to transfer to the hospital during an acute change of condition, decreased blood pressure, increased pulse rate, increased temperature, and, subsequently, death. Findings Include: Resident #101: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment toll), dated [DATE], nursing and physician progress notes dated [DATE] through [DATE], and care plans dated ,d+[DATE], revealed Resident #101 was [AGE] years-old, alert, admitted to the facility on [DATE] from the hospital with a diagnosis of sepsis, and dependent on staff for Activities of Daily Living. The resident's diagnoses included, pneumonic, acute on chronic respiratory failure with hypoxia, atrial fibrillation, metabolic encephalopathy, schizophrenia, bipolar disorder, heart failure, hemiplegia and hemiparesis, stroke, occlusion and stenosis of bilateral carotid arteries, acute kidney failure, muscle weakness, major depressive disorder, anxiety, chronic heart and lung disease, diabetes, epilepsy, high blood pressure, migraine, heart disease, history of infections. The resident was on 3 liters of oxygen at the facility and had a feeding tube. Hospital Record Prior to Admission: Review of Hospital records dated [DATE] (day of discharge to the facility), stated 59 y old female patient presented on [DATE] with chief complaint of found unresponsive at (Nursing Home). Patient was initially started on Zosyn and Zyvox (antibiotics) and was admitted to ICU. Problem Based Management: Severe sepsis with Septic shock due to bilateral pneumonia form suspected aspiration. The resident had recently been readmitted to the facility after hospitalization due to severe sepsis with septic shock likely due to aspiration pneumonia. Review of the facility nursing notes, dated [DATE] at 17:35 (5:35 p.m.), stated Nurse and CNA (Nursing Assistant) went in the room, nurse looked at the resident and immediately went to check for a pulse not found. Nurse touched the resident and found that resident was cold to touch and unresponsive. Nurse went to call a Code blue as resident was a full code. CPR initiated by two nurses at 1645 (4:45 p.m.). Review of the facility electronic medication administration record (EMAR) dated ,d+[DATE], revealed on [DATE] at 1317 (1:17 p.m.), Nurse O gave the Resident #101 Tylenol 325 mg x 2 tabs for increased temperature/temp. of 101 (temp. taken at 9:00 a.m.,on [DATE]) by CNA P). Review of the facility nursing notes dated [DATE] at 9:00 a.m. through 5:35 p.m., revealed no documentation of any physical or cognitive assessments (due to condition change, increase in temp. and pulse rate). During an interview done on [DATE] at 2:15 p.m., Nurse, RN O stated No, I did not do an assessment; yes I was supposed to. I know I should of charted better and done a assessment. During an interview done on [DATE] at 3:39 p.m., CNA P stated I told her (Nurse O) about her (Residents #101) temp. (101 F) and pulse (110) at 9:00 a.m. (on [DATE]); I know it was 9:00 a.m., because that's when I do vitals and if not normal, we report it to the nurses. I don't trust working with her (Nurse O), her responses are delayed. When I told her (Nurse O), she repeated the temp. and pulse back to me and said, I'll give her medication. During an interview done on [DATE] at 3:50 p.m., the Director of Nursing/DON stated I think she (Nurse O) did nothing after she was told the vitals; I think it's horrible. The Aide (CNA P) notified the nurse right away at 9:00 a.m., and she did not do anything until 1:17 p.m. (gave Tylenol, did not call doctor to inform of change of condition to send to ER). From 9:00 a.m. to 1:17 p.m., for 4 hours and 17 minutes she (Nurse O) did nothing. During a second interview done on [DATE] at 3:30 p.m., Nurse O stated I didn't call the doctor with the temp. and pulse change. The resident was not transferred to the hospital for evaluation when notified of an increased temperature and pulse with a known history of sepsis. During an interview done on [DATE] at 10:00 a.m., Infection Control/Education Nurse, RN stated She (Nurse O) should have first re-checked the temp. and called the doctor (to transfer to ER). During an interview done on [DATE] at 8:30 a.m., Social Service K stated The next day (on [DATE]) the CNA's told me she (CNA P) had told the nurse her temp. was high. The nurse did nothing; I told her if the nurse does not do anything go to another manager and tell them Review of the resident's facility Pain and Diabetes care plans dated [DATE], stated Notify physician if signs or symptoms of fluid imbalance such as neck vein distention, difficulty breathing, increased heart rate, monitor/document/report to MD s/sx (signs & symptoms) of hypoglycemia, sweating, tremor, increased heart rate. Review of the nursing notes dated [DATE], revealed the resident had a pulse of 110 on [DATE]. Review of the facility Registered Staff Nurse job description (un-dated) stated This position is responsible for performing the primary functions of nursing assessments, planning, implementing, and evaluating the care of all assigned residents. Assess resident condition, observe and evaluate resident symptoms, progress and reactions to treatments and medications and take correct action as necessary, accurately record resident observations in clinical records, strong critical thinking and decision-making skills, a high level of analytical abilities, ability to concentrate in performing and planning professional nursing care. Review of the facility Assessment Resident policy dated [DATE], stated Procedure is a Head-to-Toe review of the resident's functional status. Purpose: To identify the resident's care needs, Procedure: Chief complaint, Pain, Level of consciousness, speech, palpate temporal and carotid pulses, assess for tenderness, palpate femoral pulses, condition of skin (includes color, dry, tacky), color of extremities, temperature of extremities, orientation to time, place and person, ability to follow instructions. Review of the facility Change of Condition policy dated [DATE], stated Family and/or responsible party are notified anytime there is a change in the resident's condition or plan of care. Any other time there has been a change in the resident's condition will be done in a timely manner. Notify appropriate party and record in resident's medical record.

Based on observation, interview and record review the facility failed to ensure quality care was provided for one resident (Resident #90) left sitting in a wheelchair for extended periods of time resulting in increased lower leg [MEDICAL CONDITION] and a new left foot wound, of 2 residents reviewed for positioning, 2 residents (Resident #80, Resident #156) reviewed for assessment and monitoring of 25 residents reviewed, resulting in Resident's #80, #90 and #156 experiencing a decline in condition. Findings Include: Resident #80: During the initial tour of the facility on 10/27/19 at 1:14 PM, Resident #80 said she was having discomfort on her arms. Her left and right inner arms were observed to be bright red with a rash. A review of the Face Sheet and Minimum Data Set (MDS) for Resident #80 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS dated [DATE] revealed the resident had full cognitive abilities and needed assistance with transfers, walking, bed mobility, hygiene, bathing and toileting. A review of the resident's physician orders indicated a treatment with an ointment was ordered to her breast, groin and abdomen. There was no treatment ordered to her arms. A review of the Treatment administration Record (TAR) and Medication Administration Record [REDACTED].two times daily for 14 days . There was no treatment applied to the resident's arms. A review of the Skin Assessments- completed 10/4/19, 10/11/19, 10/18/19 and 10/25/19. There was no mention of redness in the folds of the resident's inner arms. A review of the Care Plan Skin Management, decreased mobility, 10/9/19 facility acquired Moisture Associated Skin Damage (MASD) to bilateral buttock, dated initiated 9/24/19, revised 10/9/9 with Interventions: CNA's (Certified Nursing Assistants) will check my skin daily with care and report anything unusual they notice to the nurse, date initiated 9/24/19. There was no mention of a rash to Resident #80's arms. On 10/29/19 at 1:00 PM, Nurse Manager F was observed assessing the resident's inner arms, which were bright red, moist with an odor of yeast. The resident told her they hurt and had been that way for a while. When asked if it was sore Resident #80 said Yes, it is. Treatment orders were reviewed with the Nurse Manager with no order or treatment found for the inner arms. The Nurse Manager washed the areas with a washcloth, soap and water, wrapped them with dry gauze kerlix and said she would contact the doctor for a treatment. The resident rated the pain at a six out of 10 (on a 0-10 scale). On 10/29/19 at 1:15 PM, during an interview with Nurse II she stated, I saw that this morning but have not had a chance to call the doctor. A review of the facility policy titled, Wound Management Program, origination date (MONTH) 1, 2008 and revised 8/17/2017 provided, To eliminate, modify or minimize factors that place residents at risk for skin breakdown . To assure that residents who are admitted with, or acquire wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing . Resident #156: According to Resident #156's Electronic Medical Record that included physician orders, physician progress notes [REDACTED]. During an observation, during the initial tour, on 10/27/19 at 01:01 PM, Resident #156 was complaining that she was very hot and that, the room was extremely warm. The resident was on oxygen and observed to be short of breath, very irritable and had a fan pointed directly at resident on high. The resident was covered with a sheet that minimally covered the torso with legs and arms exposed and the resident was noted to be lifting the sheet in an attempt to cool herself. CNA OO was present in the room and was requested to get the RN by Resident #156 and the surveyor and inform of resident's condition. CNA OO was requested to get the maintenance staff due to the heat in the room. At 1:10 PM Maintenance staff D obtained a temperature in room [ROOM NUMBER] and he reported the temperature was at 101 degrees Fahrenheit near Resident #83 and 87 degrees near Resident #156. At 1:10 PM RN [NAME] was observed in the hall near Resident #156's room and was informed of Resident #156 being over warm, and requesting blood sugar as she doesn't feel right. In an interview, on 10/27/19 at 01:18 PM, Administrator arrived and was made aware of the temperature of 101 degrees in room [ROOM NUMBER] by the window and 87 degrees by the door. Administrator instructed staff to move Resident 156 out of the room and was aware of Resident 156 being very anxious and having difficulty breathing. On 10/29/10 at 7:10 AM, review of Resident # 156's clinical record reveled there was no documentation related to the incident on 10/27/19. There was no documentation of lung sounds, Pulse oxygen saturation, respiratory assessment or blood sugar as requested by the resident. There were no nurses' progress notes and no assessments completed in the electronic medical record as of 10/29/19 at 7:10 AM. Review of Resident #156's Care plan revealed Observe for s/sx of respiratory distress and report to MD PRN: Abnormal respiratory rate, pulse ox, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color dated 9/17/19. Review of Resident #156 nurse progress note revealed On 10/29/19 at 7:39 AM, (late entry) On 10/28/19 at 05:56 PM, during an interview, NHA reported queried of documentation of the incident for Resident on 10/27/19 and expectation was the nurse should have documented the incident of resident being short of breath and anxious with Nurse was called to room for the room being too warm. Making it difficult for resident to breath. (Resident) did have a fan in her room on the table, which was directed onto her. The window was open, register turned down and patient was assisted into w/c to sit in cool hallway. She immediately felt better SPO2 93% on nc. Cont to be alert and voice needs. She was very calm afterwards. She was made comfortable with her legs elevated, no distress noted. Administrator and maintenance checked on resident and room multiple times. Review of Resident # 156 Change of condition, dated 10/25/19, revealed assessment for low blood sugar revealed documentation of a blood pressure Date: 10/24/2019 10:16 111 / 65 (mmHg). Blood sugar 97 (documentation was from previous day). In an interview on 10/29/19 at 04:01 PM, DON discussed documentation and agreed there was no documentation or assessment, and stated, the maintenance and administrator (non clinically trained staff) both stated the resident was not in distress at the time. DON was queried where the nursing assessment was? DON had no answer. DON was queried concerning having two residents in the same room with such extreme differences in preferences in room temperatures with a likelihood of distress for Resident #156 and responded, I was not aware of the concerns. In an interview, on 10/28/19 at 05:56 PM, Administrator was queried regarding documentation of the incident for Resident #156 on 10/27/19 with the heat being elevated and resident's condition and stated, the expectation was the nurse should have documented the incident of resident being short of breath and anxious. Resident #90: A review of Resident #90's medical record, revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review, of the Minimum Data Set assessment, revealed a score of 12 on the Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition. Further review of the MDS revealed the resident needed extensive assistance with two-person physical assist with bed mobility, dressing, toilet use and personal hygiene and total dependent for transfers. On 10/27/19 at 4:48 PM, an observation was made of Resident #90 sitting up in a wheelchair in the Resident's room. The Resident had a facility gown on that was falling off of the shoulder and exposing the upper part of the resident's breast area. The Resident had a mechanical lift sling underneath her back that extended from her neck to her thighs. The Resident allowed the corner of the sling to be examined and revealed a plastic/rubbery coating that was on the sling that the Resident was sitting on. The back of the Resident was exposed to the sling area and had no clothing protection between the sling and the Resident's skin. The Resident was asked why she had a facility gown on and if she had her own clothes. The Resident stated, I wish I knew the answer to that. I have my own clothes there in the closet. My daughter brought them in. An observation was made of a bright pink colored medication tablet that appeared to be partially deteriorated on the ends of the pill. The Resident was queried regarding the medication and stated, It didn't go down. The Residents' legs were positioned down and a pillow was positioned on the foot pedals. The Residents' feet were positioned together with the pillow pushed down between the foot pedals with the Resident's feet wedged between the foot pedals. The left heel was pushed into the right foot. The lower legs and feet, that were not covered with a blanket on the Resident's lap, were observed to be extremely [MEDICAL CONDITION]. The right leg, above the knee area, was not resting on the leg rest of the wheelchair, the edge of the leg rest was indenting the Resident's thigh area above the knee. A puddle of fluid was observed under the Resident's feet that encompassed the area on the floor underneath the foot pedals and extended to the front right wheel of the wheelchair. The Resident had a Foley catheter and on first observation the catheter that hung underneath the middle of the wheelchair was thought to be opened due to the fluid on the floor to be slightly yellowish. The catheter was clamped, and the puddle of fluid did not extend to the Foley catheter. Upon further observation the pillow that was under the Residents feet and part of the lower legs was noted to be saturated in moisture and dripping onto the floor. The top of the Resident's left [MEDICAL CONDITION] foot had a scabbed area and fluid was weeping out of the area. This writer left the Resident's room to find the Nurse. At 5:07 PM on 10/27/19, Nurse J came into Resident #90's room with this writer. The observations of the puddle of fluid on the floor from the weeping [MEDICAL CONDITION] legs, the position of the feet and pillow wedged between the foot pedals and the medication on the Resident's bedside table was relayed to the Nurse. Upon inspection of the large, tight [MEDICAL CONDITION] legs with the puddle of fluid on the floor and the saturated pillow, the Nurse stated, This is all new. I have not seen it like this before. It wasn't like this earlier. When queried how long the Resident had been sitting up in the wheelchair, the Nurse stated, We tried a little bit ago to get her into bed, but she didn't want to get back into bed. The Nurse was queried regarding the medication pill on the overbed table and stated, That is her [MEDICATION NAME] (an anticonvulsant medication), and threw the medication in the garbage. The Nurse began wiping up the puddle of fluid that had pooled from the Resident's weeping legs and attempted to lift the Resident's legs that were wedged in the foot pedals and pillow, but was unable to move the Resident's leg and left the room to get assistance from other staff. At 5:12 PM on 10/27/19, the Director of Nursing (DON) entered the room prior to Nurse J returning. The observations of the grossly [MEDICAL CONDITION] legs, the saturated pillow, the puddle of serous drainage that was on the floor, the leg rest indenting into the Resident's upper knee/thigh area, the partially deteriorated medication on the overbed table and the sling underneath the Resident with the skin exposed to the coating on the sling, was conveyed to the DON. The DON stated, We will take care of this. The Nurse returned and the DON instructed the Nurse to do a change of condition and stated, The weeping is new for her. We need to make sure her legs are elevated up. The Resident was observed to be transferred back to bed with the mechanical lift. The Resident's bare back was not protected from the sling from the top of the Resident's brief to the neck area. The dressing to the right calf area was loose and saturated in drainage. The left heel had a blackened area, scared area and peeling skin, reddened skin encompassed the heel area where it had been resting on the right foot. An interview, at 5:30 PM on 10/27/19 with CNA G, who was assigned care of the Resident was queried regarding when the resident had gotten up and stated, She got up just after lunch I think. When queried regarding the repositioning of the Resident, the CNA stated, I checked about two hours ago. I checked to make sure she was sitting up straight, and indicated the Resident tends to lean. The CNA was queried regarding the Resident being in a facility gown and not her own clothes, the CNA stated, The daughter said it was Ok to stay in the gown today. On 10/28/19 at 9:39 AM, an interview was conducted with a Confidential Person PP regarding Resident #90. The Confidential Person was visiting with the Resident in her room. The Resident was dressed, up in a wheelchair and had her legs elevated. The Confidential Person was queried regarding the Resident wearing a facility gown yesterday and stated, They asked if she could stay in the gown, that was fine by me, she doesn't mind. They put a fresh one on her. The Confidential Person referenced that the staff was short staffed at times. When queried regarding the Resident being up in her wheelchair yesterday, the Confidential Person stated, They got her up before lunch, probably about 11:30 (AM). I was here before her lunch came. When queried regarding the [MEDICAL CONDITION], the Confidential Person stated, She came here dealing with [MEDICAL CONDITION]. Her arms are much better. They called me yesterday about [MEDICAL CONDITION] in her legs. On 10/28/19 at 5:07 PM, an interview was conducted with the Clinical Care Coordinator (CCC), Nurse F regarding Resident #90 sitting up in the wheelchair from lunch time to approximately 5:30 PM on 10/27/19 and the [MEDICAL CONDITION] and weeping of the lower legs. The CCC was queried regarding interventions in place for positioning and reviewed the Resident's care plan. The CCC stated, Shift positioning, lay down between meals, encourage to lay down between meals, activities and therapies. When queried regarding the Resident being up for approximately six hours, the CCC stated, They could have encouraged her to lay down sooner. When queried regarding the [MEDICAL CONDITION] legs, the CCC stated, That was abnormal for her. She had some when she came but that was improving. The CCC was queried if the increased [MEDICAL CONDITION] and the weeping was caused from the Resident being up in her wheelchair for an extended period of time with her legs down, and the CCC stated, Probably. I assessed her this morning and it was much better. They did a change in condition yesterday and documented the new wound on the top of the foot that was weeping, ordered labs and notified the doctor. Further review, with the CCC, of the document in the medical record titled, eINTERACT Change in Condition Evaluation, revealed, [NAME] Situation 1. The change in condition, symptoms or signs I am calling about is/are: [MEDICAL CONDITION] (new or worsening), Skin wound or ulcer. C. Assessment, 1. Are these the most recent vital signs taken after the change in condition occurred? Yes (but no vital signs recorded in this document), 6. Most Recent Weight, Weight: 192.8 (LBS (pounds)) Date: 10/23/2019 13:12 (1:12 PM); Cardiovascular Evaluation 13. Describe cardiovascular changes: [MEDICAL CONDITION], 13b. Describe [MEDICAL CONDITION]: Abrupt onset unilateral leg [MEDICAL CONDITION], with tenderness or redness or progressive bilateral [MEDICAL CONDITION] with or without shortness of breath; Skin Evaluation, 16. Describe skin changes: Blister, Description blister left dorsal foot on top; 26. LPN: The resident appears: Increased [MEDICAL CONDITION]. Further review of the resident's medical record revealed [REDACTED]. The CCC was queried regarding the lack of information in the Change in Condition and progress note documentations that lacked a description of the weeping from the [MEDICAL CONDITION] legs and measurements of the wound on the top of the left foot. The CCC stated, She (Nurse J ) is here today and can put in a late note. When queried regarding what interventions could have been done to prevent the [MEDICAL CONDITION], the CCC stated, Well, positioning for sure. The pillow should not have been there, and her leg rests could have been brought up. They could have laid her down sooner. When queried regarding refusals to lay down, the CCC stated, She doesn't refuse. When queried regarding the wound on the top of the left foot, the CCC stated, It is dry, not weeping, measurements? no measurements yet, treatment? no treatment in place because it had improved. I don't want it to moisten. It looked really good this AM. The CCC was queried regarding the cause of the wound and stated, I think it was from the increased [MEDICAL CONDITION]. The CCC was queried regarding the facility policy on the medication that was found on the Resident's overbed table and stated, She should call the Doctor and then follow the Doctors direction, and indicated that it would be documented. A review of the progress notes with the CCC revealed no documentation that the Doctor had been notified.

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place to prevent skin breakdown, complete thorough skin assessments and provide pressure ulcer care and treatment for 2 residents (Resident #80 and Resident #90), out of four residents reviewed for pressure ulcers, resulting in both residents developing new facility-acquired pressure ulcers. Findings Include: Resident #80: During the initial tour on 10/27/19 at 1:13 PM, Resident #80 stated, I have a sore on my bottom. They rub a cream on it every night. A review of the Face Sheet and Minimum Data Set (MDS) for Resident #80 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS dated [DATE] revealed the resident had full cognitive abilities and needed assistance with transfers, bed mobility, hygiene, bathing and toileting. On 10/29/19 at 1:30 PM, Resident #80 was observed sitting in her wheelchair at the nurse's desk. She appeared newly showered, as her hair was clean and braided. Nurse Manager F assisted her to her room and Nurse's F and II were observed when they assessed the resident's skin. When Resident #80 stood from her wheelchair, there was wetness on the back of her pants along both legs. The Nurses assisted the resident in lowering her pants to view the buttock wound. Redness and excoriation were noted on the buttocks. The nurses said that was the location of the wound (Moisture Associated Skin Damage/MASD) and where they applied the treatment. Upon further assessment, the Resident was noted to have an open area on the left posterior leg/ posterior/back of the left thigh. The skin was peeled back, bright red-stage 2, approx. 1.5 in x 1 in, right posterior leg (same location) with a round blistered approximately 1inch x 1 inch. The nurses were asked about the wounds and Nurse Manager F stated, Those are new. I haven't seen those before. The nurse asked the resident if they hurt and she said, Yes. Nurse F took a wound picture. The resident had a blue cushion on the wheelchair, but it was not a specialty cushion for wounds per the nurses. Nurse F asked the resident to rate the discomfort from the new wounds on each leg and Resident #80 rated a score of 6 on the left leg and4 on the right leg. The Medication Administration Record [REDACTED]. There was a new treatment to a rash on the back of the resident's knees. A review of the Skin Care Plan provided, Skin Management, decreased mobility, 10/9/19 facility acquired Moisture Associated Skin Damage (MASD) to bilateral buttock, dated initiated 9/24/19, revised 10/9/9 with Interventions: CNA's (Certified Nursing Assistants) will check my skin daily with care and report anything unusual they notice to the nurse, date initiated 9/24/19. There was no mention of an open area on the back of the left thigh or blister on the right thigh. On 10/29/19 at 3:40 PM, during an interview with the Director of Nursing, she was asked about the new wounds identified on the back of Resident #80's thighs and stated, I just heard about it. Resident #90: A review of Resident #90's medical record, revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review, of the Minimum Data Set assessment, revealed a score of 12 on the Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition. Further review of the MDS revealed the Resident needed extensive assistance with two-person physical assist with bed mobility, dressing, toilet use and personal hygiene and was total dependent for transfers. On 10/27/19 at 4:48 PM, an observation was made of Resident #90 sitting up in a wheelchair in the Resident's room. The Resident had a facility gown on that was falling off of the shoulder and exposing the upper part of the resident's breast area. The Resident had a mechanical lift sling underneath her back that extended from her neck to her thighs. The Resident allowed the corner of the sling to be examined and revealed a plastic/rubbery coating that was on the sling that the Resident was sitting on. The back of the Resident was exposed to the sling area and had no clothing protection between the sling and the Resident's skin. The Resident was asked why she had a facility gown on and if she had her own clothes. The Resident stated, I wish I knew the answer to that. I have my own clothes there in the closet. My daughter brought them in. The Resident's legs were positioned down and a pillow was positioned on the foot pedals. The Resident's feet were positioned together with the pillow pushed down between the foot pedals with the Resident's feet wedged between the foot pedals. The left heel was pushed into the right foot. The lower legs and feet, that were not covered with a blanket on the Resident's lap, were observed to be extremely [MEDICAL CONDITION]. The right leg, above the knee area, was not resting on the leg rest of the wheelchair, the edge of the leg rest was indenting the Resident's thigh area above the knee. A puddle of fluid was observed under the Resident's feet that encompassed the area on the floor underneath the foot pedals and extended to the front right wheel of the wheelchair. The Resident had a Foley catheter and on first observation the catheter that hung underneath the middle of the wheelchair was thought to be opened due to the fluid on the floor to be slightly yellowish. The catheter was clamped, and the puddle of fluid did not extend to the Foley catheter. Upon further observation the pillow that was under the Residents feet and part of the lower legs was noted to be saturated in moisture and dripping onto the floor. The top of the Resident's left [MEDICAL CONDITION] foot had a scabbed area and fluid was weeping out of the area. This writer left the Resident's room to find the Nurse. At 5:07 PM on 10/27/19, Nurse J came into Resident #90's room with this writer. The observations of the puddle of fluid on the floor from the weeping [MEDICAL CONDITION] legs, the position of the feet and pillow wedged between the foot pedals and the medication on the Resident's bedside table was relayed to the Nurse. Upon inspection of the large, tight [MEDICAL CONDITION] legs with the puddle of fluid on the floor and the saturated pillow, the Nurse stated, This is all new. I have not seen it like this before. It wasn't like this earlier. When queried how long the Resident had been sitting up in the wheelchair, the Nurse stated, We tried a little bit ago to get her into bed, but she didn't want to get back into bed. The Nurse was queried regarding the medication pill on the overbed table and stated, That is her [MEDICATION NAME] (an anticonvulsant medication), and threw the medication in the garbage. The Nurse began wiping up the puddle of fluid that had pooled from the Resident's weeping legs and attempted to lift the Resident's legs that were wedged in the foot pedals and pillow, but was unable to move the Resident's legs and left the room to get assistance from other staff. At 5:12 PM on 10/27/19, the Director of Nursing (DON) entered the room prior to Nurse J returning. The observations of the grossly [MEDICAL CONDITION] legs, the saturated pillow, the puddle of serous drainage that was on the floor, the leg rest indenting into the Resident's upper knee/thigh area, the partially deteriorated medication on the overbed table and the sling underneath the Resident with the skin exposed to the coating on the sling, was conveyed to the DON. The DON stated, We will take care of this. The Nurse returned and the DON instructed the Nurse to do a change of condition and stated, The weeping is new for her. We need to make sure her legs are elevated up. The Resident was observed to be transferred back to bed with the mechanical lift. The Resident's bare back was not protected from the sling from the top of the Resident's brief to the neck area. The dressing to the right calf area was loose and saturated in drainage. The left heel had a blackened area, scared area, peeling skin and reddened skin encompassed the heel area where it had been resting on the right foot. An interview, at 5:30 PM on 10/27/19 with CNA G, who was assigned care of the Resident was queried regarding when the resident had gotten up and stated, She got up just after lunch I think. When queried regarding the repositioning of the Resident, the CNA stated, I checked about two hours ago. I checked to make sure she was sitting up straight, and indicated the Resident tends to lean. The CNA was queried regarding the Resident being in a facility gown and not her own clothes. The CNA stated, The daughter said it was Ok to stay in the gown today. On 10/28/19 at 9:39 AM, an interview was conducted with a Confidential Person PP regarding Resident #90. The Confidential Person was visiting with the Resident in her room. The Resident was dressed, up in a wheelchair and had her legs elevated. The Confidential Person was queried regarding the Resident wearing a facility gown yesterday and stated, They asked if she could stay in the gown, that was fine by me, she doesn't mind. They put a fresh one on her. The Confidential Person referenced that the staff was short staffed at times. When queried regarding the Resident being up in her wheelchair yesterday, the Confidential Person stated, They got her up before lunch, probably about 11:30 (AM). I was here before her lunch came. When queried regarding the [MEDICAL CONDITION], the Confidential Person stated, She came here dealing with [MEDICAL CONDITION]. Her arms are much better. They called me yesterday about [MEDICAL CONDITION] in her legs. On 10/28/19 at 5:07 PM, an interview was conducted with the Clinical Care Coordinator (CCC), Nurse F regarding Resident #90 sitting up in the wheelchair from lunch time to approximately 5:30 PM on 10/27/19 with [MEDICAL CONDITION] and weeping of the lower legs. The CCC was queried regarding interventions in place for positioning and reviewed the Resident's care plan. The CCC stated, Shift positioning, lay down between meals, encourage to lay down between meals, activities and therapies. When queried regarding the Resident being up for approximately six hours, the CCC stated, They could have encouraged her to lay down sooner. When queried regarding the [MEDICAL CONDITION] legs, the CCC stated, That was abnormal for her. She had some when she came but that was improving. The CCC was queried if the increased [MEDICAL CONDITION] and the weeping was caused from the Resident being up in her wheelchair for an extended period of time with her legs down, and the CCC stated, Probably. I assessed her this morning and it was much better. They did a change in condition yesterday and documented the new wound on the top of the foot that was weeping, ordered labs and notified the doctor. A review, with the CCC, of the document in the medical record titled, eINTERACT Change in Condition Evaluation, revealed, [NAME] Situation 1. The change in condition, symptoms or signs I am calling about is/are: [MEDICAL CONDITION] (new or worsening), Skin wound or ulcer. C. Assessment, 1. Are these the most recent vital signs taken after the change in condition occurred? Yes (but no vital signs recorded in this document), 6. Most Recent Weight, Weight: 192.8 (LBS (pounds)) Date: 10/23/2019 13:12 (1:12 PM); Cardiovascular Evaluation 13. Describe cardiovascular changes: [MEDICAL CONDITION], 13b. Describe [MEDICAL CONDITION]: Abrupt onset unilateral leg [MEDICAL CONDITION], with tenderness or redness or progressive bilateral [MEDICAL CONDITION] with or without shortness of breath; Skin Evaluation, 16. Describe skin changes: Blister, Description blister left dorsal foot on top; 26. LPN: The resident appears: Increased [MEDICAL CONDITION]. Further review of the resident's medical record revealed [REDACTED]. The CCC was queried regarding the lack of information in the Change in Condition and progress note documentations that lacked a description of the weeping from the [MEDICAL CONDITION] legs and measurements of the wound on the top of the left foot. The CCC stated, She (Nurse J ) is here today and can put in a late note. When queried regarding what interventions could have been done to prevent the [MEDICAL CONDITION], the CCC stated, Well, positioning for sure. The pillow should not have been there, and her leg rests could have been brought up. They could have laid her down sooner. When queried regarding refusals to lay down, the CCC stated, She doesn't refuse. When queried regarding the wound on the top of the left foot, the CCC stated, It is dry, not weeping, measurements? no measurements yet, treatment? no treatment in place because it had improved. I don't want it to moisten. It looked really good this AM. The CCC was queried regarding the cause of the wound and stated, I think it was from the increased [MEDICAL CONDITION]. A review of Resident #90's Skin Management care plan revealed, Focus: Skin Management Decreased Mobility, Incontinence, Malnutrition. DTI (deep tissue injury) left heel, Stage III pressure Coccyx, unstageable to right calf, Blister to R. (right) hip, Bilateral [MEDICAL CONDITION], date initiated: 10/7/19, revision on: 10/28/19. Interventions that included: - Apply protective skin barrier after each incontinence episode and as needed, date initiated 10/7/19. - CNA's (Certified Nursing Assistant) will check my skin daily with care and report anything unusual they notice to the nurse, date initiated 10/7/19. - Encourage me to make small, frequent shifts in my position, date initiated: 10/7/19. - Encourage resident to lay down with legs elevated between meals, activities and therapies, date initiated on 10/28/19. - I have a heelz up pillow, elevate my legs when in bed as I allow, date initiated 10/23/19, date created 10/28/19. - I have pressure reducing air mattress on bed-setting to resident comfort, date initiated 10/9/19, revision 10/18/19. - I have pressure reducing device on wheelchair, date initiated 10/9/19. - Labs as ordered, date initiated 10/7/19, revision 10/18/19. - Supplements as ordered, date initiated 10/7/19, revision 10/18/19. - Treatments/medication as ordered, date initiated 10/7/19. A review of Resident #90's medical record, revealed the following: -A Nurses Note, dated 10/20/19 at 13:48 (1:48 PM), Affected area noted to right lower leg/calf area. Dark black in color, red granulation to surrounding skin, no swelling. [MEDICATION NAME] given for pain. Education provided to the family regarding not wearing these boots due to [MEDICAL CONDITION] in resident's legs. Area cleansed with ns (normal saline), (Doctor) aware, new order to cleanse with ns and cover with a duoderm dressing . -A Skin and Wound Evaluation, dated 10/22/19 at 13:58 (1:58 PM), included, Describe Type: Pressure, Stage: Unstageable: Obscured full-thickness skin and tissue loss, Due To: Slough and/or eschar, Location: Right Calf (Lateral), Acquired: In-House Acquired, Exact Date: 10/20/2019, Wound Measurements: Area 1.6 cm 2, Length 2.2 cm, Width 1.1 cm, Wound Bed: Eschar, Exudate Amount: Light, Type: Serosanguineous, Periwound Edges: Attached: Edge appears flush with wound bed or as a sloping edge, Notes: The residents skin was reviewed by the IDT (interdisciplinary team). The resident has a new unstageable pressure wound to her R. (right) calf. Treatment orders in place to Cleanse right lower leg with ns (normal saline), pat dry, cut to fit [MEDICATION NAME] AG (silver), cover with [MEDICATION NAME] foam daily and prn (as needed). The resident has an air mattress. -A Nurses Note, dated 10/25/19 at 15:01 (3:01 PM), Skin assessment done and new area noted along an old scar to right hip. No redness, no drainage, no pain. Tx (treatment) initiated with duoderm to right hip . On 10/28/19 at 5:07 PM, an interview was conducted with the Clinical Care Coordinator (CCC), Nurse F regarding Resident #90's facility acquired pressure ulcer to the right calf area and right hip area. The CCC was queried regarding the origination of the pressure ulcer to the right calf area and stated, It started on 10/20 (10/20/19). When she came from the hospital, she had an elevating boot and she had those on while in bed. It caused a pressure wound on the back of her calf. When queried regarding the treatment, the CCC stated, We started with cleansing the right lower leg with normal saline, apply duoderm every five days. That was started on the 20th. It was a blackened area; I took the picture on the 22nd and changed the dressing order when I assessed it. When queried if the blackened area moistened and opened, the CCC stated, Yes. I changed the treatment to cut to fit [MEDICATION NAME] AG (silver) and cover with [MEDICATION NAME] foam daily, cleanse and pat dry daily. The CCC was queried if the duoderm kept the moisture in and opened the area and the CCC stated, Yup. We stopped the boots and did a heels up pillow instead. The CCC was queried regarding the wound to the right hip area and when the wound originated. The CCC stated, It started on 10/25 (10/25/19), pressure? Yes, stage of the wound? Blister stage two, treatment ordered? Cleanse with normal saline, duoderm every five days and change as needed. When queried regarding wound measurement, the CCC stated, I have not assessed it yet. A review of the wound assessment in the medical record was conducted with the CCC and stated, There is a change in condition form, but it does not have measurements. The CCC was queried if a new wound was found, what was facility policy in measuring? The CCC stated, They should be measuring it when they find it. Was a picture taken? No, I will take the picture when I assess it. The CCC was questioned regarding a duoderm that was put on 10/25 and no measurements had been taken, how is the wound monitored for worsening or improvement? The CCC stated, They should be doing the measurements when the wound is discovered. The CCC was queried if the Nursing staff had the tools available to measure wounds and stated, Yes they do have the tools to measure that. Further review of the pressure ulcer to the right calf revealed the wound was discovered on 10/20/19 but measurements had not been completed until 10/22/19. On 10/29/19 at 11:08 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #90 developing two facility acquired pressure ulcers and the lack of measurements in the initial assessments. The DON stated, They put a duoderm on (right hip pressure wound) and it would do more harm then good to pull it off for an assessment. When queried regarding when measurements were to be completed on new wounds, the DON stated, On assessment. The initial assessment would include measurements? Yes. The DON was queried that measurements were to be done when the wound is discovered and stated, Yes. The facility wound care policy and procedures were requested from the DON. A review of the facility policy entitled, Wound Management Program, revised date on 8/17/17, revealed, . Policy: To assure that residents who are admitted with, or acquire, wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing . Tools applicable to this policy: [MEDICATION NAME] Health Systems Wound Protocol . The Health Systems Wound Protocol was not received from the facility prior to the exit of the survey.

Based on observation, interview and record review, the facility failed to implement preventative measures to avoid the development of pressure ulcers for two Residents (#4 and 42), of three reviewed for pressure ulcers, from a total sample of 28 residents, resulting in facility acquired pressure ulcers at a Stage III (full thickness skin loss) on the buttock of Resident #81 and an unstageable pressure injury to the left heel of Resident #42 and the potential for pain, infection and a compromise of overall health. Findings include: Resident #4 A review of Resident #4's medical record revealed an admission into the facility on [DATE] with a readmission on 9/21/17 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment, dated 10/21/17, revealed the Resident had severely impaired cognition and needed extensive assistance with transfers, dressing, eating, hygiene and bathing. The Resident's Braden Scale score, dated 10/27/17, indicated the Resident was at moderate risk for the development of a pressure ulcer. A review of Resident #4's progress notes revealed a Nurses Note dated 11/19/17 that stated, Aide called Nurse into room to look at opened area on resident's bottom. Nurse observed opened area aligned with where (the Resident's) briefs sits. CNA (Certified Nursing Assistant) suggested that brief may be too small or tight. Brief size changed from large to XL. Opened area measured at 2 cm (centimeter) x (by) 2 cm x 0 cm. first layer of skin missing, no blood or drainage noted . A further review of Resident #4's medical record documents entitled Skin Assessment revealed the following: 11/20/17, site: left buttock, type: pressure, measurements of 2 cm length and 2 cm width. No depth or stage was documented. 11/22/17, site: left buttock, type: pressure, measurements of 2.5 cm length and 2.6 cm width, Stage III. No depth documented. 12/6/17, site: left buttock, type: pressure, measurements of 3.5 cm length and 2.5 cm width, Stage III. A Physician's Note, dated 1/25/18, stated, . The wound is inspected and measures 2.4 cm x 1.5 cm on the surface and 1.3 cm in depth . On 1/24/18 12:24 PM, an observation was made of Resident #4's dressing change to the wound on the left buttock area completed by Nurse Q and assisted by Unit Manager, Nurse K. The wound was dark red and moist with induration around the wound bed. The wound was cleansed, santyl ointment applied into the wound bed and packed with gauze dressing, covered with 4x4 gauze and secured. The dressing was completed as ordered. Nurse K stated, The wound is Staged at three and has 2 centimeters of tunneling. The packing started Friday and the duoderm was discontinued. During the dressing change, an observation was made of the Resident flinching, moaning and complaining of pain. On 1/24/18 12:49 PM, an interview was conducted with Nurse K, that monitored the wound weekly and biweekly, regarding the progression of Resident #4's pressure wound to the left buttocks area. Nurse K indicated the wound was identified on 11/20/17 and treatment started with the last measurement on 1/17/18 of 2.4 cm. x 1.5 cm. x 1.3 cm depth with 2 cm. of tunneling at 10 O'clock and was a Stage III. When queried about preventive measures that were in place prior to the development of the wound, with Resident #4 at risk for developing pressure ulcers, Nurse K stated, An air mattress and Roho cushion were in place. It was changed to an antithrust cushion. When queried regarding the antithrust cushion, Nurse K stated, A cushion to put in the wheelchair to help with positioning. I think that is where my root cause is. We changed back to the Roho cushion and implemented a laydown schedule for between meals and activity. (The Resident) would be up most of the time, lay down after lurch and then be up for dinner. (The Resident) was up most of the time in the wheelchair with the antithrust cushion and then developed the pressure ulcer. (The Resident) had bowel incontinence as well with antibiotic use for an infection. When queried about the interventions in place for skin breakdown, Nurse K stated, Incontinent cream, Roho cushion and bed air mattress were in place and the cushion got changed out with therapy and when the area opened, it was switched back. It did get changed in the care plan but was not verbalized to me. I did not know the cushion had changed until the wound had opened and I investigated the cause. A review of the facility policy entitled, Wound Management Program, with a revised date of 8/17/17, stated, Purpose: To eliminate, modify or minimize factors that place residents at risk for skin breakdown. Policy: To assure that residents who are admitted with, or acquire, wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing. During the review of resident #42's medical record, a nursing progress note dated 12/27/2017 at 7:27 a.m. documented that Licensed Practical Nurse (LPN) (L) observed a 5.5 centimeter (cm) by 6 cm suspected deep tissue injury to resident #42's left heel. Purple center with reddened edges. Took measurements. On call supervisor, family, and physician notified. On January 24, 2018 at 2:25 p.m., resident #42 was observed lying in her bed. LPN (L) and Unit Coordinator Registered Nurse (K) were inside resident #42's room and removed her sock and wrap on her left heel. A black circular wound area was observed on the bottom of resident #42's left heel approximately the size of a golf ball. Unit Coordinator Registered Nurse (K) stated that the wound had gotten better since it was found on December 27, 2017. She also stated that resident #42's wound was due to pressure, but she had not been able to determine the root cause. Resident #42's right heel was observed to be intact, pink in color, with no evidence of skin irritation or breakdown. The most recent skin assessment dated [DATE] to resident #42's left heel documented size of 5 centimeters length by 4.5 centimeters width. The most recent facility assessment for resident #42's risk of skin breakdown was documented on a Braden Scale dated 12/01/2017 and categorized her at MODERATE RISK (Score of 13). Resident #42's plan of care for skin management as a result of impaired cognition, diabetes, self care ability, incontinence, weight loss, history of low [MEDICATION NAME] and cardiovascular disease ([MEDICAL CONDITION]) documented that facility staff were to follow interventions that included assist with floating heels up on pillow (6/8/2016) and heels up on pillow (12/27/2017). Resident #42's wight record was reviewed. The following weights from November and December 2017 were noted: 11/7 = 165.3 pounds 11/17 = 167.1 pounds 11/18 = 163.5 pounds 11/21 = 163.5 pounds 11/28 = 164.7 pounds 12/5 = 164.4 pounds 12/12 = 166.7 pounds 12/22 = 166.7 pounds. These weights do not represent a significant loss of weight, and show that resident #42's weight was stable prior to the development of her left heel wound. Resident #42 had a podiatrist visit dated 12/15/2017. Progress notes from this visit documented that both the left and right foot had normal vascular assessments. A radiology report dated 12/27/2017 due to pain and bruising on resident #42's heel from an x-ray FOOT AP and LAT 2V, LEFT had the following results There is modest [MEDICAL CONDITION] joint disease seen. There is no acute fracture, dislocation, or soft tissue swelling. No osteo[DIAGNOSES REDACTED] is seen. The bones appear diffusely demineralized. Peripheral [MEDICAL CONDITION] disease noted along with heel spurs. Conclusion: Modest [MEDICAL CONDITION] joint disease. The review of resident #42's most recent assessment completed on a quarterly Minimum Data Set (MDS) completed on 12/1/2017 documented no prior pressure sore development of active pressure sore. Resident #42 was found at risk for the development of a pressure ulcer. The review of resident #42's nursing and physician's progress notes found no evidence of an acute medical condition to justify the development of a pressure ulcer. Therefore, resident #42's development of a pressure ulcer to her left heel was not found to be unavoidable based upon the weight, vascular assessment, x-ray, and medical condition.

Based on interview and record review the facility failed to ensure a staff member followed policy/procedure for safety while operating a mechanical lift in 1 of 4 residents (Resident #1), reviewed for falls, from a total sample of 4 residents, resulting in Resident #1 sustaining bilateral leg fractures, and a laceration to the head, when Resident #1 fell from a mechanical lift. Findings include: Review of the facility policy/procedure "Mechanical Lift Device" dated ,[DATE], last revised on ,[DATE] reflected, "Purpose: To lift residents using a mechanical lifting device. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident...The mechanical lift shall be used according to the resident care plan...Place the sling under resident...attach the sling to the lift appropriately...Using the hand held control stand near the resident and raise the resident from the bed slowly and recheck straps to insure they are fastened tightly." Resident #1 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #1 had severe cognitive impairment and required staff assistance for all activities of daily living. Review of the Falls Care Plan dated created [DATE] reflect the intervention of "Assist of 1 with total mechanical lift," dated [DATE]. Review of the nurses notes date [DATE] at 11:56 PM reflected that Certified Nurse Assistant (CNA) "A" was transferring Resident #1 from the wheel chair to the bed with a mechanical lift and during the transfer the sling attachment at Resident #1's right leg became disengaged and Resident #1 slid out of the sling and landed on the steel legs of the lift (a height of approximately 3 feet). Resident #1 sustained a laceration to the back of the head and had signs and symptoms of pain to the pelvis. Resident #1 was subsequently sent to the emergency department for further evaluation and treatment. Review of the Hospital Discharge Summary dated [DATE] reflected Resident #1 fractured both femurs (upper legs), received staples to the scalp to close the laceration, and was transferred back to the facility for comfort care on [DATE] at 12:30 PM, with a poor prognosis. Review of the nurses notes dated [DATE] at 11:17 PM, reflected Resident #1 was provided comfort care and expired at 9:50 PM. During an interview on [DATE] at 10:00 PM, the Nursing Home Administrator (NHA) stated that after Resident #1's fall from the mechanical lift occurred, CNA "A's" statement was obtained and CNA "A" was suspended pending the investigation. NHA stated that CNA "A" reenacted the transfer for the NHA and it was determined that CNA "A" did not follow the mechanical lift policy of re-checking the sling attachments to insure they are engaged before transferring Resident #1. NHA stated that when the root cause of the fall was identified that staff were inserviced starting [DATE] and that no staff were allowed to work until they completed the inservice. The NHA stated that the facility trained all employees how to use the lifts and require a return demonstration to assure competency upon hire, annually and as needed. The NHA stated that CNA "A's" employment would be terminated due to a failure to follow the facility policy/procedures and safety procedures while operating a mechanical lift that resulted in Resident #1 sustaining a serious injury when Resident #1 fell . During an interview on [DATE] at 1:00 PM, CNA "A" stated that when he was transferring Resident #1 from the wheel chair to the bed, CNA "A" remembered looking down towards the wheels of the lift and at that time Resident #1 slid out of the sling and landed on the legs of the machine. CNA "A" denied any malfunction of the mechanical lift or the sling. CNA "A" stated that when he demonstrated how the incident occurred (to the NHA) that is was determined, "I may not have rechecked the sling clips." CNA "A" stated that he did receive training on the mechanical lifts and did a return demonstration when he was hired [DATE]. (# )

This citation pertains to MI 520. Based on interview and record review, the Facility failed to maintain the highest physical well being (adequately assessment, monitor and provide adequate care after a choking incident) in 1 of 10 sampled residents (Resident #500) reviewed for a significant change in condition, from a total sample of 10 resident, resulting in an Immediate Jeopardy for Resident #500, who was to have a mechanically soft diet, choked on meat on [DATE] at approximately 12:45 p.m. during the lunch time meal, and was taken back to her room where no further care was given. Resident #500 subsequently died . This deficient practice placed all residents at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet, Minimum Data Set ((MDS) dated [DATE], Physician orders [REDACTED].#500 was admitted to the facility on [DATE], had a history of [REDACTED]. Resident #500 required assistance with all Activities of Daily Living (ADL's) and was placed in the Main Dining Room (MDR) due to her need for supervision during meals. Resident #500's [DIAGNOSES REDACTED]. Resident #500's advanced directives dated [DATE] revealed she was not to have CPR (cardio [MEDICAL CONDITION] resuscitation) and she received Hospice services at the Facility. Review of the Hospital Records dated [DATE] revealed Resident #500 was admitted to the Hospital for evaluation following a fall and was found to possibly have had a stroke. She returned to the Facility with an order for [REDACTED]. Review of the Nurses' notes dated [DATE], revealed "Resident (Resident #500) readmitted following a 2 day Hospital stay for speech [MEDICAL CONDITION] and TIA (stroke), Mech (mechanical) soft diet." Review of the Hospital Speech evaluation dated [DATE], revealed Resident #500 "demonstrated prolonged mastication (chewing) of regular solids secondary to missing bottom dentition (teeth) and reduced lingual (tongue) strength and coordination (decreased strength and coordination to chew and move food in mouth), with mild [MEDICATION NAME] pocketing of regular solids (foods left in mouth after eating). Recommendations: Diet dysphagia. Sit upright for all oral intake, small bites, supervision 1:1, small sips." Review of the Dysphagia Medical Work-Up Form dated [DATE], revealed Resident #500 was at risk for "choking" and "aspiration problems" with "drooling, oral food retention, leakage of food or liquids placed in mouth" and had "neuromotor disturbances/sensation loss/incoordination." Review of the Speech Therapy Evaluation and Initial Plan of Care dated [DATE], revealed "the ST (Speech Therapist) provided the pt.(patient) w/ (with) a ground up turkey sandwich whereby the pt. exhibited mastication/oral deficits which placed her at risk for potential choking/aspiration events, residue in the oral cavity is a concern for potential choking/aspiration after the swallowing. Supervision during and after meals to check for oral retention and to clear if necessary." Review of the Speech Therapy Resident Care Plan dated [DATE], revealed Resident #500 was "high risk of aspiration" and required "therapeutic feeding." Review of the Physician order [REDACTED]." Review of the Nutrition Care Plan dated [DATE], revealed "meals in assist dining room, [DATE] mech soft." Review of the Resident Door Sheet (Nurse aide care guide) dated [DATE] and the un-dated care guide in use at the time of Resident #500's death on [DATE], revealed she was to eat in the MDR and have, "Diet: mechanical soft, Resident to be intermittently supervised during meals to check for oral pocketing, especially after the meal. If pocketing occurs, encourage to clear with liquid rinse or with tongue. Make sure oral cavity is clear prior to lying down." Review of the Nurses Notes dated [DATE], revealed "Resident (Resident #500) had difficulty swallowing peaches and chewing meats." Review of the Nurses' Notes dated [DATE] at 1:10 p.m., revealed "called to main dining room at 12:50 (p.m.). (Resident #500) observed unresponsive and unable to follow commands. Resident appeared w (with)/pallor and w/ fixed pupils. Immediately took resident to room where she was placed in bed. At this time respirations were 2/min (2 breaths per minute) and w/ no reading using SPO2 (oxygen saturation) monitor. At this time, apical pulse was assessed for 1 minute w/no heart beat noted. (RN #3) assessed apical pulse for 1 minute w/no heart beat noted. No respirations noted. Pupils fixed. Time of death 1306 (1:06 p.m.). (Physician #1) to release remains to funeral home. (Funeral Home named) removed remains at 1400 (2:00 p.m.)." The surveyor was unable to view the Facility's video tape of the MDR on [DATE] because it was "lost." Review of the technicians written report dated [DATE], stated that "the video loss at (the Facility) was caused by a disconnected cable." Review of the Facility Dietary Menu dated [DATE], revealed "beef tenderloin tips, mashed potatoes, veggies" had been served on [DATE] for lunch. Review of Resident #500's dietary sheet dated [DATE] revealed she was on a "mechsoft (mechanical soft diet) swallo (with swallow precautions in place)." In an interview on [DATE] at 2:50 p.m., Certified Nurse Aide (CNA) #4 stated, "I heard (Dietary Aide/DA) #2 say she (Resident #500) was choking. I heard (DA #1) tell (Director of Nursing (DON) #1, Registered Nurse (RN) #2, Licensed Practical Nurse (LPN) #1) she was choking. She had blue lips, it looked like lip liner. A few CNA meetings back, (DON #1) said do the [MEDICATION NAME] maneuver in the dining room if they choke, because it takes too long to get them back to their room. No one looked in her mouth (staff was instructed to check the Residents mouth during and after meals per the Residents Nursing Assistant Care Guide)." Per interviews on [DATE] at 8:43 a.m., on [DATE] at 12:25 p.m., and per written statement dated [DATE], DA #2 said she asked Resident #500 if she was choking and Resident #500 nodded her head affirmatively and said Resident #500 "looked red in the face and her lips were bluish/purple." DA #2 stated, "I called for another co-worker (DA #1) to help out; she started doing the [MEDICATION NAME] maneuver on her. (RN #3) and (DON #1) came in (the MDR), (RN #3) did one abdominal thrust and then stopped after she asked (DON #1) if (Resident #500) was a full code and (DON #1) hollered out "Hospice" and then she stopped, that's when (LPN #1) and (RN #2) came into the dining room and took her back to her room. (Resident #500) was holding her chest and had a scared look on her face." Per interviews done on [DATE] at 8:30 a.m., [DATE] at 2:40 p.m., [DATE] at 8:00 a.m. and per written statement dated [DATE], DA #1 stated, "(Resident #500) was eating lunch on the 27th ([DATE]), (DA #2) was her feeder. She was assisting feeding her beef tips and mashed potatoes when all the sudden (DA #2) said to (DA #1) 'I need help'. (Resident #500) had both hands on her throat, she was not breathing, lips were blue and she was still alert and not coughing. (CNA #4) said a piece of meat came up when I was doing the [MEDICATION NAME] maneuver. (RN #3) then came in and was at my side. I backed off and told her some food came up. I did not see anyone do anything for her after I stopped doing the [MEDICATION NAME] maneuver. When (RN #3) asked her code status, (DON #1) said 'she's Hospice', (RN #3) put her hands up and stepped back and at that point everything stopped, you could hear a pin drop and they took her back to her room. I also did it ([MEDICATION NAME] maneuver) on (Resident #500) before, it wasn't too long ago." DA #1 was unable to recall the date she had performed the [MEDICATION NAME] maneuver/abdominal thrusts on the Resident prior to [DATE]. In an interview on [DATE] at 11:00 a.m. Cook #3 stated, "I was here a different day, it was about 3 to 4 weeks before (prior to [DATE]), in the beginning of August, and she (Resident #500) choked on an orange. I saw (DA #1) do the [MEDICATION NAME] on her, it popped right out on the table." Review of the nurses' notes dated ,[DATE] and ,[DATE], revealed no documentation that Resident #500 had a choking episode or had abdominal thrusts performed on her. In an interview on [DATE] at 9:00 a.m. CNA #4 stated, "(DA #2) was feeding her, she went to gag, she did not say anything, (DA #1) started doing the [MEDICATION NAME] maneuver and a piece of meat came out. She still had food in her mouth, she opened her mouth and there was still food in her mouth." In an interview on [DATE] at 8:00 a.m. CNA #3 stated, "I heard (DA #1) say she (Resident #500) was choking. I ran to the phone and paged Nurse Stat to Main Dining Room, then (DA #1) started abdominal thrusts on her. She was sitting in her wheelchair, she looked scared, her eyes were bulging out, they were big. I did not hear her breathing or coughing. I did not hear any noise coming from her. (DON #1) said she's on Hospice and no one did anything after (DA #1) stopped doing abdominal thrusts. I saw tinting to her lips, they were a light blue in color, then (LPN #1) asked her to squeeze his fingers and she did. Then slowly (RN #3) wheeled her to her room. Me and (CNA #9) did post-mortem care. (DON #1), (LPN #1), (RN #2), (RN #3) said they needed toothettes when they were in there (Resident #500's room)." In an interview on [DATE] at 11:00 a.m. CNA #8 stated, "I was feeding in the main dining room. I remember (CNA #3) running to the phone to call for help. I heard her say 'someone's choking'. I turned around and I saw it was (Resident #500). I did not hear or see anyone do vital signs or get her oxygen and no one even looked in her mouth." In an interview on [DATE] at 11:15 a.m. CNA #7 stated, "(DA #2) said 'she's choking' and I looked up and saw (DA #1) was giving her (Resident #500) the [MEDICATION NAME] maneuver. Then (RN #3) and (DON #1) said she's on Hospice and they started to take her out." In an interview on [DATE] at 10:50 a.m. CNA #6 stated, "I was in the dining room feeding when I heard (DA #2) say 'she's choking'. I saw (DA #1) do the abdominal thrusts, I did not hear the Resident talk at all. I did not see the Nurses check her mouth or do vitals. I heard (CNA #3) page stat to the dining room. (Sampled Resident #501) was sitting at the table next to her (Resident #500) and he's alert." In an interview on [DATE] at 3:20 p.m., sampled Resident #501 said he was eating in the MDR near Resident #500's table on [DATE] at 12:45 p.m. Resident #501 stated, "I remember her, I saw her choke, gasp for air and coughing." Review of Resident #501's Advanced Directive dated [DATE] and physician progress notes [REDACTED]." In an interviews on [DATE] at 10:15 a.m.and [DATE] at 7:10 a.m. RN #3 stated, "I was the first one in (the MDR). (Resident #500) nodded her head 'ok' when I asked her; (DA #1 and #2) said she was choking. I asked what her code status was and (DON #1) said Hospice, she was completely alert at this time." RN #3 stated, "(DON #1) called me to go in with (RN #2), when I got to her room she was pale, her eyes were open, she was taking deep breaths. She was in her room about 10 minutes before she died . We swabbed her mouth to check her oral care and her oral cavity. No oxygen was put on her because she was Hospice. I didn't chart because the (DON #1) delegated charting to (LPN #1)." When the surveyor asked RN #3 if vital signs were taken on Resident #500, RN #3 stated, "we did not do vitals." When the surveyor asked RN #3 why no vital signs were done she stated "I cannot honestly answer that. I did not look in her mouth because we were moving her out of the room (the MDR); yes I agree we should have looked in her mouth." Review of the Nurses notes dated [DATE] at 1:10 p.m., revealed "called to main dining room at 12:50. (Resident #500) observed unresponsive and unable to follow commands. Resident appeared w (with)/pallor and w/ fixed pupils." In an interview on [DATE] at 12:45 p.m., RN #1 (Staff Educator)said signs of choking, could be, hands on throat or chest, a blue color, eyes big or bulging, a stressed look, blue color to the lips and the person could be sitting up alert. RN #1 said staff should assess lung sounds, vital signs and stated, "I don't think it's unreasonable to look in the mouth, just because someone is not choking does not mean they are not partly obstructed." In an interview on [DATE] at 3:35 p.m. RN #2 stated, "I was at station 3 and I heard a page stat from the Main Dining Room. I went down, I stood by the window, I heard later from CNA #3 she (Resident #500) was choking. In front of the Nurses' Station (Resident #500's) respirations changed, I got about 12 per minute. I did not chart and you can bet I will be doing a late entry. We (RN #2 and LPN #1) put her in the bed and I remember saying to (LPN #1), 'she's holding her chest'. I did not do CPR because she was Hospice. After she was dead we (RN #2, DON #1 and LPN #1) did oral care, we got something black out of her mouth. (CNA #2) brought a washcloth and toothettes back. I know she was a Hospice patient and expected to die." In interviews conducted on [DATE] at 8:20 a.m. and [DATE] at 11:55 a.m. CNA #2 stated, "(RN #2) asked me for mouth swabs for (Resident #500) when she was taken to her room. (DON #1) told me they needed me in the room and then (RN #2) told me to get some mouth swabs (toothettes) and then I left and they shut the door. I did not ask why they wanted mouth swabs. (LPN #1) told me she had a [MEDICAL CONDITION]." In an interview on [DATE] at 9:35 a.m. LPN #1 stated, "(RN #3) came in first (to the MDR), then (DON #1). When I came in I saw (Resident #500) sitting up in her chair, she was not talking. Within 30 seconds, she squeezed my hand; she made a gutteral grunt noise. (RN #2) asked for toothettes. (RN #2) looked in the Residents mouth with the toothetts in her room. She pulled out a piece of meat from her mouth, about the size of a nickel or dime. She took a couple of breaths and time of death was 1306 (1:06 p.m.). No one hooked up oxygen to the Resident or did an assessment because she was a DNR (do not resuscitate) and on Hospice, no oxygen because it's extraordinary care. If we are not taking actions to save a life, oxygen is not necessary. I feel the actions in the room where appropriate; I feel it was a natural death." In an interview on [DATE] at 3:55 p.m. DON #1 stated, "I was in my office; I heard nurse stat to main dining room. When I got there, I observed (RN #3) and (DA #2) with (Resident #500). No one told me the [MEDICATION NAME] was done. (DA #2) looked up and said she was choking. She was alert, color was a little pale, her hand was on her upper chest area. I did not assess her for choking because in my clinical judgment, she was in no distress." DON #1 stated, "I said let's get her to her room. Then (LPN #1) and (RN #3) took her out of the dining room. We took her out mostly for dignity; I know she does not appreciate everyone staring at her. When I walked in (Resident #500's) room, (RN #2), (RN #3) and (LPN #1) were in the room. At that time she was gray and not in any distress what's-so-ever. We did not have the opportunity to assess her because she died ; I think she died when she was being transferred in her bed. I did not ask anyone to get a toothette or swab for her mouth, I did not see anyone clean out her mouth, no one used a toothette on her. From a clinical perspective it looked cardiac." When DON #1 was asked if she had looked in Resident #500's mouth for food, DON #1 stated, "It did not dawn on me; she was end stage and Hospice and it was an expected death, a natural decline, the angels came and got her, it was a beautiful death." DON #1 revealed the only Nurse she "designated" to chart the incident on [DATE] regarding Resident #500's death was LPN #1. DON #1 stated, "If I charted for all my Nurses, I would never get off the floor." DON #1 said that neither an incident/accident report nor an investigation was done regarding Resident #500's death because she "felt it was a natural, expected death." Review of the Nurses' Notes dated [DATE] at 1:10 p.m., stated "called to main dining room at 12:50. (Resident #500) observed unresponsive and unable to follow commands, Resident appeared w (with)/pallor and w/ fixed pupils. On [DATE], at 1:35 p.m., this surveyor and the Facility Administrator watched the video of the hall Resident #500 was on. LPN #1 and RN #2 were observed pushing (walking) Resident #500 in her wheelchair to her room on [DATE] at 12:53 p.m. Resident #500 was sitting up in her wheelchair with her head down slightly to the right; the back of Resident #500 was the only view on the video. When Resident #500 was in her room, CNA #2 was observed going into her room, he come back out and then went back in with something in his left hand (toothettes and a washcloth per previous interview). In a telephone interview on [DATE] at 1:05 p.m. Physician #1 reported that the Facility did not inform him after Resident #500 had deceased on [DATE], that she had choked on a piece of meat. In a telephone interview on [DATE] at 9:30 a.m., Family Member #1 stated, "I received a call from the Facility, (RN #2) called me after she (Resident #500) died (on [DATE]). She (RN #2) said they went in there (the MDR) and she had her hands on her chest. (RN #2) said someone asked her if she was all right and she said "yes". Then they said she was in her wheelchair with her hands on her heart, she said her heart rate was '30'. Then she said she died peacefully." Family member #1 requested to meet with the Facility regarding Resident #500's death and stated, "I came in for a meeting a couple of days later. (DON #1) and (RN #2), they talked with me. They said (Resident #500) was in the lunch room and they got a code Blue. I was told that (RN #2) was getting ready to do the [MEDICATION NAME] maneuver on her and then she coughed so she was all right. They didn't tell me if she coughed anything up. (DON #1) said at the meeting she could of choked because she was at risk, (RN #2) did not tell me that on the phone. Her meat always had to be ground, she had difficulty swallowing, they were crushing her pills and putting them in pudding because she had difficulty swallowing. (DON #1) said she probably died of a [MEDICAL CONDITION]." Review of the Certificate of Death dated [DATE], revealed Resident #500's cause of death was "end stage debility, advanced [MEDICAL CONDITION] "with possible aspiration." Review of the Facility Emergency Medical Response and Management/Code Blue policy dated ,[DATE], revealed "When a resident has a DNR status, and stops breathing: Document all interventions in the medical record, two Nurses must verify that signs of life are not present, documentation includes the assessment and lack of vital signs, the names of both Nurses are recorded in the medical record." The Administrator was notified on [DATE] at 12:25 p.m. of the Immediate Jeopardy that began on [DATE] at 12:45 p.m., when the facility failed to maintain the highest physical well being of Resident #500 when Resident #500 choked on meat during the lunch time meal, and was taken back to her room where no further care was given. Resident #500 subsequently died . On [DATE], the surveyor confirmed that the Facility implemented the following to remove the Immediate Jeopardy. 1. On [DATE] the Director of Nursing identified that all residents are at risk for needing nursing assessment and the management of possible choking and potential aspiration. 2. On [DATE], the Director of Nursing revised the Facility [MEDICATION NAME] maneuver policy and procedure. The policy and procedure was approved by the Administrator on [DATE], The Management and Prevention of Choking and Aspiration and [MEDICATION NAME] Maneuver includes: a. The procedure to identify residents with signs of choking and possible aspiration. b. Nursing assessment procedures. c. Nursing interventions. d. Nursing documentation requirements. e. Continued evaluation of implemented interventions and ongoing Nursing assessment. 3. On [DATE] at 7:00 a.m., 12:30 p.m. and 3:00 p.m., the Director of Nursing educated the licensed nursing staff regarding the Management and Prevention of Choking and Aspiration policy. 30 out of 33 licensed nurses completed the education on [DATE], 1 is on medical leave and 2 remaining nurses will be educated prior to working their next scheduled shift. 4. On [DATE], Dietary and Nursing Assistant staff was educated on the identification and reporting of choking residents. 11 out of 20 Dietary staff and 20 out of 78 Nursing Assistants were educated on [DATE]. The remaining staff will be educated by the Director of Nursing or Educational Coordinator prior to working their next shift. 5. On [DATE], for 30 days staring at the evening meal, there will be a licensed nurse in the Main Dining Room to monitor residents for choking symptoms. The nurse will report to the Director of Nursing any resident choking immediately. 6. The Administrator will be responsible for the overall compliance of this plan of correction. Although the Immediate Jeopardy was removed on [DATE], the Facility remained out of compliance at a pattern scope and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to not all staff had been in-serviced and sustained compliance had not been verified by the State Agency. ( )

This citation pertains to MI 520. Based on interview and record review, the Facility failed to provide an ordered therapeutic diet in 1 of 10 sampled Residents (Resident #500) reviewed for therapeutic diet, from a total sample of 10 residents, resulting in Resident #500 choking on 8/27/12 at approximately 12:45 p.m., and Dietary Aide (DA) #1 performed abdominal thrusts ([MEDICATION NAME] maneuver). Resident #500 subsequently died . Findings include: Review of the Face Sheet, Minimum Data Set (MDS, Resident assessment tool) dated 7/16/12, Physician orders [REDACTED].#500 was admitted to the facility on [DATE], had a history of [REDACTED]. Resident #500 required assistance with all Activities of Daily Living (ADL's) and was placed in the Main Dining Room (MDR) due to her need for supervision during meals. Resident #500's [DIAGNOSES REDACTED]. Resident #500's advanced directives dated 4/24/12 revealed she was not to have CPR (cardio [MEDICAL CONDITION] resuscitation) and was on Hospice service. Review of the Hospital Records dated 4/23/12; revealed Resident #500 was admitted to the Hospital for evaluation following a fall and was found to possibly have had a stroke. She returned to the Facility with an order for [REDACTED].#500) readmitted following a 2 day Hospital stay for speech [MEDICAL CONDITION] and TIA (stroke). Mech (mechanical) soft diet." Review of the Nutrition Care Plan dated 3/19/12, Nurses' notes and Physician order [REDACTED]." Per the Speech Therapy care plan dated 4/24/12, Resident #500 was at "high risk of aspiration." Resident #500 was able to feed herself and was assigned to the MDR due to her need for increased supervision during meals (the main dining room was assist and/or supervision during meals). In an interview on 8/29/12 at 8:30 a.m., DA #1 said on 8/27/12 at approximately 12:45 p.m., she observed Resident #500 choking in the MDR. Resident #500 "had both hands on her throat, not talking, coughing and her lips were blue in color." DA #1 reported that she then initiated abdominal thrusts on Resident #500. In an interview on 8/29/12 at 8:43 a.m., DA #2 said she asked Resident #500 if she was choking and Resident #500 nodded her head up and down for yes and she "looked red in the face and her lips were blue/purple." In an interview on 8/29/12 at 3:20 p.m. Resident #501 (who was eating in the MDR near Resident #500's table on 8/27/12 at 12:45 p.m.) stated, "I remember her, I saw her choke, gasp for air and coughing." Review of the nurses notes dated 8/27/12 at 13:10 (1:10 p.m.) revealed, "called to main ding (dining) room at 12:50 p.m. Resident observed unresponsive and unable to follow commands. Resident appeared w (with)/pallor, w/fixed pupils." In interviews conducted on 8/29/12 at 9:00 a.m. and 2:50 p.m., and per a telephone interview on 9/3/12 at 1:05 p.m. Certified Nurse Aide (CNA) #4 stated, "I heard (DA #2) say she (Resident #500) was choking. (DA #2) was feeding her, she went to gag, she did not say anything, She had blue lips, it looked like lip liner. (DA #1) started doing the [MEDICATION NAME] maneuver and a piece of meat came out. She still had food in her mouth, she opened her mouth and there was still food in her mouth." CNA #4 stated, "it was like stringy (the beef tips served to Resident #500 on 8/27/12 at the noon meal); her meat was stringy and about 1 ? to 2 inches in length." In interviews conducted on 8/30/12 at 12:00 p.m. and 4:10 p.m., Registered Dietician (RD) #1 reported beef tips were served to Resident #500 in the MDR on 8/27/12 at the noon meal and she stated "They run it (beef tips) through the food processor (called a RoBo blender) to get mechanical soft; you shouldn't get strips or strings of meat. It should look like hamburger, ground meat." In a telephone interview on 8/30/12 at 4:22 p.m., Cook #1 revealed she had prepared Resident #500's meat for her noon meal on 8/27/12. Cook #1 stated "the mechanical soft meat was shredded. The RoBo grinded it up, the shredded pieces of meat were the size of my pinky finger, about 1 ? to 2 inches long." In interviews conducted on 8/30/12 at 4:14 p.m. and 9/4/12 at 4:13 p.m., Cook #2 said that mechanical soft meat "shouldn't have been shredded, mechanical soft diet is completely ground up, it shouldn't of been shredded. It could happen with the wrong setting (on the RoBo blender). No one ever watches the consistency (of pureed and mechanical soft diets) here." In an interview on 9/5/12 at 11:00 a.m., Cook #3 stated, "I blend beef tips at high speed until they are about ? inches long, if I put my mechanical soft meat in soup, it would be so small you could barely see it. A person needs to be shown or trained how to do it because you don't know what mechanical soft means. No one has trained us cooks on how to make mechanical soft meats, we just show each other, no one else shows us." In an interview on 9/4/12 at 2:58 p.m., Staff Educator RN #1 reported that the dietary staff had not been in-serviced on exactly how to blend meats for the correct consistency of mechanical soft or pureed (completely blended) diets. In an interview on 9/4/12 at 1:35 p.m., Speech Therapist #1 stated, "mechanical soft meats should be ground-up, between a regular diet and pureed diet. It should look like ground hamburger. I shouldn't be stringed; it shouldn't have pieces of meat." Speech Therapist #1 denied being aware of any training or education done by the Facility to dietary staff regarding how to blend meats to the consistency of mechanical soft or pureed diets. In an interview on 9/4/12 at 2:15 p.m., Dietary Manager #1 said no one in the kitchen had been in-serviced regarding mechanical soft or pureed diets and stated, "I have never done an in-service with the cooks on how to make the consistency of mechanical soft, because everyone's been here a long time." Dietary Manager #1 said he thought that all the cooks knew how to correctly blend mechanical soft meats because they had been working at the Facility prior to him and he assumed they had been trained. Review of the Facility's Diet Descriptions policy dated 3/1/1985, (found in the Dietary Policy book given to the surveyor by the Dietary Manager) revealed, "There will be on file a written description of the Nursing Homes diets, both therapeutically and mechanically." Review of the Dietary Descriptions Policy book revealed no documentation of a written description or visual example of a mechanical soft diet, or how to correctly blend it using the RoBo blender. Review of the Facility's menu fall and winter cycle (un-dated), revealed, "mechanical soft diet, foods provided are soft or mechanically altered to meet diet manual guidelines for dysphagia (difficulty swallowing)." When the Dietary Manger was asked for the "diet manual for dysphagia", he denied being aware of the manual or where it may be. Review of the Indiana Diet Manual eighth edition 2011, given to the surveyor by RD #1 on 9/5/12, who said "that is what the Facility goes by", revealed documentation indicated mechanically altered meat should look like, "Level 2: Mechanically Altered, Moist-ground or minced, tender-cooked meat with no larger than ? (inches) pieces." Review of the Certificate of Death dated 8/29/12, revealed Resident #500's cause of death was "End Stage Debility, Advanced [MEDICAL CONDITION]" with "possible aspiration." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 805. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE SUPERVISION AND PREVENT ACCIDENTS FOR 1 (#501) OF 7 SAMPLED RESIDENTS FROM A TOTAL SAMPLE OF 7 RESIDENTS WITH COGNITIVE IMPAIRMENT AND A HISTORY OF PREVIOUS FALLS, RESULTING IN A HEMATOMA (AN UNUSUAL CLOTTED MASS OF BLOOD) AND CONTUSIONS OF THE FACE, SCALP AND NECK, AND REQUIRING hospitalization . FINDINGS INCLUDE: REVIEW OF THE FACE SHEET, MINIMUM DATA SET (MDS, RESIDENT ASSESSMENT TOOL) DATED 6/14/11, NURSES AND SOCIAL WORKER NOTES DATED 7/14/10 THROUGH 6/24/11, physician progress notes [REDACTED].#501 WAS ORIGINALLY admitted to the facility on [DATE] AND RE-admitted on [DATE], CONFUSED WITH SHORT AND LONG TERM MEMORY LOSS, DECREASED SAFETY AWARENESS, BLIND IN HIS LEFT EYE, HARD OF HEARING, DEPENDENT ON STAFF ASSIST FOR ALL ACTIVITIES OF DAILY LIVING AND REQUIRED THE ASSIST OF 2 FOR ALL BED MOBILITY. THE RESIDENTS [DIAGNOSES REDACTED]. THE RESIDENT fell OUT OF BED WHILE RECEIVING CARE ON 6/24/11, HIT HIS FACE ON THE BEDSIDE STAND, WAS THEN TRANSFERRED TO THE HOSPITAL FOR EVALUATION AND DID NOT RETURN TO THE FACILITY. REVIEW OF THE MDS dated [DATE], SAID "HE (RESIDENT #501) HAS IMPAIRED STRENGTH, ENDURANCE, BALANCE AND MOBILITY R/T (RELATED TO) ADVANCED AGE (85) AND HEALTH FACTORS AND DEMENTIA. HE HAS DEMENTIA WHICH INTERFERES WITH HIS SAFETY AWARENESS AND COMMUNICATION". REVIEW OF THE FACILITY REHAB QUARTERLY assessment dated [DATE], REVEALED RESIDENT #501 DISPLAYED "DIFFICULTY FOLLOWING COMMAND" HAD "DECREASED SAFETY AWARENESS" AND THE DOOR SHEET (CNA RESIDENT CARE DIRECTIONS) REQUIRED "2 ASSIST" FOR BED MOBILITY. RESIDENT #501 WAS NOT AT THE FACILITY AT THE TIME OF THE INVESTIGATION, 1/4/12 THROUGH 1/6/12. REVIEW OF RESIDENT 501'S FACILITY NURSING ASSISTANT (CNA) RESIDENT CARE GUIDE (UN-DATED) STATED " BED MOBILITY, ASSIST OF 2". REVIEW OF THE IMPAIRED MOBILITY AND AT RISK FOR FALLS CARE PLAN DATED 1/31/03, UP-DATED ON 6/24/11, REVEALED RESIDENT #501 HAD A ? SIDE RAIL ON THE RIGHT SIDE OF HIS BED FOR BED MOBILITY AND STATED "PROVIDE ASSIST OF TWO PERSONS TO TURN/REPOSITION IN BED". REVIEW OF THE RESIDENTS COGNITIVE CARE PLAN DATED 6/22/11, STATED "RESIDENT HAS A DX (DIAGNOSES) OF SENILE DEMENTIA THAT AFFECTS RESIDENT'S SHORT AND LONG TERM MEMORY AS WELL AS IMPAIRS DECISION-MAKING ABILITIES, DECISIONS POOR, CUES/SUPERVISION REQUIRED". REVIEW OF THE FACILITY ACCIDENT/INCIDENT REPORT DATED 6/24/11, REVEALED AT 6:20 P.M., RESIDENT #501 "ROLLED OFF THE BED ON THE LEFT SIDE AND ACCRUED A HEMATOMA THE SIZE OF A GOLF BALL AND LACERATIONS TO HIS FACE". REVIEW OF THE NURSES NOTES DATED 6/24/11 AT 6:32 P.M., STATED "CNA AT SIDE WASHING BLOOD OFF RES. (RESIDENT #501) FACE. ASSESSMENT REVEALED RES WITH HEMATOMA APPROX. SIZE OF GOLF BALL, TO RT (RIGHT) FOREHEAD, LACERATION TO RT SIDE OF NOSTRIL WITH SWELLING. CNA STATED WHILE ROLLING RES TO LT (LEFT) SIDE, RES fell OOB (OUT OF BED) AND HIS NOSE WAS BLEEDING, RES ASKED WHERE DOES IT HURT, RES REPLIED BACK (UPPER), HEAD, NOSE". REVIEW OF THE FACILITY TRANSFER SUMMARY DATED 6/24/11 STATED "RESIDENT fell OUT OF BED, SUSTAINED GOLF BALL SIZE HEMATOMA AND NOSE BLEED WITH SWELLING NOTED". REVIEW OF THE HOSPITAL EMERGENCY DEPARTMENT REPORT DATED 6/24/11, REVEALED RESIDENT #501 WAS diagnosed with [REDACTED]. REVIEW OF THE HOSPITAL HISTORY AND PHYSICAL DATED 6/27/11, STATE "fell WHILE HE (RESIDENT #501) WAS RECEIVING CARE AT THE NURSING HOME WHEN HE ROLLED OFF THE BED AND HIT HIS HEAD. HE WAS NOTED TO HAVE SWELLING ON HIS SCALP. HE WAS ALSO NOTED TO HAVE SOME SWELLING IN HIS NOSE". REVIEW OF THE EMERGENCY MEDICAL RESPONSE REPORT DATED 6/24/11, STATED "STAFF STATES PT (PATIENT, RESIDENT #501) SLID OUT OF BED WHILE THEY WERE CHANGING HIM. PT HAS HEMATOMA ON FOREHEAD, ABOVE RIGHT EYE, GOLF BALL SIZE". AN INTERVIEW WAS DONE ON 1/6/12 AT 6:38 A.M., WITH CHARGE NURSE LPN #1. CHARGE NURSE LPN #1 REVEALED CNA #1 WAS CHANGING THE RESIDENT AND HE ROLLED OUT OF HIS BED. CHARGE NURSE #1 STATED "(CNA #1) TOLD ME THE RESIDENT HIT HIS HEAD ON THE NIGHT STAND. I GOT THE ORDER FOR A LOW BED AND FLOOR MATS ON 6/24/11 (AFTER THE RESIDENT fell OUT OF BED)". CHARGE NURSE #1 REVEALED CNA #1 TOLD HER HE DID NOT ASK FOR ASSISTANCE PRIOR TO GIVING THE RESIDENT CARE. CHARGE NURSE #1 ALSO REVEALED CNA #1 ROLLED THE RESIDENT TO HIS LEFT AND HIS SIDE RAIL TO ASSIST WITH BED MOBILITY WAS ON THE RIGHT SIDE OF HIS BED. AFTER SEVERAL ATTEMPTS, THE SURVEYOR WAS UNABLE TO CONTACT CNA #1 BY PHONE FOR AN INTERVIEW. AN INTERVIEW WAS DONE ON 1/5/12 AT 1:35 P.M., WITH NURSE MANAGER #1. THE NURSE MANAGER REVEALED ON 6/24/11 AT APPROXIMATELY 6:00 P.M., RESIDENT #501 ROLLED OUT OF HIS BED DURING HIS CARE GIVEN BY CNA #1. THE MANAGER AGREED CNA #1 DID NOT GET ASSISTANCE PRIOR TO GIVING THE RESIDENT CARE AND HE WAS CARE PLANNED TO HAVE 2 STAFF MEMBERS FOR ALL CARE REQUIRING BED MOBILITY. THE NURSE MANAGER STATED "HE (RESIDENT #501) HIT HIS HEAD ON THE TABLE (BEDSIDE STAND) OR THE FLOOR, HE WAS BLOODY, WE ASSESSED HIM AND SENT HIM OUT (TO THE HOSPITAL)". AN INTERVIEW WAS DONE ON 1/5/12 AT 9:15 A.M., WITH THE FACILITY ADMINISTRATOR. THE ADMINISTRATOR CONFIRMED RESIDENT #501 REQUIRED THE ASSIST OF 2 STAFF MEMBERS FOR HIS "CARE AND TURNING". A PHONE INTERVIEW WAS DONE ON 1/6/12 AT 7:35 A.M., WITH RESIDENT #501'S PRIMARY PHYSICIAN #1. THE PHYSICIAN CONFIRMED THE RESIDENT fell OUT OF BED ON 6/24/11, RECEIVED A SCALP HEMATOMA AND FACIAL INJURIES AND WAS TRANSFERRED TO THE HOSPITAL FOR EVALUATION. A PHONE INTERVIEW WAS DONE ON 1/4/12 AT 11:45 A.M., WITH FAMILY MEMBER #1 (RESIDENT #501'S FAMILY MEMBER). FAMILY MEMBER #1 STATED "THE DON (DIRECTOR OF NURSING) CALLED ME AND TOLD ME SHE WAS SORRY (RESIDENT #501) WAS IN THE HOSPITAL. SHE TOLD ME THERE SHOULD HAVE BEEN ANOTHER PERSON ON THE OTHER SIDE OF HIS BED (DURING CARE ON 6/24/11). SHE TOLD ME THIS WAS UNACCEPTABLE. TWO DAYS AFTER WHEN I CALLED, SHE (THE DON) WOULD NOT GIVE ME ANY INFORMATION; SHE SAID SHE COULDN'T GIVE ME ANY INFORMATION. THE DON OPENLY admitted IT WAS THEIR FAULT". A PHONE INTERVIEW WAS DONE ON 1/4/12 AT 10:05 A.M., WITH FAMILY MEMBER #2 (RESIDENT #501'S FAMILY MEMBER). FAMILY MEMBER #2 STATED "WE WENT TO THE HOSPITAL (ON 6/24/11), HE WAS BLOODY, THEY DROPPED HIM, I TOOK PICTURES OF HIM". REVIEW OF THE PICTURES TAKEN BY FAMILY MEMBER #2 (UN-DATED) REVEALED RESIDENT #500 HAD LARGE DARK BLUE/PURPLE BRUISING LIKE AREA'S UNDER BOTH EYES AND ON BOTH EYE LIDS. HE ALSO HAD A BUMP WITH BRUISING ON HIS RIGHT FOREHEAD AND BRUISING LIKE AREA'S UNDER AND AROUND HIS NOSE. REVIEW OF THE INCIDENT REPORTS DATED 10/30/09 AND 11/6/09, REVEALED RESIDENT #501 had a history of [REDACTED]. REVIEW OF THE FACILITY TYPED EMPLOYEE (CNA #1) LETTER DATED 6/29/11, SAID "DURING YOUR WORKDAY OF FRIDAY 6/24/11, YOU PROVIDED PERSONAL CARE WITHOUT ASSIST OF ANOTHER PERSON TO A RESIDENT (RESIDENT #501). THIS PERSON IS CARE PLANNED TO HAVE 2 PEOPLE ASSISTING WITH ALL BED MOBILITY FOR SAFETY BECAUSE OF HIS SIZE AND MOBILITY. WHILE GIVING CARE THE RESIDENT ROLLED OVER AND fell OUT OF BED FACE FIRST ONTO THE FLOOR, SUSTAINING SEVERE INJURIES AND WAS TRANSPORTED TO THE HOSPITAL FOR CARE. YOU AGREED THAT YOU WERE AWARE THE RESIDENT REQUIRED 2 PEOPLE FOR ALL BED MOBILITY AND THERE WAS NOT A REASON THAT YOU DID NOT OBTAIN ASSISTANCE BEFORE PROVIDING CARE". REVIEW OF THE FACILITY FALL ASSESSMENTS DATED 4/12/03 THROUGH 11/16/09; REVEALED RESIDENT #501 HAD "A HISTORY OF FALLS, IMPAIRED SHORT TERM MEMORY, STRENGTH, BALANCE & MOBILITY" AND "IMPAIRED COGNITION/SAFETY AWARENESS". REVIEW OF THE FACILITY FALL RISK assessment dated [DATE], REVEALED THE FACILITY HAD SCORED THE RESIDENT TO BE A NUMBER "14" FOR FALLS (A SCORE OF 10 OR GREATER MEANS THE RESIDENT IS AT HIGH RISK FOR FALLS). REVIEW OF THE SIDE RAIL USE assessment dated [DATE], REVEALED THE RESIDENT REQUIRED EXTENSIVE ASSIST FOR TRANSFERS AND BED MOBILITY, HAD A ? SIDE RAIL FOR ASSIST WITH BED MOBILITY ON THE RIGHT SIDE OF HIS BED, WAS BLIND IN HIS LEFT EYE AND HAD DECREASED COGNITIVE ABILITIES. REVIEW OF THE FACILITY FALL AND SAFETY SHEET SIGNED BY CNA #1 DATED 9/14/10, SAID "TO PROTECT THE RESIDENT AND YOURSELF FROM PHYSICAL INJURY, YOU ARE REQUIRED TO FOLLOW THE CARE REQUIREMENTS AS DIRECTED ON THE RESIDENT CARE DOOR SHEET (CNA CARE INSTRUCTION SHEET) AND TRANSFER REFERENCE SHEET WHEN PROVIDING OR ASSISTING WITH RESIDENT CARE". ( )