Every finding on record at Huron Woods Nursing Center

Based on observation, interview and record review, the facility failed to prevent facility-acquired pressure ulcer/skin injuries for two residents (Resident #103, Resident #105) of 3 residents reviewed, resulting in the development of bilateral heel ulcers/injuries for both Resident #103 and Resident #105 with the verbalization of pain and frustration regarding care. Findings include: Resident #103: Record review of Resident #103's Minimum Data Set (MDS) dated [DATE] revealed a female resident with a Brief Interview of Mental status (BIMS) score of 15 out of 15, cognitively intact and able to make her own medical decisions. Medical diagnoses included: hypertension, renal insufficiency, neurogenic bladder, diabetes, thyroid disorder, paraplegia and quadriplegia, and others. Section GG: Functional abilities noted impairment to both lower and upper extremities. The resident was assessed as dependent on staff for putting on and off footwear. Section M: Skin conditions noted no unhealed pressure ulcers/injuries. In an Interview on 7/27/2026 at 12:58PM, Resident #103, while seated up in an electronic power chair with tilt in place ability, revealed that she was wearing stiff boots (Prafo offloading boots) to protect her feet. Resident #103 could not feel from the waist/chest down and couldn't feel the sores develop. Resident #103 stated that her daughter found the wounds to her heels while she was visiting. Resident #103 was frustrated that the staff turned her and bathed her, and no one noticed them. and that it took her daughter to find the heel wounds. It made Resident #103 mad and upset that they cared for her and let her get the bilateral heel wounds. Resident #103 stated that she would have stopped wearing the boots if she could have felt the sores, but that she is paralyzed below the waist/chest. The nurses and aides are supposed to be checking that stuff, checking the skin for her when she showered. Resident #103 did not know why they let it happen to her. Resident #103 also stated that she got a big blister/sack on the back of my calf from the boots and that popped when an aide was providing care and now, they put a bandage on it, and that she also got a wound in her groin area from the catheter tube rubbing in the groin and they are putting gauze on it now. In an interview on 7/28/2026 at 8:10AM, Resident #103 stated that the Prafo boots came from the Saginaw hospital rehab place to protect from foot drop. The facility knew she wore the boots and they were to be checking her skin, and what did she get, sores on her heels. Observation and interview was conducted on 7/28/2026 at 1045 AM of Resident #103's bilateral heel wounds and left calf wound with Licensed Practical Nurse (LPN) C and Certified Nurse Assistant (CNA) F. Resident #103 was seated up in an electronic floating mobile chair that can recline to lift the legs upward. Current dressings dated 7/27/2026 were removed. Right Heel: Observation of the right heel was cleansed with wound cleaner and there was bleeding noted during the wiping of the wound and measured at length 4cmx width 4cm, depth was not measured, but bleeding was noted from the wound when the old dressing was removed and during the cleaning process, skin prep placed on peri wound area, Santyl debridement ointment placed in the wound bed and ABD dressing applied and gauze wrap was used to pad the heel. Left Heel: Observation of the left heel wound measured: length 1cm x width 0.5cm. depth was not measured, open wound with a new dime sized blister (which was new development per nurse) was observed, intact above the open wound of the left heel wound. Left heel wound was cleansed, bleeding noted during cleaning wipes and Santyl debridement ointment applied to the base of the wound bed, ABD dressing applied and wrapped with gauze and taped in place. Left Posterior Calf of Leg: During the observation Resident #103 stated that the wound started as a blister from her Prafo boots. She stated that she kept asking them to look at her feet, because she is paralyzed from the wait/chest down and cannot feel anything. Her daughter came to visit, and she found the sores on her feet not the staff. Resident stated that she had sores on her heels in May 2026 this year and she kept asking for them to look at her feet. But earlier this month there were sores on both heels that were bleeding. Observation of left calf posterior wound measured 3cm length x 1.5cm wide, depth was not measured, with yellow slough noted in wound bed. LPN C cleansed the wound, applied Santyl debridement ointment into the wound bed, covered with an ABD dressing and wrapped with gauze. Record review of Resident #103's Nurse Practitioner note dated 7/16/2026 noted: Patient seen today for wound follow-up. Nursing reports suspected deep tissue injuries to the bilateral heel and Stage 3 pressure injury to the left lateral lower leg. Wounds are thought to have developed secondary to pressure and friction from offloading boots . Resident #105: Record review of Resident #105's progress notes revealed: dietary note dated 6/1/2026 revealed that the resident's skin was intact. Nursing progress note dated 6/7/2026 at 5:56AM noted sheering observed to bilateral buttocks. Zinc applied. Dark purple circular area observed back of left heel. Area blanchable. Skin prep applied . Interdisciplinary noted dated 6/7/2026 at 10:54PM noted treatment to buttocks and left heel as ordered. Resident requires assist of one (person) for bed mobility and transfers . Record review of Resident #105's 'Wound Measurement' form, dated 6/8/2026, revealed left heel pressure length 1.75cm x width 3cm x depth 0.1cm. Definitions on form: Stage II- Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Wound/Type/etiology pressure-wound over bony prominence, potential shearing damage. Wound bed eschar dry black/brown, dead tissue. In an interview on 7/27/2026 at 2:30PM, Resident #105 revealed that she was a retired nurse and her left heel Wound was a purple sore to her heel and that she did not know what or how she got it. She stated that she was week after she had been in hospital and came back to the facility. Resident #105 stated that Yes it was painful and they would treat it and put a dressing on to it, but it did hurt quite a bit. I am a nurse and I believe that I got it from being in bed. It's mostly healed now, but I am careful not to let it happen again.An interview and record review were conducted on 7/28/2026 at 8:22AM with the Director of Nursing (DON) about Resident #103's bilateral heel ulcer/injuries. They were facility acquired, and that the resident was paraplegic and has no feeling from the chest down, Resident #103 had Prafo boots at rehab in Saginaw. In April/May Resident #103 had Deep Tissue Injury (DTI) bilaterally and stopped the use of the boots. The daughter took the boots home, and The Deep Tissue Injury (DTI) resolved. The beginning of July 13th, the DON did a wound assessment with measurements of right heel 2cm x 2cm and depth of 0.1cm open wound when it was found. The DON stated that the staff do weekly skin assessments, and Resident #103 was on skin prep treatment twice daily prior to the development of the July wounds because of the May 2026 friction scabs that were already being treated on the bilateral heels. On May 6, 2026, there were documented bilateral friction scabs identified to Resident #103 heels and the DON did a full skin assessment. On 5/22/2026 documentation was the last wound measurement, and we considered the heels to be resolved. And then the daughter brought the boots back into the resident and the resident #103 was wearing the boots again. Then on July 12, 2026, the staff found a blister to the mid left calf, and a treatment was put in place to monitor. Who was monitoring the wearing of the boots??? No answer was given. We were doing the skin prep twice daily to the bilateral heels so the nursing staff should have been looking at the heels, but they were not, after speaking with the nursing staff they were only feeling the heels when they wiped the skin prep on. We had a care conference in the resident room with the resident, daughter and the DON and the resident had concerns of her feet. Record review of Resident #103 'Wound Measurement' dated 7/13/2026 noted: Left lower leg pressure length 2.5cm x width 3.5cm x depth 0.1cm stage 3, Right heel pressure length 2cm x width 2cm x depth 0.1cm (depth would be opened wound), left heel pressure length 1.5cm x width 1.5cm x depth 0.1cm. The wounds are open now and so is the left calf blister. Interview and record Review with the DON of Resident #105's left heel wound also had developed at the facility. Record review of the facility 'Skin at Risk Assessment Documentation, Staging & Treatment' dated 1/2020 revealed it was the policy of the facility to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred.,, to provide prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. To limit the development of avoidable pressure ulcers and provide evidenced base guidance on effective strategies to promote pressure ulcer healing. Pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed. without slough or bruising. May also present as an intact or open/ruptured blister . Stage III: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible but does not obscure the depth of tissue loss .

This citation pertains to intake Number 2796974. Based on interview and record review, the facility failed to implement physician's orders for one resident (Resident #1) of three residents reviewed, resulting in a chest x-ray not being performed. Findings include:Resident #1 (R!): R1 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction, dysphagia, chronic cough and the need for assistance with personal care. Record review of a progress note from Licensed Practical Nurse (LPN) H, dated 1/14/2026 at 22:40pm, revealed that nursing staff were called to the room of R1. The daughter was observed feeding R1 Tic-Tacs and stated she was checking R1's swallowing abilities. The daughter stated that R1 did seem to be having some issues with swallowing and her lungs sounded bad. At this time the daughter requested a chest x-ray be ordered. The nurse present in the room assessed R1's lungs sounds and noted the lungs were clear to auscultation (CTA) but diminished throughout. The nurse made the Director of Nursing (DON) aware and R1 will be seen by the nurse practitioner (NP). Record review of an assessment titled, Health Care Practitioner Progress Note- [NAME] Woods, dated 1/15/26 at 13:56pm, revealed that the NP saw R1 and ordered a chest x-ray to evaluate for possible aspiration of acute pulmonary process. The NP reinforced the continuation of the pureed diet with nectar thick liquids due to aspiration risk. The NP stated to monitor for cough, fever, hypoxia or respiratory distress. Record review of physician orders for R1 revealed two orders were placed for a chest x-ray. One order was placed on 1/15/26 at 16:53pm and another order was placed on 1/15/26 at 17:37pm. Record review of a progress note from Registered Nurse (RN) D, dated 1/16/26 at 10:25am, revealed that the daughter of R1 phoned the facility, an update was given on the condition of R1. The daughter was upset that she was not told that R1 had vomited. The daughter also stated she was in the facility during the week was concerned that R1 had aspiration pneumonia because her lungs sounded bad and she had a productive cough. A chest x-ray was ordered, All-Stat (diagnostic company) was contacted and they stated they did not have an order for an x-ray, but that the nurse could place one. The health care practitioner was present in the building and saw R1, the daughter was pleased with this. The nurse stated she would contact the daughter once the x-ray results came back. The nurse assessed R1 and noted that her bilateral breath sounds were clear but diminished. R1's temperature was 97.1 and her oxygen saturation was 92% on room air. R1 received normal saline at 75ml/hr until 500cc's were completed due to not taking in as many fluids recently. Record review of a progress note dated 1/16/26 at 23:28pm, revealed that a speech therapy evaluation was completed per the daughters request due to thinking R1 was having difficulty swallowing. The speech therapist completed the bedside evaluation and believed that R1 should not have anything by mouth. The physician was notified of the findings and asked that the family be notified and for them to make a decision on further care or to have R1 sent to the hospital. The daughter wanted to keep R1 in the facility until they could speak with additional family members. Record review of a progress note dated 1/17/26 at 10:15am, revealed that the daughter wanted R1 sent to the hospital for evaluation and treatment. Record review of a progress note dated 1/19/26 at 8:54am, revealed that R1 was admitted to the 5th floor, neurosurgery of the hospital.On 5/27/26 at 11:40am, an interview was conducted with the Director of Nursing (DON). The DON was asked about the family request for a chest x-ray on 1/14/26. When the family requested a chest x-ray be ordered, should the nurse have notified the practitioner and had it ordered? The DON stated, typically, if a family is requesting some care we would notify the practitioner and go off their recommendations. Why was there a delay in getting the chest x-ray ordered? The DON stated, I know there was an issue with us placing orders and receiving faxes. I believe there is a communication gap between us and All-Stat. Our systems are integrated now, but at the time of this chest x-ray request, the nurses would have to enter an order into Point Click Care (PCC) and then enter an order into All-stat to have the x-ray done. The nurse didn't enter the order on the all-stat portal. Prior to the order on 1/17/26 were any other orders placed on All-Stat for R1? The DON stated, no, that was the only CXR that was ordered.The DON provided the order for the chest x-ray for R1 from All-Stat; it indicates that the service date was 1/17/26. R1 had already been discharged to the hospital for other reasons. The All-Stat portal revealed there were no results from the chest x-ray, which indicates the chest x-ray was never completed.On 5/27/26 at 12:43pm, an interview was conducted with RN D. RN D was asked what day did you place the order for a chest x-ray for R1? RN D stated, I believe I placed it on 1/16/26 after speaking with All-Stat. When you placed the order for the chest x-ray, did the company say when they would be out? RN D stated, no, they don't say when they will be out. I believe the tech told me they will send this order out, then they would call me with an approximate time. They never called back with an approximate time by the end of my shift. Did you listen to the lung sounds of R1? RN D stated, yes, I did and they were clear but diminished. If a family was requesting any kind of care what is your process? RN D stated, typically we look at their code status, to see the wishes of the resident, then I would do an assessment and notify the physician and receive orders and then we would call the family and let them know.On 5/27/26 at 12:57pm, an interview was conducted with LPN H. LPN H was asked what they did after the family requested the chest x-ray for R1? LPN H stated, I believe when something like that happens and there is no clinical indication (LPN H didn't think R1's lung sounds were bad based on assessment) that I will contact my on-call person and give them a report. I do believe that the on-call person said that they will contact the daughter the next day. The other thing I could have done was put a note in the communications book to the doctor so they could follow up the next time they are in. Whether or not I did that I cannot remember.

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 02/18/2026 at 8:44am during the initial kitchen tour with Corporate Dietician F observed the drain line to the ice machine sitting directly in the drain. According to the 2022 Food Code, 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).On 02/18/2026 at 12:25pm during lunch observation, observed a tray with purees individually stored in bowls on the tray line. Puree green beans were temped at 123 F and puree chicken was temped at 127 F using Thermapen. During this observation, [NAME] G was interviewed on what the temperature should be while hot holding, and she answered 135 F. Corporate Dietician F was also interviewed on whether there is a facility policy on hot holding, and she stated the facility follows the FDA Food Code.According to the 2022 FDA Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control . time/temperature control for safety food shall be maintained .at 57 C (135 F) or above.

Based on interview and record review, the facility failed to ensure that residents' Advanced Directives' code status was documented and accessible in the medical record for 2 residents (Resident #3 and Resident #5) of 8 residents reviewed for Advanced Directives. Findings Include: Resident #3 (R3):A record review of R3's [NAME] Data Set assessment (MDS) dated [DATE] revealed a brief interview mental status (BIM's) score of 11 of 15, which indicated R3 was moderately cognitively impaired. R53 was admitted to skilled nursing on [DATE] with diagnoses of Inflammatory disorder of scrotum, diabetes mellitus type 2, chronic atrial fibrillation (irregular heartbeat), malignant neoplasm of left main bronchus (left lung cancer), need for assistance with personal care and spinal stenosis of cervical and lumbosacral regions.A record review of R3's physician determination of decision-making capability dated [DATE] revealed that R3 was capable of making medical treatment decisions. A record review of R3's face sheet revealed an Advance directive document link with no code status of CPR or DNR. A review of R3's Advanced directives link revealed no identifiable code status or preferred treatment option (PTO). It revealed the physician determination of decision-making capability signed [DATE] with no clear code status of CPR or DNR listed.A record review of R3's orders dated [DATE] revealed: Refer to Preferred Treatment Option for Advanced Directives.A record review of R3's care plan revealed: Initiated: [DATE]; Focus Potential with acute condition change with cardiopulmonary, metabolic or infectious complications. Intervention: Review advanced directives and know residents wishes for treatment.Resident #5 (R5):A record review of R5's [NAME] Data Set assessment (MDS) dated [DATE] revealed a brief interview mental status (BIM's) score of 15 of 15, which indicated R5 was cognitively intact. R5 was admitted to skilled nursing on [DATE] with diagnoses of displaced intertrochanteric fracture of right femur (right hip fracture), multiple sclerosis and need assistance with personal care.A record review of R5's physician determination of decision-making capability dated [DATE] revealed that R5 was capable of making medical treatment decisions. A record review of R5's face sheet revealed an Advance directive document link revealed no identifiable code status of CPR or DNR and no PTO. A review of R5's Advanced directives link revealed no code status or PTO. It revealed the physician determination of decision-making capability signed [DATE] with no clear code status of CPR or DNR listed.A record review of R5's orders dated [DATE] revealed: Refer to Preferred Treatment Option for Advanced Directives.A record review of R5's care plan revealed: Initiated: [DATE]; Focus: (R5) has the potential with acute condition change with cardiopulmonary, metabolic or infectious complications. Intervention: Review advanced directives and know residents wishes for treatment.-------------------On [DATE] at 2:50 PM, During an interview with the contract interim SW C she was asked about resident's code status/advance directives and who is responsible for getting them. SW C said it was a combination or responsibilities between the nurses and SW that ensure the code status for resident was put in place for residents, she said nurses or SW can complete the care plans.On [DATE] at 11:35 - 12:55 PM, The DON was queried about code status for R3 and R5 and where information could be found in the chart. The DON said it was under advanced directives and advanced care planning in the resident's chart. The DON was asked about the code status on face sheet, care plan and orders referencing the advanced directives to find PTO and code statuses, but they were filed under advanced care plan not was not in advanced directive (the link to find code status in the chart), she did not have an explanation.The DON said all updated code statuses are kept in a red binder at the nurse's station. The binder is updated as needed by the nurses and weekly by the scheduler. The DON said the scheduler will upload the documents to the medical chart after they are signed by the doctor. The DON said the red book labelled Resident Code Status- Preferred treatment option is the up-to-date code status and residents preferred treatments and where the staff find residents code status and not in the resident's chart. The DON said that in an emergency, staff would grab the red binder and look up the resident, it is alphabetized. When asked if the code book was not at the nurse's station and nothing had been uploaded into the medical chart, how would the staff know the code status of a resident, The DON said the book is always kept at the nurse's station and up to date. The DON agreed the red book is not a part of the residents' medical record and the medical chart does not reflect residents code status until the doctor signed it.Observation of the red book with DON revealed that R3 has a different PTO in the red book than in his chart that has handwritten DNR on it dated [DATE], the DON said that it was pending signature but was the resident's active status. Reviewed that the residents chart reflect a different PTO than the red book because the updated one int the red book was not signed and uploaded into the medical chart. The DON was asked could that lead to confusion, she said I see what you're saying. R5 had a PTO signed [DATE] with no distinction of code status CPR or DNR written on it. When the DON was asked about the handwritten code DNR on the PTO form for R3's and no distinction on R5's, the DON said they changed the practice of handwriting in the code status since November or December, to clarify either CPR or DNR on the PTO. The DON was asked why they not updated all the residents in the red book to reflect the clarity since it is updated weekly and admitted ly what the staff used as the code status, she did not have an answer. Clarified with the DON, the resident's medical records had no PTO or code status identified until it was signed by the physician and then uploaded into residents' chart and staff relied on the red book only. Also, clarified that nowhere in facilities written policies or procedures or in the resident's charted care plan, orders or advanced directives was the red code - PTO book referenced to identify residents' code status; Nor is there a written clarification of the preferred treatment option statuses to reflect clear coded statuses of CPR or DNR. The practice of not readily and clearly identifying a resident code status in an emergency could cost valuable time and or mis interpretation of the immediate response desired. A record review of the facilities policy and procedure titled Cardiopulmonary Resuscitation. revealed: Purpose: this facility will provide basic life support, including CPR - cardiopulmonary resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the residence advance directives.A record review of the facilities policy and procedure Advanced directives revealed: Policy: It is the policy of this facility to honor the health care decisions made by residents with decision making capacity or the resident's legal representative if the resident has not been made deemed of making decisions. a resident who lacks decision making capability and legal representation may require a preferred treatment option status 4. Purpose: to define the rights of residents to establish decisions concerning their medical and psychiatric care comma including the right to formulate advanced directives and the right to refuse unwanted medical treatment.Definitions: Advanced directives: an oral or preferably written statement by a resident with decision making capacity expressing his/her preferences for health care agent and or for future medical care in the event that he/she becomes unable to participate in medical decision making. Decision making capacity: the capacity of a resident to 1. understand his/ her medical condition. 2. appreciate the consequences of various treatment options including non-treatment. 3. judge the relationship between the treatment options and his or her personal values, preferences and goals. 4. reason and deliberate about his or her options and 5. Communicate his or her decision in a meaningful manner . Cardiopulmonary resuscitation (CPR): a procedure performed to attempt to support and restore ventilation and circulation in a resident experienced cardiac arrest or respiratory arrest. It includes establishment and maintenance of an airway, assisted ventilation, trust compressions, call to 911 emergency medical technicians and paramedics to provide establishment of intravenous access, cardiac monitoring, administration of medications, Defibrillation or other controlled arrhythmias, and immediate care after resuscitation. Do not resuscitate (DNR): an order written on the preferred treatment options form that indicates the residence or health agent's decision to refuse cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. A DNR order only becomes effective when the resident has experienced A cardiac or respiratory arrest. Clear and convincing evidence: generally, means it has to be in writing when referencing to advanced directives.Procedure: 1. admitting personnel assess whether the resident is capable of making decisions or has a legal medical decision maker. This information is documented on the preferred treatment option form. 2. An inner query is made upon a mission as to whether the resident possesses or wishes to execute an advanced directive. 3. If the resident already possesses an advance directive a copy of the advance directive will be placed with the preferred treatment option in the resident's clinical record.A record review of the facilities document named preferred treatment option (PTO) revealed status options labelled 0-4 defined as: Status 0: the resident is to be treated only in the nursing home. Interventions are limited to enduring comfort. No treatments are to be given beyond those necessary to relieve or prevent pain. Such treatments are not to include resuscitation; Status 1: the resident is to be treated only in the nursing home and is to receive interventions to promote comfort and treatments for presumed infection are limited to medications. Therapeutic testing may be performed, no diagnostic testing is to be performed, nor tube feedings. Such treatments are not to include resuscitation; Status 2: the resident is not to be hospitalized but is to be treated in the nursing home and to receive all interventions necessary to promote comfort and treat illness. Such interventions are limited to their availability in the nursing home, but include diagnostic tests, hydration through tube feedings, IV fluids if available, and IM or IV antibiotics. Such treatments are not to include resuscitation; Status 3: the president is to be hospitalized for any treatments that exceed the nursing home's capabilities and that are necessary to extend life or maintain comfort. Such treatments are not to include resuscitation. Surgical intervention is limited to conditions with a high probability of successful outcome; Status 4: a resident is to be hospitalized for any treatments that exceed the nursing home's capabilities and that are necessary to extend life or maintain comfort. Such treatments are to include resuscitation and surgical intervention.

Based on observation, interview and record review, the facility failed to ensure that diabetic foot care was provided for one resident (R34) of one resident reviewed for ancillary services. Findings include: Resident #34 (R34):A record review of R34's [NAME] Data Set assessment (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 of 15, which indicated R34 was cognitively intact. R34 was admitted to long term care (LTC) on [DATE] with diagnoses of diabetes mellitus type 2 with diabetic polyneuropathy (nerve damage), difficulty walking, need for assistance with personal care, history of falling, abnormalities with gait and mobility and lack of coordination. On [DATE] at 11:03AM, During an interview with R34 she said that she had asked to be seen by the podiatrist several times and stated that she felt he doesn't have enough time for me. R34 said the podiatrist 'pops in when he gets time' otherwise the staff told me that I needed to be on the calendar to be seen. R34 stated my nails are getting so long. R34 pulled off her socks and revealed her feet, an observation of R34's feet displayed a long and thickened toenail on the little toe of the left foot and long unkempt toenails throughout all five toes on the right foot.On [DATE] at 2:43PM, During an interview R34 said that she needed to see the podiatrist. R34 said that she was afraid she would not be seen by the podiatrist because she wouldn't be included on the podiatry schedule. R34 said she had seen the podiatrist several months ago, and when she asked the staff about being placed on the schedule for the next visit they said, 'they did not know when he was coming next or if she was on his schedule'. R34 verbalized that she was upset staff did not follow up with her on the information she had requested. R34 said she was concerned because she is diabetic and she needed regular foot care. R34 said when her kids visited that they occasionally trimmed her toenails, however her kids were afraid to clip them and shouldn't need to. A record reveal of R34's medical record revealed an active order dated [DATE] for dental, optometry, podiatry, audiology, or psychiatric / behavioral consult per consent.A record review of R34's chart revealed a request for services and consent for services through (facilities contracted company) for Podiatry services dated [DATE].A record review of R34's documents revealed a Podiatry visit note dated [DATE] revealed an initial and routine foot care exam was completed. On [DATE] at ~(approximately)10AM, The Director of Nursing (DON) was asked to provide (facilities contracted company) active census into (electronic document system).A record review of the summary of benefits page in the contract to residents enrolled in (facilities contracted company) under podiatry services revealed: Upon requesting services the podiatrist will perform an initial exam to evaluate the podiatric conditions of the patient and determine a plan of continued care for any outstanding issues; Routine foot care: a patient is eligible for routine foot care every 60 calendars days. Nail care is performed when the nails are elongated; Additional Podiatry exam: subsequent exam for a specific podiatric complication, complaint or issue.A record review of the (facilities contract company) NHQA report with R34's podiatry services listed revealed that on [DATE]: R34 had 'nail debridement of 6 or more nails and an initial visit with diagnoses of Tinea Unguium (toenail fungus and thickening) and generalized Atherosclerosis (buildup of plaque inside of arteries)'. The report also revealed the status of R34 as discharged .On [DATE] at 11:35AM, during an interview, the DON was asked how residents received services from (facilities contract company) for ancillary services and she said residents or responsible parties get the information in their admission packet and they sign a consent that they wish to receive the outside services or decline the outside services, she confirmed that consent/declination was kept in residents medical charts as part of admissions. The DON was asked to review the NHQA report provided by (facilities contract company) and clarify if the census was active residents enrolled in services. The DON called the (facilities contract company) for clarification. The DON advised that the report included every resident that was enrolled in (facilities contract company) services at the time it was printed. The DON confirmed the date the report was printed was [DATE]. The DON was asked and clarified that if a service was listed it was performed, if it was offered and not performed it indicated the service was refused. The DON was queried on the abbreviations use in the resident services census, she stated DNT = do not treat resident 'on hold'; DEC = deceased resident and DIS = discharge resident. The DON was asked to review R34's chart and was asked if there was an order for R34 to have Podiatry services and she said yes there was one in the chart as a batch order and everyone gets that order, and said that it said per consent so one would have to go to the consents and see if the resident accepted or declined the services.The DON was asked if R34 had seen Podiatrist and she said yes, in June of 2025 there was a consent, a Podiatry visit and confirmed that R34 was also present on the NHQA report received from the (facilities contract company) that indicated a completed visit. The DON was asked to why R34 had not seen podiatry since June of 2025 for routine foot care, she replied I think it was an oversight. The DON said that R34 was originally at facility for skilled nursing and had left the facility for a hospital stay and that when R34 returned to the facility she changed from skilled to LTC status. The DON said the facility would have had to re-enroll R34 in the (facilities contract company) program with readmission. The DON was asked about the re-admission and if there was a different consent/declination present in R34's chart for the original dated [DATE], she agreed there was not. After we consulted with the admissions staff, the DON agreed they could not produce any documentation that differed from the original consent to services in R34's chart nor that R34 received a new (facilities contract company) agreement to accept or decline upon her readmission, the DON stated that is a problem and agreed the resident had consented to and requested Podiatry services originally. The DON said that she would reinstate R34's enrollment to (facilities contract company) for Podiatry services and make sure was seen on the next scheduled visit which was for [DATE].

Based on interview and record review, the facility failed to provide adequate notice of non-coverage and maintain documentation for three residents (#56, #58, #59) of five residents reviewed, resulting in the lack of full disclosure related to Medicare rights and the inability to appeal the discharge in the time frame allotted by Medicare. Findings include: Record review of the facility 'Advanced Beneficiary Notice' policy, dated 11/2022, revealed that it is the policy of the facility to prepare and deliver to the resident or resident authorized representative an Advanced Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) when the utilization review entity expects that Medicare probably will not pay for or will not continue to pay for extended care items or services . In an interview and records review on 02/18/2026 at 1:48 PM, Staff A Admissions Director reviewed 5 residents records with the state surveyor for Advanced Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC):Resident #56:Record review of Resident #56 who was discharged home on 9/19/2025, did not have an ABN/NOMNC 2025 documentation found in the medical record. Staff A went through Resident #56's documents in the electronic medical record and doubled checked. Staff A stated that the only one the facility had dated for 2024, a previous stay that the resident had discharged from. Staff A stated that the facility did not have an admission director at that time. and that there was no 2025 NOMNC/ABN. Resident #58:Record review of Resident #58 who was discharged home on [DATE] did not have an ABN/NOMNC 2025 documentation found in the medical record. Staff A went through Resident #58's documents in the electronic medical record and doubled checked. Resident #58 was a Medicare Part A recipient. Staff A stated that the facility did not have an admission director at that time. and that there was no 2025 NOMNC/ABN for Resident #58's stay/discharge.Resident #59:Record review of Resident #59 who was discharged home on 9/24/2025 did not have an ABN/NOMNC 2025 documentation found in the medical record. Staff A went through Resident #59's documents in the electronic medical record and doubled checked. Resident #59 was a Medicare Part A recipient. Staff A stated that the facility did not have an admission director at that time. and that there was no 2025 NOMNC/ABN for Resident #59's stay/discharge.Record review of the facility 'Advanced Beneficiary Notice' policy, dated 11/2022, revealed that the facility will provide a completed copy of the notice of Medicare Non-Coverage (NOMNC) to enrollees receiving skilled care no later than two days prior to the termination of services. The NOMNC conveys notice to the beneficiary of his or her rights to an expedited review of a service termination

Based on observation, interview and record review the facility failed to ensure that oxygen was ordered, and care planned for 1 resident (Resident #9) of 2 residents reviewed for respiratory care. Findings Include: Resident #9: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #9 was admitted to the facility on [DATE] with diagnoses: Heart failure, history of a stroke, left side weakness, hypertension, hypothyroidism, COPD, diabetes, depression and anxiety. The MDS assessment dated [DATE] revealed the resident had mild cognitive decline with a Brief Interview for Mental Status/BIMS score of 12/15 and needed assistance with all care. On 2/17/2026 at 3:39 PM, during a tour of the facility Resident #9 was observed lying in bed awake, an oxygen concentrator was running with oxygen set at 3 liters per minute. The resident was asked if that is what it was normally set at and she said she didn't know.On 2/17/2027 at 3:50 PM, Nurse H was interviewed about Resident #9's oxygen and asked what the oxygen should be set at. Upon entering Resident #9's room, the nurse looked at the oxygen concentrator for Resident #9 and said she wasn't sure, but she would check the order. Nurse H proceeded to the Nurse's desk and after looking at the resident's chart in the computer, she said there was no order for oxygen. Nurse H said the resident was supposed to have oxygen, and she wasn't sure why there was no order. Nurse H called another nurse, and she advised her to obtain an order for the oxygen.A review of the physician orders for Resident #9 identified an order for oxygen dated 2/17/2026 at approximately 4:30 PM, Respiratory distress: Check oxygen saturation prn (as needed), start oxygen at 2 L per minute per nasal cannula. Recheck oxygen saturation prn and titrate oxygen to maintain oxygen saturation > 90%. Notify Health Care Practitioner prn.A review of the Care Plans for Resident #9 revealed, (Resident #9) has the potential with acute condition change with cardiopulmonary, metabolic or infectious complications., date initiated and revised 4/21/2025 with Interventions including: check oxygen saturation levels SAO2% and capillary refill prn, initiate O2 as ordered, 4/21/2025.On 2/18/2026 at 9:35 AM, the Director of Nursing was interviewed about the oxygen order for Resident #9, she said there should have been a physician order.

Based on interview and record review, the facility failed to ensure that Certified Nursing Assistants (CNA) yearly performance reviews were conducted for two of five CNA's reviewed, resulting in the lack of yearly education training. Findings include: Record review of the facility 'Facility Staffing Template' policy, dated 6/2019, revealed it is the policy of the facility to conduct, document and annually review a facility-wide assessment, which included both the residents' population and the resources the facility needs to care for the residents. (c.) Facility resources needed to provide competent care for residents including staff, staffing plan, staff training/education and competencies, education and training . Record review of the facility 'Facility Assessment', dated 10/13/2025, revealed the facility used computerized training assigned specialized training with lessons to address Alzheimer's disease and pertinent communication strategies with the resident experiencing behavioral health needs. Individualized training will further assist with interventions to specifically address behavioral training and meaningful interventions. Annual CNA/Nurse skills training is performed by the Corporate Clinical Educator. PCC Behavioral Care Assessment and Infection Prevention features have been implemented to better identify and track resident associated behaviors and infections and trends. Current CNA/Nurse training courses are sufficient and address our residents' needs. As changes in population occur, our interdisciplinary team meets to determine the best plan of care for their specific needs. Our Corporate, Clinical Nursing Educator, assists and oversees training and assesses annually, and as needed.An interview and records review were conducted on 02/19/2026 at 10:58 AM with the Human Resource Staff B of employee files during the staffing task of the annual survey. Staff B stated that the annual employee performance evaluations/competencies start with the human resource tracking and forwarding the annual performance evaluation forms, names of the employees that are to have the evaluations. The Director of Nursing (DON) and/or Clinical Care Coordinator E oversee the annual performance evaluations, and they are to perform the evaluations. They are to return the forms to human resources and then track the dates and upload them into the employee file. Staff B stated that there was a spread sheet that tracks all staff for the whole building, and that goes by the hire date, and then whenever the annual performance was completed. Record review of employee files: Certified Nurse Assistant G had a Hire date of 10/12/2021 and the last documented annual Performance/competency was dated 11/8/2024 with recommendations to increase personalization and communication. There were no annual 2025 performance/competency evaluation documents found in the employee file. In an interview and records review on 02/19/2026 at 11:38 AM Staff B human resource stated that there was no 2025 annual performance/competency evaluation for employee CNA G. Staff B stated the reminders sent out. No other documents were presented to the state surveyor during the annual survey for employee G annual performance evaluation.Certified Nurse Assistant/Medication Tech F had a Hire date of 2/22/2002 and the last documented annual Performance/competency was dated 8/13/2024. There were no annual 2025 performance/competency evaluation documents found in the employee F file. In an interview and records review on 02/19/2026 at 11:38 AM Staff B human resource stated that there was no 2025 annual performance/competency evaluation for employee F. Staff B stated the reminders sent out. No other documents were presented to the state surveyor during the annual survey for employee F annual performance evaluation.

Based on interview and record review, the facility failed to implement an effective in-service nurse aide training program, that ensured continued compliance with educational training of 12 hours required annually for aides employed at the facility for 1 of 5 certified nursing assistants (CNA) resulting in continued non-compliance. Findings include: Record review of the facility 'Facility Assessment', dated 10/13/2025, revealed that the facility used computerized training assigned specialized training with lessons to address Alzheimer's disease and pertinent communication strategies with the resident experiencing behavioral health needs. Individualized training will further assist with interventions to specifically address behavioral training and meaningful interventions. Annual CNA/Nurse skills training is performed by the Corporate Clinical Educator. PCC Behavioral Care Assessment and Infection Prevention features have been implemented to better identify and track resident associated behaviors and infections and trends. Current CNA/Nurse training courses are sufficient and address our residents' needs. As changes in population occur, our interdisciplinary team meets to determine the best plan of care for their specific needs. Our Corporate, Clinical Nursing Educator, assists and oversees training and assesses annually, and as needed.Record review of the facility 'Facility Staffing Template' policy, dated 6/2019, revealed it is the policy of the facility to conduct, document and annually review a facility-wide assessment, which included both the residents' population and the resources the facility needs to care for the residents. (c.) Facility resources needed to provide competent care for residents including staff, staffing plan, staff training/education and competencies, education and training . An interview and records review were conducted on 02/19/2026 at 10:58 AM with the Human Resource Staff B of employee files during the staffing task of the annual survey. Staff B stated that the facility used a computerized staff training system that issued required training for Certified Nurse Assistance to get the required 12 hours of continuing education annually. Record review of employee Certified Nurse Assistant G had a Hire date of 10/12/2021 and the last documented annual Performance/competency was dated 11/8/2024 with recommendations to increase personalization and communication. There were no annual 2025 performance/competency evaluation documents found in the employee file. In an interview and records review on 02/19/2026 at 11:38 AM Staff B human resource stated that there was no 2025 annual performance/competency evaluation for employee CNA G. Staff B stated the reminders sent out. No other documents were presented to the state surveyor during the annual survey for education training for employee G.

This Citation Pertains to Intake 1341963. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure physician supervision of medical care for one (#701) of one resident reviewed, resulting in lack of physician and/or advanced practice Health Care Provider (HCP) assessment and treatment of an alteration in skin integrity. Findings include: Review of Facility Reported Incident (FRI) documentation, submitted on 6/24/25 at 7:37 PM, revealed the facility received a concern from Family Member Witness C on 6/24/25 at 5:40 PM that Resident #701 had called them on 6/23/25 at approximately 10:00 PM and told them that someone had been sexually harming them. The facility completed an investigation and determined there was insufficient evidence to support the occurrence of the alleged event. Record review revealed Resident #701 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of right sided hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), epilepsy, depression, and anxiety. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required maximum/total assistance to complete all ADLs with the exception of eating and oral hygiene. The MDS further detailed the Resident displayed delusions and rejected care one to three days. Further review of Resident #701's Electronic Medical Record (EMR) revealed the Resident had been deemed incapable of making medical decisions and Family Member Witness C was their Durable Power of Attorney (DPOA). An interview was completed with Witness C on 7/17/25 at 12:00 PM. When queried regarding the incident involving Resident #701, Witness C stated, It was late at night when (Resident #701) had called me. They were pretty frantic. When asked why the Resident was frantic, Witness C stated, (Resident #701) felt for whatever reason that the workers were making (another Resident) eat their own shit. Then (Resident #701) made the comment that I wouldn't believe them even if they told me they were being molested. When asked if Resident #703 told them they were being molested, Witness C stated, I don't necessarily think that (Resident #701) was molested. With further inquiry, Witness C revealed the Resident has asked them, What were you talking about me being molested. Witness C revealed they believe the Resident was confused due to their nighttime medications, staff waking them to check for incontinence, and new Urinary Tract Infection (UTI- infection known to cause increased confusion in the elderly). When asked if Resident #701 was sent to the hospital following the allegation for a sexual assault assessment, Witness C replied, No. The (Director of Nursing [DON]) told me they could do that there. Witness C then stated, The boil on the vagina is new and concerning. With further inquiry, Witness C revealed they were told a boil was found on Resident #701's vagina by the Director of Nursing (DON) during the assessment as the facility. An interview was completed with the DON on 7/17/25 at 12:40 PM. The DON was asked what the boil on Resident #701 labia was, the DON stated, I think it is a hair follicle or something. (The Resident) has had it before - it comes and goes. The DON was asked to provide documentation of prior instances. On 7/17/25 at 1:07 PM, an interview was completed with Resident #701 in their room. When asked questions, Resident #701 was pleasantly confused, slow to respond, and unable to recall events and/or provide meaningful responses to questions when asked. Review of Resident #701's EMR revealed a care plan entitled, (Resident #701) has altered functional mobility and ADL's related to weakness associated with supporting diagnosis list. (Initiated: 4/17/25; Revised: 3/28/25). The care plan included the intervention, Skin Impairment Location: MASD (Moisture Associated Skin Damage) to groin and abdomen folds. (Initiated: 6/25/24). A second care plan entitled, (Resident #701) is at risk for impaired skin integrity related to reduced functional mobility, exposure of her skin to urine and fecal incontinence. (Initiated 4/30/23; Revised: 12/20/24) and included the intervention, Skin inspections with am/pm care and showering report abnormal to the charge nurse (Initiated: 7/25/23). Further review of Resident #701's Short Term Care Plan (STCP) documentation revealed the Resident did not have a current or discontinued STCP in place for labial skin alterations. Review of Resident #701's Documentation Survey Report for June 2025 revealed a skin assessment was completed one to two times a week during the month. Review of documentation in Resident #701's EMR revealed the following: - 6/24/25 at 10:16 PM: Skin Assessment. Assessment Notes. Under abdominal fold and slight redness and in the groin area redness. No marks or bruises noted in the groin area. Buttock and rectum no redness or bruises noted. incontinent of B&B (Bowel and Bladder) .- 6/25/25 at 9:30 AM: Skin Assessment. Assessment Notes. A thorough skin assessment was performed. findings were as follows. No bruising or abrasions were noted. The vagina was assessed. no redness to the external/internal labia. A small clear fluid filled pustule was noted to right labia that was mentioned in a previous assessment. No redness or irritation to the vaginal canal.No sign or symptoms of sexual assault observed. Resident #701's progress note documentation did not include any documentation related to the boil/pustule. Review of Resident #701's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June 2025 revealed the Resident had no orders and was not receiving any treatment related to the boil/pustule. On 7/17/25 at 2:00 PM, the DON provided a nursing Skin Assessment dated 4/21/24 at 5:01 PM for Resident #701. The skin assessment included, Assessment Notes. Small pustules with clear fluid observed on labia. Some scabbed areas observed to groin area. states the area is painful. When queried, the DON revealed the provided Skin Assessment was the only other documentation of labia pustules they were able to locate in the Resident's EMR. An interview was conducted with Physician D on 7/174/25 at 2:20 PM. When queried regarding Resident #701 and the recent sexual abuse allegation, Physician D confirmed they were aware of the allegation. When asked if they assessed the Resident following the allegation, Physician D stated, I just tried to talk to (Resident #701) and tried to figure out what happened. Physician D was then asked if they completed an exam on the Resident and stated, No, they (facility nursing staff) did an exam and did not find anything. There was no point of doing another one. When queried regarding the boil or pustule found on Resident #701's labia, Physician D stated, They did not tell me that they found it that day on the exam. When queried regarding the etiology and diagnosis of the pustule/boil, Physician D revealed the Resident has the area on and off and stated, I personally have not seen it. When asked why they did not do a physical assessment of the Resident, Physician D replied, The DON said it was fine and there was nothing abnormal. Physician D was then asked how the DON is qualified to assess Resident #701 for specific signs/symptoms of sexual assault and if they were certified as a SANE (Sexual Assault Nurse Examine) nurse but did not provide a response. Physician D was then asked if the DON is able to diagnose skin alterations and confirmed the DON and nursing staff were unable to diagnose. When asked how they knew what the area was on the Resident's labia, if they had not seen it, Physician D verified they did not. Physician D revealed there are several providers, within the group that sees residents at the facility, and they were unaware if another provider had assessed the area. At 2:59 PM on 7/17/25, an interview was completed with the DON. When queried if they were able to locate documentation of Physician and/or Health Care Provider (HCP) assessment of the pustule/boil on Resident #701's labia, the DON replied, I reviewed the documentation and did not find any documentation of (HCP) assessment.An interview was completed with the facility Administrator on 7/17/25 at 3:25 PM. When queried regarding the lack of physical assessment by a Physician following the sexual assault allegation and the identification of a boil/pustule on Resident #701's labia, the Administrator verbalized Witness C did not want the Resident to go to the hospital. Resident #701's Skin Assessment documentation dated 6/25/25 was reviewed with the Administrator. When asked if the DON was SANE certified and/or trained to complete internal vaginal examinations, the Administrator indicated they were not. The Administrator was then informed of the interview with Physician D. When queried regarding the Physician not completing a physical examination of the Resident following the allegation and abnormal finding during skin assessment on the Resident's labia, the Administrator verbalized understanding of concerns. Facility policies/procedures related to nursing assessment and physician services were requested at this time. At 4:12 PM on 7/17/25, the Administrator revealed the facility did not have a specific policy/procedure related to nursing assessment. An interview was completed with the DON on 7/17/25 at 4:20 PM. When queried if the facility has speculums (medical equipment used to complete and visualize the vaginal canal during examination), the DON stated, No but we could get one if the doctor wants one. When queried how they were able to visualize the vaginal canal, as documented in the Skin Assessment on 6/25/25, without a speculum, the DON verbalized they did not use a speculum and did not visualize Resident #701's vaginal canal. When asked why they documented they did if they did not, the DON revealed they examined the external genitalia and probably could have worded that better. When queried regarding the Resident not being sent to the hospital, the DON replied that Witness C did not want the Resident to go to the hospital. The DON then stated, I am not a SANE nurse, and I did not do a sexual assault assessment. When asked if Witness C was educated regarding the different examinations/assessments, the DON did not provide further explanation. When queried why Physician D said they were not made aware of the skin alteration on the Resident's labia, the DON stated, I talked to (Physician D) too and was unable to provide further explanation. Review of facility policy/procedure entitled, Physician Services (Revised: Sept. 2017) revealed, The facility will arrange for the provision of physician services 24 hours a day, to respond to emergencies that do not require medical care in an alternative setting.

This Citation Pertains to Intake Number MI00153102. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure safe transfer utilizing a mechanical lift (device to move a dependent individual from one surface to another) and ensure planned interventions were in place for fall prevention, for one resident (#701) of three residents reviewed, resulting in Resident #701 experiencing a fall during a mechanical lift transfer resulting in an intraventricular hemorrhage (IVH- bleeding into the ventricles of the brain). Findings include: Resident #701 Review of intake documentation revealed a concern that Resident #701 had a fall with head injury while being transferred with a mechanical lift. The intake detailed that the facility did not identify a root cause of the fall/accident and did not report the fall with severe injury to the State Agency. Per the Intake, Resident #701's health had declined since the occurrence, and they are not communicating and making eye contact as they did prior to falling from the mechanical lift. An interview was conducted with Confidential Witness G on 5/21/25 at 8:52 AM. When queried regarding Resident #701, Witness G stated, (Resident #701) had a week ago Monday not yesterday but a week ago Monday while being transferred with the Hoyer (mechanical) lift and had a laceration on their head. Witness G revealed they believed the incident/fall should have been reported to the State Agency via a Facility Reported Incident (FRI). When queried how Resident #701 fell while being transferred in a Hoyer lift, Witness G revealed the facility did not clearly identify the root cause of the fall. Witness G disclosed the facility initially specified that (Resident #701) had slippery clothing on and that they moved in the Hoyer, rolled, and slipped up and out of the sling. Witness G stated, Unless (Resident #701) defied gravity, I don't know how that would happen. Witness G then stated, (Resident #701's) got dementia. They are on Ativan (controlled medication commonly used to treat anxiety) and doesn't fight. I know (Resident #701) wasn't squirming around in there (mechanical lift) but even if I was in a Hoyer lift and tried to do that (roll and slip up and out of the sling), it would be very difficult. Witness G then stated, The next day, (the facility) stated, We think that maybe we need to do some extra training with (staff) and that maybe the people that were using the lift weren't trained properly. Witness G stated, That doesn't sound good either. That indicates that they're not properly training people. Witness G revealed the next day the facility was back to the slipping out part. Witness G verbalized they were told that Resident #701 started to roll (in the sling) and with their slippery clothing, they slipped up and out of the Hoyer sling. Witness G stated the staff member wasn't able to get over there to save (Resident #701) from falling out. Witness G verbalized it did not make sense as the Hoyer sling cradles the Resident and it would have been very difficult for the Resident to fall out. When asked about the Resident's care following the fall, Witness G revealed a CT (diagnostic test to used to visualized soft tissues and organs in the body) was completed because Resident #701 was complaining of severe pain in their neck and head. When queried regarding the CT results, Witness G replied, It did show an intracranial hemorrhage in the frontal lobe which is where the laceration is on the forehead. Witness G was asked if Resident #701 had a change in mental status following the fall and replied, (Resident #701) has Alzheimer's so obviously it's hard to do a neuro exam unless you know their baseline but (Resident #701's) not operating at their baseline. When queried what changes were identified from the Resident's baseline, Witness G replied, Before the fall, (Resident #701) was able to you know interact with us and make eye contact. They would kind of sing along to some songs that they knew from the past and things such as that. Witness G continued, (Resident #701) is not making eye contact anymore and when you try to feed (the Resident) now, they are not interested or doesn't understand. With further inquiry, Witness G revealed there was really no interaction from Resident #701 at all now. Witness G then stated, (Resident #701's) forehead took the impact of the fall and verbalized that, as someone who has used a Hoyer lift as part of their job, they could not understand how a Resident could fall headfirst out of the sling if the Resident was properly positioned, and lift was being utilized appropriately. Witness G disclosed Resident #701 was receiving Hospice services and stated, I know (Resident #701) doesn't have a great quality of life. They are 87 (years old) and have Alzheimer's, have for several years, but I don't want the reason they pass (die) to be something traumatic and due to negligence. Witness G stated, I don't want someone else to get hurt. That's the fear that I have. When queried regarding the laceration Resident #701 received when they fell, Witness F revealed a facility nurse had put steri-strips (thin, adhesive bandages used to cover small cuts to keep the skin closed) on the laceration but it had continued to bleed so the Hospice nurse came to the facility and applied a pressure dressing. When asked to clarify if they were saying steri-strips were not holding the wound edges together, Witness F confirmed. Witness F indicated the most appropriate treatment for the laceration would have been evaluation in the Emergency Department (ED) and sutures. When asked if there was any additional information related to the fall they wanted to discuss, Witness F reiterated they were concerned that the facility had not been able to provide a clear explanation of how the fall occurred and indicated they felt there was either a lack or investigation or transparency. Witness F stated, (Resident #701's) not doing well. There was a notable decline following the fall and reiterated they were concerned for other residents who resided in the facility and required a Hoyer lift for transfers. Record review revealed Resident #701 was admitted to the facility on [DATE] with diagnoses which included dementia with other behavioral disturbance, weakness, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, had one sided impaired Range of Motion (ROM) in their upper and lower extremities, and was dependent upon staff to complete all Activities of Daily Living (ADLs). The MDS further detailed the Resident displayed no behaviors. Resident #701 was receiving Hospice Services related to their diagnosis of dementia. A comparative review of Resident #701's admission MDS assessment dated [DATE] revealed the Resident had no impairments in ROM at that time. On 5/21/25 at 11:18 AM, Resident #701 was observed sitting alone in their room in a Broda chair (high back, reclining wheelchair with side cushions for positioning and a one-piece solid leg/footrest) with their eyes partially closed. A dark-colored scabbed and red area, approximately 3 inches long by half an inch wide was present on the left side of the Resident's forehead. The leg/footrests were down, and the Resident was holding a doll. When spoke to, Resident #701 did not respond verbally or non-verbally. The Resident's bed was the first bed, closest to the hallway in a shared, two-person room. Their bed was positioned against the wall of the room with the top of the bed (pillows) away from the door and towards the window and other resident area of the room. An overbed table was positioned over the bed and a dresser was next to the door towards the bottom of the bed on the wall with the hallway door. At 11:21 AM on 5/21/25, an interview was completed with Licensed Practical Nurse (LPN) A and Registered Nurse (RN) F. When queried regarding the large, scabbed area on Resident #701's forehead, RN F revealed they were orientating with LPN A and had recently started at the facility. LPN A was asked what happened to Resident #701's forehead and hesitantly responded that Resident #701 had a fall. When queried regarding the fall, LPN A replied, I wasn't there. Would you like to talk to the DON (Director of Nursing)? When queried regarding the Resident sitting in the Broda chair in their room and lack of response, LPN A replied, (Resident #701) has been up since 6 (6:00 AM) or 7 (7:00 AM) and indicated the Resident is most likely tired. An interview was completed with Certified Nursing Assistant (CNA) H on 5/21/25 at 11:26 AM. When queried if they were Resident #701's assigned CNA, CNA H confirmed they were. CNA H was then queried regarding the scabbed area on Resident #701's forehead and replied that the area was from a fall. When queried, CNA H revealed they were not working when the fall occurred and stated, (CNA I) and (CNA J) were. At 11:30 AM on 5/21/25, an interview was conducted with CNA I. When queried regarding Resident #701's fall, CNA I confirmed they were working and stated, We had (Resident #701) in the shower sling (mesh, quick dry sling frequently used to shower dependent individuals). When asked if they had given the Resident a shower, CNA I replied, (Resident #701) is assigned one (shower sling). CNA I then stated, Me and the other (CNA) didn't even have (Resident #701) that day. We just do it as a team and do all the Hoyer's together. When asked what they meant, CNA I replied, The first two people who aren't busy get all the lift resident's back in bed. CNA I revealed they will start at one end of the hall and move their way down until all the residents are back in bed. When asked if Resident #701 usually becomes combative and/or anxious while being transferred with the Hoyer lift, CNA I replied, No. When asked what happened, CNA I revealed they were transferring the Resident from their chair to the bed. CNA I stated, (Resident #701) sat up and went out the left side of the sling. (Resident #701's) head hit the metal bar leg on the Hoyer. When queried if that was how the Resident got the laceration on their forehead, CNA I replied, Yes. When asked how Resident #701 fell out of the side of the Hoyer sling, CNA I attempted to describe the incident detailing the Resident landed directly on the front of the head. When asked about the Resident's reaction to the fall, CNA I responded that the fall was traumatizing for everyone involved. Incident and Accident as well as any investigation documentation pertaining to Resident #701's fall was requested from the facility Administrator at 11:35 AM on 5/21/25. An observation of the Hoyer lift that was utilized during Resident #701's transfer occurred on 5/21/25 at 12:00 PM with the DON, CNA I and CNA K in the conference room. The mechanical lift was an Invacare 450 model battery powered lift with attached Reliant scale (body weight scale). The sling that hung over the lift was a blue mesh style sling with a purple edge. The mechanical lift had a single bar hanger with hooks for the sling to attach. The lift functioned with the controller and there were no obvious mechanical faults observed. When asked what occurred when Resident #701 fell while being transferred, CNA J verbalized they were behind the base and using the electronic controller and CNA I was on the right side of the Resident who was suspended in the in the sling during the transfer. CNA I stated, (Resident #701) leaned to the side and fell out the side gap of the sling to the floor. When asked how the Resident was able to fall out of the side of the sling, CNA I stated, (Resident #701) started to sing and to lean and then fell out. When queried, both CNA I and CNA J confirmed the sling present on the mechanical lift was the same type and size sling used when Resident #701 fell during the transfer. A demonstration of how Resident #701 fell from the lift was provided by the staff at this time. The staff proceeded to attach the sling to the hanger and the DON got into the sling. The sling was noted to be in a sitting, not reclined position. The DON demonstrated they were able to fit through the side gap of the sling. The DON then stated, May be related to the sling attachments and indicated the model of mechanical lift used (Invacare 450). When asked what they meant, the DON pointed out that the model lift has a single hanger rod where there is minimal distance between the sling hook points on the bar enabling the bar to swivel and tip easily. A demonstration by sitting in the sling was completed. With no staff guidance on the sling/individual in the sling, the individual in the sling was able to purposefully position their body to move through the side gap of the sling. Due to the characteristic swivel and tilt motions of the mechanical lift hanger, once the momentum of the body began, without a staff member intervening, guiding and stopping them, the individual was able to tip and subsequently fall from the sling. The DON revealed the mechanical lift was removed from use after the fall. When asked if they were saying there was a mechanical malfunction with the lift, the DON replied, No and revealed they felt that once Resident #701 started to tip sideways in the sling, they were unable to prevent the fall because they could not physically stop themselves and the hanger bar part of the mechanical lift allowed the sling to tip sideways. The DON verbalized the other mechanical lifts in the facility were different models which were less tippy due to having a larger hanger and more space between the sling hooks. An observation of the other mechanical lifts in the facility was completed at this time with the DON. The other mechanical lift model is the facility was an Invacare 650 mechanical lift. The DON stated, The CNAs prefer these (model 650 mechanical lift) over the other one (model 450 mechanical lift). When asked why the CNA staff preferred the 650 model over the 450 model, the DON revealed it was because they liked the way the sling attached to the lift hanger as it has three-point connection and is more stable. A facility policy/procedure pertaining to mechanical lift and sling use was requested from the facility Administrator on 5/21/25 at 12:45 PM. At 1:00 PM on 5/21/25, the DON entered the conference room and stated the facility did not have a policy/procedure for mechanical lift and sling use. With further inquiry, the DON stated, We use the manufacturers guide. When asked if the staff who utilize the lift have access to the manufactures guide/owners manual, the DON indicated they do not. The DON then stated that staff have a check off competency completed by the regional nurse educator for lift use when they are hired. Review of Resident #701's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #701) has altered functional mobility and ADLs related to dementia with behavioral and psychological symptoms . (Initiated: 12/1/24; Revised: 12/2/24). The care plan included the intervention, Transfer: Mechanical Lift-Follow guide for sling type and loop attachment (Initiated: 12/2/24). A form entitled, Mechanical Lift Guidance dated 12/2/24 was scanned into Resident #701's EMR. The form specified the Resident was a full mechanical lift using a mesh full body, medium violet edge sling. The sling loop attachments were Upper: Green and Lower: Purple Review of documentation in Resident #701's EMR revealed the following: - 5/12/25 at 1:15 PM: Fall Management (assessment) . Cognitive / Behavior Status: 1. Has the residents Behavior changed in the previous 90 days? No. 2. Have the following behaviors been displayed in the previous 90 days: Restlessness, lethargy, resists care, does not follow or understand direction . No . Summary . STCP (Short Term Care Plan) initiated for latent injury due to recent fall . is assessed as a fall risk r/t (related to) dementia. - 5/12/25at 1:30 PM: Skin Assessment . Face . Open Wound . Length: 3.5 cm (centimeters) . Width: .5 cm . Depth: .3 cm . Assessment Notes: Resident was lying in bed during this assessment and tolerated movement of limbs. Wound noted to L (left) forehead above eyebrow measuring as stated above. Wound washed with NS and patted dry, x 6 steri-strips were applied with edges well approximated . Abrasion without bruising noted to L (left) forearm-cleansed with warm water and air dried, abrasion with scant bruising noted to L (left) chin, cleansed with warm water and air dried. No other injury was observed . - 5/12/25 at 2:39 PM: Interdisciplinary Documentation . at 1315 (1:15 PM) (Certified Nursing Assistant- CNA) called nurse to room, patient on floor laying on left side. Staff stated (Resident#701) slide out of sling during transfer using the mechanical lift. 2 (CNAs) were present. Laceration by left eye, six steri-strips applied. Notified doctor, (Family Member C) notified. when asked if we could send to ER for exam. (Family Member C) refused stated to monitor (Resident) here. Neuros initiated DON (Director of Nursing). hospice aware. X-rays ordered. Hospice nurse here at this time. Doctor called at this time, new orders for pain medications . Note was authored by Licensed Practical [LPN] Nurse A - 5/12/25 at 3:21 PM: This writer spoke with (Family Member C) . regrading incident and wishes for resident to not seek immediate medical attention. Education provided on risks that could result in death if treatment is not perused. (Family Member C) stated he understood and that he would like to proceed with x-rays in house and in-house monitoring. It was explained that even STAT x-rays could take 24 hours to be completed. He said he does not want (Resident #701) sent to the hospital as that is a 'harsh environment' and he did not want to make any 'rash decisions'. Witness C stated 'I would like for (Resident #701) to be comfortable, please just keep them there. HCP (Health Care Provider) notified of (Family Member C) wishes. Hospice nurse arrived and new orders obtained for comfort and any expected pain that (Resident) may experience . STAT x-rays ordered . Wound head dressed with 6 steri-strips applied to left side of forehead by IP (Infection Prevention) nurse. Hospice applied pressure dressing as head continued to bleed . - 5/13/25 at 8:37 AM: Interdisciplinary Documentation . (DON) contacted x-ray services. X-ray services stated that the order is visualized and due to a technical delay within the region the plan is to arrive to compete the ordered x-rays between 11a and noon today. - 5/13/25 at 9:40 AM: Medical Professional Note . Late Entry . Seen and evaluated today for an acute visit. Patient had a fall yesterday from the hoyer (mechanical lift) . Unable to obtain any information from (Resident #701). X-rays are pending, laceration to the left forehead with intact steri strips . Patient is on hospice . - 5/13/25 at 11:50 AM: Interdisciplinary Documentation . x-rays completed on resident, awaiting results. - 5/13/25 at 17:00 PM: Interdisciplinary Documentation . HCP aware of x-ray results, (DON) spoke with (Family Member C) over the phone to review results of x-rays and (Family Member C) is choosing not to pursue with suggested CT brain. (Family Member C) is aware of potential outcome . - 5/14/25 at 9:45 PM: Interdisciplinary Documentation .Call placed to (Family Member C), who stated they and (Family Member E) would like to have a CT of the head on an outpatient basis. Coordination of care call made to (DON) who will call (Family Member C) in the morning - 5/15/25 at 7:51 AM: Interdisciplinary Documentation . (DON) spoke with (Family Member C) and a conference call was had with (other family), Medical Director and (DON). A CT brain without contrast will be ordered for today and completed outpatient as requested by family. Family stated they are requesting the CT of the brain to make a determination if the family members should prepare for the resident passing sooner rather than later. HCP here to evaluate resident. Hospice has also been updated. - 5/15/25 at 7:55 AM: Medical Professional Note . Seen and evaluated today for an acute visit . had a fall on day before yesterday from the Hoyer lift . Discussed with the nurse and family and updated and will have (Resident) go for a CT scan for the brain to rule of ICH . - 5/15/25 at 12:46 PM: Interdisciplinary Documentation . (Resident#701) had Roxanol (narcotic pain medication for severe pain) at 0730 this am with noted pain relief. At 1000 (Resident #701) was observed holding the back of the left side of their neck and facial grimacing. Roxanol could not be administered until 1130. This nurse spoke with family in building and spoke with (Family Member C) over the phone . spoke with hospice. New orders for Ativan (controlled antianxiety medication) 0.5 mg milligrams) every 4 hrs. prn (as needed) and Roxanol 0.25 ml (milliliters) every 2 hrs prn . - 5/15/25 at 10:15 PM: Interdisciplinary Documentation . Spoke with (Family Member C) to report results of today's CT head examination. Resident has intracranial bleed. The provider called the facility and asked the registered nurse to call (Witness C) to determine any further treatment. (Witness C) does not want any surgery for resident . - 5/19/25 at 12:24 PM: Interdisciplinary Documentation . Late Entry . Resident observed holding steri-strips from forehead in hand. Wound is well approximated with no drainage . Review of diagnostic imaging results in Resident #701's EMR revealed the following: - 5/13/25 at 1:51 PM: X-Ray of the Skull, 2 Views . Findings . Ill defined intracranial lucency noted over bilateral fronto-parietal regions, more pronounced on left . Intracranial Compartment . lucency is projected within the cranial vault and not clearly confined to soft tissues - may represent intracranial air . Impression: 1. Ill-defined intracranial lucency over bilateral fronto-parietal regions (frontal and parietal lobes of brain), greater on the left side- concerning for intracranial air (air in brain) in the clinical context of trauma, suggest CT scan . - 5/15/25 at 4:14 PM: CT Brain/Head w/o (without) contrast . Indication: Trauma. Intracranial hemorrhage . Findings: There is intracranial hemorrhage in the dependent occipital hors of the lateral ventricles (fluid filled area of the brain which contains cerebral spinal fluid) . Soft tissue swelling about the left extracranial (outside the skull) frontal region . Postinfarct encephalomalacia (brain tissue softening or loss which can develop days to middle brain lobe) . Impression: 1. There is intraventricular hemorrhage (bleeding in the ventricles of the brain) in the occipital (posterior -back) hors of the lateral ventricles as seen bilaterally (blood will often collect in the dependent area of the ventricles - the occipital horns when an individual is flat or recumbent) . Review of Hospice documentation in Resident #701's EMR revealed a RN PRN (as needed) Hospice Visit note dated 5/12/25 at 2:31 PM. The note detailed, Reason for PRN Visit: Pt (Patient) fell from sling today and has a large laceration . Approx. 6 in. (inch) laceration above left eye. Indicate Functional/Safety Assessment Findings: Pt fell out of Hoyer . Narrative: Received call from facility reporting that patient had fallen and requesting nurse visit. Patient was lying in bed with steri strips on left side of forehead. There was a small trickle of blood that was draining down into right eye (sic). Gauze dressing applied and covered with gauze wrap for a pressure dressing . No other complaints other than head hurting on left side . (Family Member Witness C) notified and didn't want (Resident #701) taken to hospital . On 5/21/25 at 1:30 PM, an interview was attempted to be completed with Resident #701's family member Witness C. A voicemail message with a return phone number was left. An interview was completed with Therapy Director Occupational Therapist (OT) K on 5/21/25 at 2:00 PM. When queried regarding Therapy Staff evaluation for mechanical lift devices including slings, OT K stated, I just eval for the slings based on (resident) weight. When asked if Therapy trains staff regarding mechanical lift use and procedures, OT K indicated they do not and stated, The nursing educator does the training. OT K was then queried regarding Resident #701's fall from the mechanical lift and indicated they were aware of the fall. When queried regarding Resident #701's ability to sit up independently and support themselves, OT K revealed Resident #701 does not really have any core strength and is not able to support themselves. On 5/21/25 at 3:00 PM, an interview was completed with the facility Administrator. When asked why the facility did not report Resident #701's fall from the Hoyer lift which resulted in severe injury, the Administrator stated, We reviewed it and it was not an injury of unknown origin. On 5/21/25 at 3:45 PM, an interview was completed with the DON. When queried why there was not a statement in the facility provided investigation documentation from Resident #701's nurse and/or the nurse who first assessed the Resident, the DON stated, I was the first nurse to respond. When asked what happened, the DON stated, I was walking down the hall and heard a request for help and went in (Resident #701's room). (Resident #701) was on their left side next to the bed. Their left arm was bent and their fist was by their chin. When asked, the DON revealed they were able to see the right side of the Resident. The DON then stated, The Hoyer was away, (Resident #701) wasn't still resting on the Hoyer. The DON was asked where the Resident's legs were and replied, Feet were out of the sling and head looked like they slightly moved it off of the leg of the Hoyer. When to clarify where the Resident's head was, the DON stated, (Resident #701's) head was just inside the legs (of the Hoyer). The DON was asked where the mechanical lift was in the room and replied, The Hoyer was moved back, and the sling was still attached to the Hoyer. (Resident #701) was completely out of the sling. When asked what they meant when they said the sling was still attached to the Hoyer, the DON responded that the sling was connected to the Hoyer lift as though a person was in it but (Resident #701) was completely out of it. When queried if they were saying that the CNA staff moved the Resident and Hoyer lift prior to the nurse responding to the room to assess, the DON replied, They lowered the sling to the ground but didn't do anything else. The DON then stated, They probably lowered it down and got the rest of (Resident #701) out. Guessing they moved it. When asked where Resident #701's Broda chair was positioned in the room, the DON replied, The Broda was moved out of the way. It was aways away. The DON was unable to provide the exact location of the chair when asked. When queried if the legs of the Hoyer lift were apart or together, the DON replied, Not sure. The DON was then asked the specific location of the Resident in their room and stated, Right next to the bed. We were able to get around (Resident #701) but not at the side where the bed was. The DON proceeded to draw a picture of the Resident and their room. In the picture, Resident #701 was on the floor directly next to their bed with their body and head parallel to the bed. In the image drawn by the DON, the Resident's body was pointed with their head towards the room window and their feet towards the door. The DON did not include the Resident's overbed table in the drawing. When asked where the overbed table was in the room, the DON replied, Not sure. The DON was then asked who Resident #701's assigned nurse was on the day Resident #701 fell and replied, (LPN A). When queried why the investigation documentation did not include a statement from LPN A and where they were at the time of the transfer and fall, the DON stated, I told (LPN A) we had it. Review of facility-provided investigation documentation for Resident #701's fall during mechanical lift transfer contained the following: - Signed Statement by CNA I dated 5/12/25: We was putting (Resident #701) to bed and I was right next to her in front of the lift and (CNA J) was in the back of the lift controlling it. (Resident #701) leaned forward and fell out the side. - Signed Statement by CNA J dated 5/12/25: I was operating the controls helping (Resident #701) to bed. My coworking was right next to (Resident #701) helping moved the Hoyer. (Resident #701) leaned and slipped between the straps, hitting their head on the Hoyer. - Return Demonstration Mechanical Lift Competency Check Off Sheets for Facility Staff. - Mechanical Lift Guidance Forms dated 5/14/25 for 15 Residents including Resident #701. Resident #701's form specified the Resident was a full mechanical lift using a medium sized, violet edged, Canvas, full body sling. The sling loop attachments were Upper: Green and Lower: Purple. - Typed Summary: Allegation Type: Witnessed Fall with Injury. Event Information: Event occurred on 5/12/25 at approximately 1:15 PM. (CNA I) and (CNA J) were assisting . (Resident #701) to bed . utilizing an Invacare mechanical lift and an Invacare mesh sling . from their Broda chair to their bed . (CNA J) was working the controls at the base of the mechanical lift while (CNA (I) was next to the resident on the residents right side. The bed was on the resident's left side. (CNA I) was guiding the resident from the Broda chair towards the bed as the height of the lift was being adjusted by (CNA J). (CNA I) was on the right side when the resident leaned too far left and slipped out of the mesh sling that was attached to the mechanical lift. It was observed that the resident touched the left side of their forehead to the leg of the mechanical (lift), th[TRUNCATED]

This citation pertains to Intake Number MI00150598. Based on observation, interview and record review, the facility failed to prevent repeated falls for one resident (Resident #101) of 4 sampled residents, resulting in Resident #101 sustaining repeated falls from her wheelchair, Findings include: Resident #101: In an observation and interview on 3/5/2025 at 8:10 AM, Resident #101 was seated up in the resident's room in a wheelchair with the footrest in place. Resident #101 was asked about a fall in February 2025. The Resident stated that yes, she fell from her wheelchair and went to the hospital. Record review of Resident #101's Minimum Data Set (MDS), a quarterly assessment dated [DATE] revealed an elderly female with a Brief Interview of Mental Status (BIMS) of 14 out of 15- indicating cognitively intact. Section I- Active diagnoses included: Medically complex conditions, diabetes, hemiparesis, seizure disorder, anxiety, depression, ischemic cardiomyopathy, dysphagia, insomnia. Section G- Functional Abilities: Dependent, helper does all of the effort, resident does none of the effort to complete the activity. Dependent for toileting hygiene, shower/bath. Maximum assist helper does more than half of the effort for: upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and rolling left and right. Record review of Resident #101's accident/incident reports revealed 3 separate falls had occurred since 01/01/2025: On 1/7/2025 Resident #101 was observed lying face down on the floor by staff in the resident's room. On 2/17/2025 Resident #101 was observed laying on her right side on the floor by staff in the resident's room. On 2/20/2025 Resident #101's roommate heard the resident fall but did not see the event and yelled out for help. Nursing staff heard the roommate yelling and responded to the room to find Resident #101 lying face down on the floor. Record review of Resident #101's care plans, pages 1-46, revealed care plans for: -Altered Mobility and ADL's Fall Risk Management- encourage non-skid footwear, personal items within reach, Floor mat next to bed while resident is in bed as tolerated, soft touch call light 4/19/2023. Wheelchair seat to have a decreased rear of the seat to assist with comfort as well as fall prevention 6/3/2023. Reacher provided to resident with education to use call light, Dycem applied to side table to place phone and glasses on 2/17/2025, basket for loose items added to tray table. Encourage to be in highly visible areas when up in wheelchair 2/20/2025, encourage curtain to be pulled back when cares are not being performed, date initiated: 4/17/2023, Revision on: 2/20/2025. 'Risk for Falls or Injury' interventions dated 2023: - Assist rails, Call light: resident is able to utilize the call light for assistance, Document resident response to interventions, prn. Examine internal and external risk factors upon admission and post fall as noted on the fall risk assessment tool. Examine the resident's diagnosis and orders and assess the ability to ambulate and bear weight- provide direction to staff via care card. MDS review of the relationship of fall risk and medication side effects, prn. Post- Fall review room for environmental factors/re-act situations prn to assist with development of cause specific interventions, neurological checks prn. Review and modify environmental factors as indicated. Review medications with potential side effects that could contribute to gait disturbance- care plan risk vs benefit prn. See ADL plan of care for fall risk interventions. With history of exit seeking and mobility independence apply interventions as indicated and reassess prn. Interventions Date initiated 4/19/2023. -Adaptive Equipment: wheelchair, full mechanical lift revision date. Assess orthostatic hypotension prn (as needed), Assess postural alignment prn, evaluate side effects of thromboprophylaxis therapy, i.e., itching, bruising, petechiae, hematuria, coffee ground emesis, increased bleeding from injury, black tarry stool; consult health care practitioner as indicated by evaluation date initiated 7/25/2023. There where no interventions for monitoring or increased supervision of Resident #101. Record review of the facility's 'Accident/Incident Report Fall Management' policy, dated 6/2018, revealed it is the policy of the facility to complete an accident incident report for unexplained bruises or abrasions; accidents or incidents where there is injury or the potential to result in injury; falls . (6.) It is recognized that not all falls can be prevented, the facility will utilize applicable elements of the systemic process of assessment, intervention, and monitoring to minimize fall risk and injury In an interview on 030/5/2025 at 10:30 AM, former roommate, Resident #105 stated it was after supper around 8:30-9:00 PM, when she heard a loud crash. Resident #105 stated that she was trying to talk to (Resident #101), but she did not respond, so she pushed the call light. No, Resident #101 was not choking when she fell over. The curtain was pulled between them, so she could not see what actually happened. Resident #105 stated that there was no response from staff. It seemed like forever, so she started to scream for help. It felt like it took them 30 to 40 minutes to get into the room. Finally, 3 staff members came running in and they found Resident #101 on the floor. Resident #105 stated that she guessed Resident #101 went face first to the floor, busted her lip and was bleeding from her nose and mouth. The staff called 911 and they took Resident #101 away around 9:30 PM by ambulance to the hospital. In an interview on 030/5/25 at 11:43 AM, Resident #101 was seated up in wheelchair in room with her black glasses on. Resident #101 recalled the fall, and the roommate calling for help, while she was on the floor. Resident #101 stated that she was reaching for something and just fell out headfirst from her wheelchair. Resident #101 stated that she did get hurt and that staff did come after 45 minutes to help her, while she was on the floor. The roommate was yelling, and she didn't know what happened.

Based on observation, interview and record review, the facility 1) Failed to ensure a clean and sanitary ice machine and 2) Failed to ensure safe service and holding food temperatures during a breakfast meal for all residents who consumed food, resulting in unsafe serving food temperatures with the likelihood of continued unsafe temperature food service. Findings include: On 11/20/24, at 8:00 AM, an observation of the back dining room revealed the breakfast meal was already in the warmer. On 11/20/24, at 8:04 AM, an observation along with [NAME] I who obtained meal temperatures as follows: Sausage Gravy 159 degrees Fahrenheit, Scrambled eggs 132 degrees Fahrenheit [NAME] I was asked if 135 degrees for the scrambled eggs was ok and [NAME] I looked down to the dial and turned it clockwise. [NAME] I was asked if the steam table was off and [NAME] I offered, no, but I thought it was on medium. It's on medium now. [NAME] I again was asked if the scrambled eggs temperature of 135 degrees was ok and [NAME] I stated, I have to go check and left out to the kitchen. A moment later, [NAME] I returned the scrambled eggs to the kitchen and placed them in the oven. On 11/20/24, at 8:14 AM, Dietary Manager(DM) J entered the kitchen and was asked if 135 degrees Fahrenheit for scrambled eggs service was ok and DM J offered as long as she heats them back up to 165 degrees. [NAME] J then removed the scrambled eggs, placed them in a frying pan and heated the eggs to 190 degrees. At 8:16 AM, [NAME] J moved the scrambled eggs back to the steam table for breakfast service. On 11/20/24, at 8:19 AM, an observation of Dietary Staff K in the front dining room was conducted. Dietary Staff K was asked if they had obtained temperatures of the food they were serving and Dietary Staff K stated, I did, but I forgot to write them down and offered to retemp the foods. Dietary Staff K obtained the following food temperatures: sausage gravy 153.9 degrees, scrambled eggs 142.7. On 11/20/24, at 8:30 AM, Dietary Manager J was asked to provide the breakfast food temperature logs for that morning. In the kitchen with DM J, a record review of the food logs revealed the scrambled eggs were 160 degrees Fahrenheit prior to leaving the kitchen for service. DM J was asked again if the egg temperatures were ok for service and DM J offered, as long as they don't go below 135. DM J was asked how the serving staff ensure safe food temperatures during meal service and DM J offered, that's what I tell them. You push your food cart down there. Put the food in the warmer right away and turn it on high. They're not going to burn the food in that amount of time. DM J was asked to clarify again when the food items are temped prior to service and DM J offered, they temp when done cooking prior to leaving the kitchen. DM J was asked if staff temp the food at the steam tables and DM J stated, they temp again at the end of service. DM J was asked to provide the facility food service, cooking and storage policies. On 11/20/24, at 8:45 AM, an observation of the front dining room revealed that there was one resident tray left to prepare. Dietary Staff K was asked to obtain the temperature of the scrambled eggs which revealed 131.0 degrees. On 11/20/24, at 2:00 PM, a record review along with DM J of the facility provided food policies and there was no mention of scrambled eggs on it. DM J offered that they follow the food code for eggs. DM J was asked to provide the food code for serving scrambled eggs safely. On 11/20/24, at 2:20 PM, Registered Dietician (RD) L entered the conference room and offered the FDA Food code 2022 chapter 3 - 28. RD L was alerted the production logs were not fully completed and revealed storage no less than 135 degrees RD L offered the FDA Food code for review. RD L was alerted that the production logs revealed missing temperatures for food served out of the kitchen and RD L repeated we follow the FDA food code. 37668 On 11/18/24 at 9:31 AM, an ice machine was noted in the facility kitchen. An observation of the ice machine was completed with Dietary Manager J, Dietary Staff Q, and Dietary Staff R. An unknown black colored substance was observed inside the ice machine along in the interior ledge of the plastic in the ice machine. The black colored unknown substance came in contact with the ice. Manager J, Staff Q, and Staff R confirmed the presence of the unknown, black colored substance in the ice machine. When queried regarding the facility policy/procedure related to cleaning the ice machine, Manager J responded that maintenance staff clean the ice machine. When queried if dietary staff maintain and/or clean the ice machine, Staff Q and Staff R verbalized the ice machine is not cleaned by dietary staff. A copy of the cleaning log for the ice machine as well as the facility policy/procedure were requested from Manager J at this time. An interview was conducted with Dietary Manager J and Dietary Staff K on 11/20/24 at 9:00 AM. The food temperature logs for the past month were requested to review at this time and Manager J indicated they would need to locate the logs. When asked if the logs were maintained in a binder, Manager J revealed they were unable to provide copies of documents without administrative approval. When asked to review the log with them, Manager J provided two log forms for 11/1/24. One log form was for the Front dining room and the other was for the Back. The form contacted columns titled, Food Item, Production, Regular, Mech Soft, Puree, Leftovers, Initials. The rows in the form were divided into Breakfast, Lunch, Dinner and detailed the initial food items served. When asked what Production meant, Manager J explained it was the number of servings prepared. The food temperatures documented on the form for both the front and back dining rooms were identical for every food item. When queried regarding the identical temperatures, Staff K explained the food is prepared at the same time and the temperature is checked when it is removed from the oven. With further inquiry regarding facility procedure related to checking food temperatures for food service, Staff K stated, We only temp (the food) once when we remove it from the oven in the kitchen. When asked what they do after the food is removed from the oven and the temperature is checked, Staff K revealed it is placed in the service carts and taken to the dining room. When asked if food temperatures are checked again, prior to servicing the food to residents, Manager J and Staff K verbalized it was not. When queried regarding documentation of food temperatures at the end of food service, Staff K stated, We don't document what temp is when done in dining room. With further inquiry, Staff K indicated they take the food temperatures when they have finished serving the food to residents but do not maintain a record of the temperature. When asked why they do not maintain a record of the food temperatures, Manager J stated, We only need to take temperatures once. When asked why they do not check the food temperature at the time of and during food service to ensure food remains at a safe temperature for consumption, Manager J reiterated they were told they only need to check the temperature once which is done when the food is removed from the oven.

Based on observation, interview and record review, the facility failed to ensure timely assessment and implementation of interventions for pressure ulcer prevention for one resident (Resident #5) of three residents reviewed for pressure ulcers. Findings include: Resident #5: On 11/18/24 at 2:07 PM, Resident #5 was observed in their room. The Resident was in bed positioned on their back with their eyes open. The Resident's legs and feet were positioned directly against the mattress. When spoke to, Resident #5 responded verbally but did not provide meaningful responses to questions. Record review revealed Resident #5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart failure, cerebral infarction (stroke), and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and was dependent upon staff for bed mobility and transferring. The MDS further revealed the Resident was at risk for pressure ulcer development but had no pressure ulcers. Review of Resident #5's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #5) has potential risk for impaired skin integrity related to: History of fragile skin, History of or actual impairment . (Initiated and Revised: 11/17/24). The care plan included the interventions: - Bridge heels in bed . (Initiated: 11/17/24) - Measure open areas upon admission, weekly, prn (as needed) (Initiated: 11/17/24) A second care plan entitled, (Resident #5) . is alert and oriented 1-2 with garbled speech and is difficult to understand at times originally admitted to hospital for weakness and alerted mental status with a new finding of Covid pneumonia and received treatment . (Initiated: 10/24/24; Revised: 11/15/24). The care plan included the interventions: - Skin: Apply barrier cream with incontinence care prn; inspect skin with bathing and care . APM (alternating pressure mattress) mattress set to residents' level of comfort (Initiated: 10/25/24; Revised: 11/15/24) - Skin Impairment Location: Coccyx (Initiated: 11/15/24) - Skin: Heels elevated in bed as tolerated (Initiated: 10/24/24) Review of documentation in Resident #5's EMR revealed a Wound assessment dated [DATE] at 4:05 PM which detailed, Wound Measurement . Coccyx . Pressure . Length: 4.5 (centimeters [cm]) . Width: 5 (CM) . Stage: Suspected Deep Tissue Injury (SDTI- pressure ulcer with unknown depth) . Wound Bed . Pink / Red - Clean, open area, red/pink Tissue . Exudate: Serous . Assessment Notes: wound was developed during hospital stay and was present upon admission. A fluid filled blister on coccyx with purple blue SDTI present . An Interdisciplinary Documentation Note in the EMR, dated 11/15/24 at 10:55 AM specified, . Skin Assessment noted 1+ Slight Pitting (edema) disappears rapidly, Skin is dry and intact . Review of Resident #5's EMR revealed the Resident had an external health care provider appointment on 11/11/24 and were admitted to the hospital from the appointment for further testing. Resident #5 returned to the facility on [DATE] at approximately 5:00 PM. A review of Resident #5's skin assessment documentation prior to their appointment and hospitalization on [DATE] revealed skin assessments were completed on 10/26/24 and 11/2/24. A review of the Skin assessment dated [DATE] indicated the Resident had no alterations in skin integrity. On 11/19/24 at 1:01 PM, Resident #5 was observed in their room. The Resident was in bed positioned on their back. The Resident's heels were positioned directly against a pillow and the bottom of their right foot was pressing against the footboard of the bed. On 11/19/24 at 3:00 PM, Resident #5 was observed in their room. The Resident was in bed positioned on their back. The Resident's heels were positioned directly against a pillow and the bottom of their right foot was pressing against the footboard of the bed. At 3:24 PM on 11/19/24, an observation of Resident #5 was completed with Clinical Registered Nurse (RN) O. Resident #5 remained in bed, positioned on their back with their heels directly against a pillow and their right foot pressing against the footboard of the bed. When queried regarding the Resident's positioning, RN O confirmed positioning concerns and indicated the Resident's heels should be floated and the bottom of their foot should not be pressing against the footboard of the bed. RN O stated, We have a bari (larger) bed we can get (Resident #5). On 11/20/24 at 11:03 AM, an interview was completed with Certified Nursing Assistant (CNA's) A. When asked if Resident #5 had any wounds, CNA's A stated, (Resident #5) has a sore on their bottom. An interview was completed with Wound Care Registered Nurse (RN) P on 11/20/24 at 12:33 PM. When queried how frequently skin assessments are completed by nursing staff, RN P stated, Weekly. When asked why Resident #5 did not have an assessment completed in nine days, from 11/2/24 until they went to an external appointment and were hospitalized on [DATE], RN P reviewed the EMR and confirmed a skin assessment had not been completed. When queried how they knew the Resident's pressure ulcer started at the hospital and not the facility when an assessment had not been completed and documented, RN P responded that pressure ulcer was not present when the Resident was discharged and indicated they would review the documentation further. An observation of Resident #5's wound care was completed on 11/20/24 at 2:15 PM with RN P and CNA's A. Upon removing the prior dressing, the wound bed was observed to be open. RN P measured the wound bed and stated it was 8 (cm) by 2 (cm) on the coccyx. Two separate, dark discolored areas were observed on the Resident's left sacrum/buttocks area. When queried regarding the areas, RN P assessed the areas and stated the tissue was non-blanchable. RN P measured the areas and said the top area was 6 cm x 5 cm and the lower area was 4 cm X 4 cm. After application of a new dressing, RN P and CNA's A repositioned the Resident in bed. The Resident's heels were positioned directly on a pillow. When queried regarding the Resident's heels, RN P stated, Should be floating. When asked if the Resident's heels were currently floating, RN P confirmed they were not. Review of facility provided policy/procedure entitled, Skin at Risk Assessment Documentation, Staging & Treatment (Revised: 1/2020) revealed, It is the policy of this facility to assess resident risk factors for the development of impaired skin integrity and intervene as indicated . It is the policy of this facility to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred .

Based on observation, interview, and record review, the facility failed to ensure the availability and provision of fluids to maintain appropriate hydration for one resident (Resident #5) of three residents reviewed, resulting in Resident #5 not having fluids available and verbalizations of thirst. Findings include: Resident #5: On 11/18/24 at 2:07 PM, Resident #5 was observed in their room. The Resident was in bed positioned on their back with their eyes open. The Resident's mouth was open. Resident #5's mouth and tongue were visibly dry, and their lips were chapped. The Resident did not have a beverage in their room. When spoke to, Resident #5 responded verbally but responses were unable to be understood. Record review revealed Resident #5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart failure, cerebral infarction (stroke), and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and was dependent upon staff for bed mobility/transferring and required supervision/touching assistance for eating. On 11/19/24 at 1:01 PM, Resident #5 was observed in their room, positioned on their back in bed. The Resident's lips remained dry and chapped. A beverage was not present in their room. On 11/19/24 at 3:00 PM, Resident #5 was observed in their room. The Resident positioned on their back in bed. The Resident's lips remain dry and cracked. When asked how they were, Resident #5 clearly stated, Can I get a sip of water? Resident #5 was asked if they were thirsty and indicated they were. Resident #5's call light was turned on and a CNA's entered the room. The CNA's obtained a beverage and held the Kennedy cup (adaptive cup with handles and non-spill lid) to the Resident's mouth. Resident #5 drank the entire glass of water. The CNA's exited the room, got another cup of water, reentered the room, and placed the cup on the overbed table next to the Resident's bed. At 3:24 PM on 11/19/24, an observation of Resident #5 was completed with Clinical Director Registered Nurse (RN) O. Resident #5 remained in the same position in bed. Upon entering the room, Resident #5 asked for another drink of water. With RN O's assistance, Resident #5 was observed drinking another entire cup of water. After exiting Resident #5's room, RN O was queried regarding facility policy/procedure related to the availability of fluids/beverages and indicated Residents should have a drink available unless they are NPO (nothing by mouth). Review of Resident #5's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #5) . is alert and oriented 1-2 with garbled speech and is difficult to understand at times originally admitted to hospital for weakness and alerted mental status with a new finding of Covid pneumonia and received treatment . (Initiated: 10/24/24; Revised: 11/15/24). The care plan included the interventions: - Adaptive equipment: Cups with Lids for Hot Liquids (Initiated and Revised: 10/30/24) - Liquids: Nectar thick (Initiated: 11/19/24) - Diet: Regular Diet, Mechanical Soft Texture, nectar Liquid Consistency. Cups with Lids for Hot Liquids. Likes Fruit Juice, Hot Tea, Milk (Initiated: 10/24/24; Revised: 11/19/24) The discontinued intervention, Resolved: Liquids: Thin-regular, covered hot liquids (Initiated: 10/24/23; Discontinued: 11/19/24) was noted in Resident #5's EMR. An interview was conducted with the Director of Nursing (DON) on 11/21/24 at 10:22 AM. When queried how frequently water/beverages are passed to residents, the DON stated, At the end of the shift. When queried regarding observations of Resident #5 not having water, their oral cavity and lips being dry, and how much they drank upon request, the DON verbalized Residents should have fresh water and be assisted to drink if needed. No further explanation was provided. A policy/procedure related to hydration was requested at this time but not received by the conclusion of the survey.

Based on interview and record review, the facility failed to implement an infection control program including comprehensive outcome surveillance, including monitoring of initial infection signs/symptoms and ongoing surveillance and monitoring of potential infections, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for spread of microorganisms and illness for all 47 facility residents. Findings include: Upon request for facility Infection Control Surveillance Data, the facility provided handwritten Infection Control Resident Surveillance line listing documentation for November 2023 to October 2024. Review of the provided forms revealed each resident listed on the forms received a form of antimicrobial treatment. The columns on the form included Resident/admitted , Room, Unit, Onset, Category, Qualifying signs & Symptoms, Nosocomial (facility acquired) or Community, Treatment and Resolution Date. The forms provided did not include any residents with signs/symptoms of infection who did not receive treatment to identify and prevent the potential spread of contagious illnesses. An interview and review of facility Infection Control data was completed with Infection Control (IC) Licensed Practical Nurse (LPN) S on 11/20/24 at 3:15 PM. When queried regarding the provided Infection Control Resident Surveillance line listing documentation only containing residents who received antimicrobial treatment, IC LPN S confirmed all residents on the line listing received antimicrobial treatment. When asked if they had additional IC surveillance tracking documentation, IC LPN S stated they did not. When asked how they monitor and track residents who have signs/symptoms of infection to identify and prevent potential spread, IC LPN S replied, Not track on a line list. A review of the October 2024 Infection Control Resident Surveillance line listing revealed six rows detailing infections for five residents. Resident #36 was listed twice, once for an oral infection and once for a skin infection. Resident #29 was listed once for a skin infection and had three antimicrobial medications (two antibiotics and one antifungal) included on the same row. The admitted for all the residents on the list was incomplete. The Onset Date column for each listed infection included two dates. Resident #22 was listed as receiving a prophylactic antibiotic due to a Right eye abrasion. There were no carry over infections listed on the line list but a review of the September 2024 line list revealed the resolution date for a resident listed as having a nosocomial skin infection was 10/15/24. A follow-up interview and review of facility Infection Control data was completed with Infection Control IC LPN S on 11/21/24 at 10:37 AM. The October 2024 Infection Control Resident Surveillance line listing was reviewed with IC LPN S at this time. When queried if the line listing was used to track infections or antibiotics, LPN S responded that the line listing was their infection tracking. When queried if an individual can have an infection and not require antimicrobial treatment such as Norovirus (highly contagious viral infection which causes nausea, vomiting, and diarrhea and it not treated with antimicrobial medications), LPN S confirmed they can. LPN S was then asked why there were no infections which did not require antimicrobial treatment included on any of the facility Infection Control Resident Surveillance line listing documents from November 2023 to October 2024 and stated they do not track infections which do not receive antimicrobial treatment on the Surveillance form. LPN S then revealed nursing staff implement a short term care plan when a resident has a change including a potential infection. LPN S was then asked which, if any, residents had a short-term care plan related to a potential infection during October 2024 and revealed they did not know without reviewing each resident's medical record. When asked how they are monitoring and analyzing potential infections in a timely manner to prevent potential spread if they are not tracking data related to potential infections, LPN S verbalized understanding and indicated they would add infections and potential infection which are not treated with antimicrobial's to their surveillance documentation. A detailed review of Resident #29's infection surveillance documentation for October 2024 was completed with LPN S at this time. Per the documentation on the line listing, Resident #29 had a nosocomial skin infection of their genitalia with qualifying signs/symptoms including edema, pus, red, warm . with an onset date of 10/9, 10/22. The Resident received Keflex (antibiotic), Bactrim (antibiotic), and Diflucan (antibiotic). The Resolution Date of the infection was 10/25/24. When queried why Resident #29 was listed one time on the line list with three different antimicrobial medications, LPN S replied it was because all the treatments were related to the same infection. When asked what the Onset Set meant on the line listing, LPN S replied it was the dates of treatment. LPN S was asked if all the antimicrobial medications were started on 10/9/24 and stopped on 10/22/24 and revealed they would need to review the Resident's medical record to answer. LPN S proceeded to review Resident #29's medical record and stated, Keflex from 10/9 to 10/16, Bactrim from 10/14 to 10/21, and Diflucan from 10/16 to 10/24. When asked what 10/22 meant under the onset column as none of the medications were started and/or discontinued on that date, a response was not provided. When queried what date the Resident began to display signs/symptoms of infection, LPN S revealed they would need to review the Resident's medical record as they tract the dates of antimicrobial treatment and not the date that the signs and symptoms of infection began. When queried why the Resident was started on a second antibiotic, Bactrim, on 10/14/24, LPN S indicated it was due to culture results. Resident #29's culture results were reviewed at this time. The culture results were dated as obtained on 10/9/24 at 2:00 AM, received on 10/10/24 at 11:50 AM, and reported on 10/14/24 at 9:10 AM. The culture showed Isolate One - Staphylococcus aureus (bacteria which commonly causes skin and soft tissue infections), Isolate Two - Proteus mirabilis (bacteria normally found in the gut and commonly responsible for complicated Urinary Tract Infections), Isolate Three -Yeast (fungus), and Isolate 4 - Enterococcus faecalis (bacteria normally found in the gut and eliminated in stool). Keflex was not listed on the culture and sensitivity results. The culture and sensitivity showed Isolate One - Staphylococcus aureus was sensitive to Bactrim but Isolate Two - Proteus mirabilis was resistant to Bactrim. Bactrim is not effective in treating Isolate 4 - Enterococcus faecalis. When queried why Keflex was continued when other antibiotics were identified on the culture and sensitivity as being sensitive to the organisms, LPN S replied, I guess the doctor wanted them to finish the course. LPN S was asked if they had discussed the antibiotic treatment with the physician related to rationale for continuing and indicated they would need to review the notes in the medical record. When asked why Diflucan was not started until 10/16/24, when the culture results were back on 10/14/24, LPN S was unable to provide an explanation. A review of the provided monthly summary form titled, Infection Control Summary/Analysis QAPI October 2024 revealed the form did not provide any additional data related to the onset of Resident #29's skin infection nor did it address antimicrobial treatments. The summary form did not address surveillance for potential infections and/or infections which did not receive antimicrobial treatment. The Summary did not address carry over infections and/or treatment in relation to surveillance and monitoring for prevention of spread. Review of facility provided policy/procedure entitled, Infection Prevention and Control Plan (Updated: March 2024) revealed, It is the policy of this facility to implement the Infection Prevention and Control Program utilizing a systematic, coordinated and continuous approach guided by OSHA regulations, and pertinent state, federal and local regulations pertaining to infection control. Purpose: The prevention and control program is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 2. Surveillance includes HAI's among staff and residents. Infections are monitored when a treatment plan is ordered by a Health Care Practitioner. a. Continuously collect and screen data to identify potential outbreaks . d. The Infection Prevention Manager assumes direct accountability for the surveillance, aggregation and analysis of the data . f. Provide documentation in accordance with Antibiotic Stewardship policies . 4. Monitoring and evaluation of key performance aspects of infection control through preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents .

Based on observation, interview, and record review, the facility failed to implement and operationalize a comprehensive Restorative Nursing Program (RNP) for two residents (Resident #15 and Resident #30) of three residents reviewed, resulting in a lack of communication and implementation of planned RNP per Therapy recommendations, Resident #15's verbalization of increased pain and decreased Range of Motion (ROM), and Resident #30 developing a contracture (permanent tightening of muscles, tendons, skin, and tissues causing stiff and immobile joints), and the potential for further functional decline, diminished mobility, and unnecessary, increased pain. Findings include: Resident #15: On 11/18/24 at 1:12 PM, Resident #15 was observed sitting in a wheelchair in their room. A walker was observed in the room. An interview was completed at this time. When queried regarding the walker in their room, Resident #15 verbalized they use the walker to go to the bathroom but revealed they are only able to walk when staff are with them and usually use the wheelchair. Resident #15 was asked if they were receiving Therapy services and indicated they were but had been discharged . When asked if they were receiving Restorative Nursing Services, Resident #15 stated, No. Resident #15 was then asked if they have any pain or limited ROM and stated, I can't use my right arm. The pain is getting worse. When asked if they had hurt their arm, Resident #15 revealed they thought it was from Arthritis. Resident #15 then stated, I can't cut anything with it. When asked what they meant, Resident #15 revealed they were having trouble cutting up their food due to the increasing pain in their right arm. When asked if that was new for them, Resident #15 revealed it was getting worse. Resident #15 also stated, I have quite a bit of pain in my legs. When queried if they were receiving medication to help with their pain, Resident #15 revealed they were taking something when they were getting therapy but did not believe they were getting anything now. When queried if they had informed nursing staff about their increased pain and difficulty using their right arm, Resident #15 verbalized they had. Record Review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included heart disease, depression, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to moderate assistance for toileting, bathing, and dressing. The MDS further detailed the Resident had one-sided upper extremity impaired Range of Motion (ROM). Review of Resident #15's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #15) has altered functional mobility and ADL's (Activities of Daily Living) related to: weakness . has a history of falls . has dizziness and Vertigo (Initiated: 10/12/19; Revised: 9/28/21). The care plan included the interventions: - Ambulation: One Assist FWW (Four Wheeled Walker) (Initiated: 10/12/19; Revised: 7/26/24) - Eating: Provide set up assist as desired . is right hand dominant, however due to limited ROM in right shoulder . uses left hand to feed self (Initiated: 10/12/19; Revised: 1/8/21) - ROM: Independent, Impaired ROM to right shoulder due to Arthritis (Initiated: 10/12/19; Revised: 1/8/21) - Transfer: One Assist (Initiated: 10/12/19) An interview was completed with Certified Nursing Assistant (CNA's) A on 11/20/24 at 2:48 PM. When queried regarding the facility RNP, CNA's A revealed that floor CNA's staff complete Restorative Nursing tasks that are ordered and show on the task section of the EMR. CNA's A was then asked if Resident #15 was receiving Restorative Nursing Services and responded they were not. When queried if the Resident had any ROM limitations, CNA's A stated, Can't pull up their pants and has trouble with bra. With further inquiry, CNA's A revealed the reason Resident #15 had difficulty pulling up their pants and with their bra was because they had difficulty moving their arm. On 11/21/24 at 8:46 AM, an interview was conducted with Physical Therapist (PT) B and Occupational Therapist (OT) C. When queried if Resident #15 was receiving Therapy Services, PT B and OT C revealed Resident #15 had been discharged on [DATE] from PT and OT. OT C was then asked about Resident #15's ROM and replied, Full range passively. When queried regarding the MDS assessment specifying the Resident had impaired one-sided, upper extremity ROM, OT C confirmed they did in their shoulder. When asked which shoulder had impaired ROM, OT C replied, Right. When asked why Resident #15 had been on Therapy Services, PT B and OT C both revealed the Resident had been picked up for Covid recovery. A copy of the Resident's OT and PT evaluation and discharge documentation was requested at this time. When queried regarding the facility RNP, both PT B and OT C revealed the facility did not have a designed RNP CNA's and that the residents assigned floor CNA's complete Restorative Nursing tasks. When asked if Resident #15 had been discharged to RNP following therapy discharge, PT B reviewed their documentation and stated, Did exercise class. PT B further revealed the Resident also walked to the bathroom with staff as part their RNP. When queried what the exercise class was, PT B replied, There is an exercise class at 10:00 (AM) almost every day. With further inquiry regarding the exercise class, PT B revealed the class was part of the facility Activities program. When queried regarding staff stating the Resident was unable to pull up their pants independently and Resident #15 stating they were no longer able to cut up their food and having increased pain, OT C stated, When I had (Resident #15) a month ago, they were able to pull up their pants so that could be new. OT C and PT B were asked if they were made aware of Resident #15's complaints and the change/decline by nursing staff and verbalized they were not. A review of Resident #15's Activity Task documentation for the prior 30 days revealed the Resident had completed Exercises two times on 11/16/24 and 11/19/24. Review of Resident #15's Physical Therapy Discharge Summary dated 10/21/24 revealed, Discharge Status and Recommendations . Prognosis to Maintain CLOF (Current Level of Functioning) = Good with consistent staff follow-through . RNP . Res. to ambulate with staff to bathroom as tolerated, attend exercise class . An interview was completed with Activity Director D on 11/21/24 at 9:56 AM. When queried if they were familiar with Resident #15, Activity Director D verbalized they were. When asked what the exercise class was, Activity Director D revealed exercises were offered as an activity. With further inquiry regarding what the exercise class included, Activity Director D revealed it was different activities games with balls. When queried where exercise activities are documented, Activity Director D verbalized they are all documented under Exercises in the task documentation. Resident #15's Activity Task Documentation was reviewed with Activity Director D at this time. When asked if Resident #15 had only attended exercises two times in the past 30 days, Activity Director D reviewed Resident's the documentation and confirmed. When asked if they were aware that Therapy Services recommended Resident #15 attend exercise class as part of their RNP, Activity Director D indicated they did not know that. Resident #15's Physical Therapy Discharge Summary dated 10/21/24 was reviewed with Activity Director D at this time. After reviewing the Resident's Therapy Discharge documentation, Activity Director D stated that was Not communicated with me. Activity Director D further revealed they would have implemented an individual one to one exercise program for Resident #15 if they would have been made aware of Therapy RNP recommendations. An interview was conducted with the Director of Nursing (DON) on 11/21/24 at 10:09 AM. Resident #15's Physical Therapy Discharge Summary dated 10/21/24 recommendations for RNP were reviewed with the DON at this time. The DON was informed of Resident #15's verbalization of difficulty completing ADL's due to limited ROM and pain, CNA's staff statements related to limited ROM, and Therapy staff statements related to being unaware of the Resident's difficulties as well as recent discharge and RNP recommendations. The DON was asked why the RNP recommendations from 10/21/24 were not implemented on the Resident's care plan, the DON did not provide an explanation. When queried if Activities Staff are included in communication pertaining to the RNP, the DON verbalized they were not. When queried regarding the Resident only attending exercises with Activities twice during the prior thirty-day period, the DON reviewed the documentation and confirmed. When asked why the RNP recommendations from Therapy were not communicated and implemented, the DON confirmed and verbalized understanding but did not provide further explanation. Resident #30: On 11/18/24 at 1:41 PM, an observation occurred of Resident #30 in their room. The room was dark with the lights off and the window blinds closed. The Resident was in bed, positioned on their back. The Resident's fingers were bent inward toward their palm and their right knee was observed to be bend. The Resident's left leg was unable to be visualized. Resident #30 had tube feeding infusing via pump and the head of their bed was elevated at a 30-degree angle. When spoke to and asked questions, Resident #30 made eye contact and responded with garbled, unintelligible verbalizations. Record review revealed Resident #30 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction (stroke) with left sided paralysis, dysphagia (difficulty swallowing), gastrostomy (surgically created opening through the abdomen into the stomach for the provision of nutrition), and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and was dependent upon staff for completion of all ADL's. The MDS further specified that Resident #30 had impaired Bilateral Upper Extremity (BUE) and Bilateral Lower Extremity (BLE) ROM. Review of Resident #30's EMR revealed a care plan entitled, (Resident #30) has the potential for altered functional mobility and ADL's . Dependent on staff . (Initiated: 3/9/22; Revised: 6/20/23). The care plan included the interventions: - Restorative: Bilateral lower extremity PROM (Passive Range of Motion), Bilateral hip, knees, and ankles. 10 reps x 2, in all planes of motion. PROM to bilateral upper extremities in all planes of motion. 10 reps x 2. 5-7 x week for length of stay. Impaired ROM to Right knee/leg (Initiated: 4/13/22; Revised: 12/14/22). - Palm guards to bilateral hands as tolerated . (Initiated: 3/9/22; Revised: 6/4/24) On 11/19/24 at 12:57 PM, Resident #30 was observed in their room. The Resident was in bed, positioned on their back. The Resident's right knee was bent. When queried if they were able to move their legs, Resident #30 responded verbally but the response was unintelligible. The Resident was asked to move their arms or legs if able and no movement was observed. The Resident did not have palm/hand protectors in place. An interview was completed with CNA's A on 11/20/24 at 2:48 PM. When queried regarding Resident #30, CNA's A revealed they were not the Resident's assigned CNA's and specified CNA's E was. CNA's A was asked if they were familiar with the Resident and/or if they had provided care to them and confirmed they had. When queried regarding Resident #30's ROM, CNA's A responded that Resident #30 had contractures. With further inquiry regarding the Resident's contractures, CNA's A revealed the Resident required total assistance and had ROM limitations in their upper and lower extremities. When asked if the Resident was receiving Restorative Nursing Services, CNA's A indicated they were. Review of Task documentation in Resident #30's EMR revealed, Task: Restorative-Other program/ ROM: Bilateral lower extremity PROM, Bilateral hip, knees, and ankles. 10 reps x 2, in all planes of motion. PROM to bilateral upper extremities in all planes of motion. 10 reps x 2. Daily and PRN (as needed) 5-7 x week for length of stay. Impaired ROM to Right knee/leg. A review of Resident #30's Documentation Survey Report for November 2024 in the EMR revealed the task was documented as being completed as ordered. CNA's E had documented completion of the Resident #30's Restorative Nursing Task during the month of November. An interview was completed with CNA's E on 11/20/24 at 3:08 PM. When queried if Resident #30 had contractures, CNA's E stated they did. CNA's E was asked where the Resident had contractures and replied, Left arm move a little bit. CNA's E then stated, When you touch (Resident #30), they don't like it. I think it hurts when you spread their legs. CNA's E was asked why they think it hurts Resident #30 to spread their legs and stated, (Resident #30) told me it hurts. CNA's E continued, (Resident #30) can't move their head up and down. When queried if they complete and document Restorative Nursing tasks for/with Resident #30, CNA's E verbalized Restorative tasks are part of their daily CNA's tasks. CNA's E was asked what they do for Resident #30's Restorative and replied, I do (Resident #30's) arms but I really don't do their legs because it hurts. When queried what they do when completing ROM for the Resident's upper extremities, CNA's E revealed they move their arms. When ask if they extend all joints in all planes of motion, CNA's E indicated they move the Resident's extremities when providing ADL care. CNA's E did not state they provide ROM for all joints in all planes of motion for a specific number of reputations. With further inquiry, CNA's E reiterated they do not complete ROM on the Resident's legs due to pain. When queried if they documented the task as completed in the EMR, even though ROM was not completed, CNA's E revealed they document the task as completed if they attempt to provide ROM. An interview was conducted with PT B and OT C on 11/21/24 at 9:00 AM. When queried regarding Resident #30, PT B revealed the Resident was last seen by Physical therapy in April 2022 and by Occupational Therapy in November 2023. When queried regarding a RNP, OT C stated, (Resident #30) is on a Restorative program for ROM. With further inquiry regarding the RNP, OT C revealed the OT Discharge (dated 11/14/23) specified, PROM BUE times all planes of movement and Bilateral palm protectors daily. When queried regarding the Resident's LE's, PT B reviewed the Physical Therapy Discharge documentation (dated 4/12/22) and indicated a referral for a RNP to include BLE ROM was initiated at that time. When queried if Resident #30 had any contractures when last seen by Therapy services, both PT B and OT C verbalized the Resident did not have any contractures when last seen/evaluated by therapy. When queried if they had been made aware of staff not being able to complete ROM on the Resident's LE's due to pain, both PT B and OT C verbalized they were not notified of any changes in ROM and/or increased pain with movement by nursing staff. When asked if the Resident should have bilateral palm protectors in place, both Therapy Staff indicated they should. When asked why the Resident had not had palm protectors in place at any observation, PT B and OT C were unable to provide an explanation. With further inquiry regarding Resident #30's current level of functioning and ROM, PT B and OT C indicated they would assess Resident #30. Resident #30's current joint ROM measurements as well as their most recent OT and PT evaluation and discharge documentation was requested at this time. Review of Resident #30's most recent Therapy Documentation revealed the following: - PT Evaluation and Plan of Treatment . Certification Period 3/11/22 - 6/6/22 revealed, Current Referral . referred to PT due to new onset of decrease in transfers . Measurements . RLE ROM = WFL (PROM). LLE ROM = WFL . RUE ROM = WFL (PROM). LUE ROM = WFL . Joints: Right Hip = WFL (PROM); Knee - WFL; Ankle = WFL, Ankle = WFL . Interventions Provided . ankle pumps and straight leg raises and knee extension in supine (laying on back) - AAROM (Active Assist Range of Motion) . - PT Discharge Summary dated 4/12/22 revealed, Prognosis to Maintain CLOF = Excellent with consistent staff support . RNP . Restorative program for BLE ROM, contracture prevention . - OT Evaluation and Plan of Treatment . Certification Period 10/10/23-11/28/23 revealed, Current Referral . referred for OT evaluation due to . declines with ROM specifically hand ROM with possible need for palm protectors . new onset of decrease in range of motion placing patient at risk for contractures and decreased skin integrity . Measurements . RUE ROM = Impaired (MCP [Metacarpal joint- finger joint] -30 degrees of extension)' LUE ROM = impaired (MCP joints -30 degrees of extension) . RLE ROM = WFL (Within Function Limits); LLE WFL . Shoulder = WFL; Elbow/Forearm = WFL; Wrist = WFL; Shoulder = WFL; Elbow/Forearm = WFL; Wrist = WFL . - OT Discharge Summary dated 11/14/23 revealed, Discharge: 0 degrees of B MCP joint extension . Skill: Interventions Provided . PROM to B (bilateral) hand X all joints with prolonged stretch for improved ROM to prevent contracture and prevent pain . tolerating bilateral palm protectors . Discharge Status and Recommendations . Prognosis to Maintain CLOF = Excellent with consistent staff support . RNP . PROM performed for BUE X all planes of movement and resident to wear B (bilateral) palm protectors daily . On 11/21/24 at 9:20 AM, Resident #30 was observed in their room in bed with their eyes open. The room lights were off, and the window shade was closed. Upon approaching the Resident, their face was noted to be shiny, and they were visibly sweating. The Resident was observed to be covered with multiple blankets. When asked how they were, Resident #30 loudly and clearly stated, I'm burning up. When queried if they had called for staff assistance, Resident #30 replied, Can't. With further observation, the Resident's call light was observed on the floor. At 9:25 AM on 11/21/24, CNA's H was observed in the hallway of the facility and asked to assist Resident #30. An observation of care was completed at this time. CNA's H confirmed Resident #30 was sweating and began to remove blankets and reposition the Resident. Upon removing the blankets, Resident #30's hands were observed to bend with their fingers inward towards their palms. The Resident's right knee was bent upward at a defined angle. When queried if Resident #30 was supposed to have palm protectors, CNA's H stated, I haven't seen any. As CNA's H attempted to move Resident #30's legs to reposition them, the Resident began to yell out. When asked why they were yelling, Resident #30 revealed moving their leg caused pain. An interview was completed with Registered Nurse (RN) M on 11/21/24 at 9:32 AM. When queried regarding Resident #30's pain, RN M indicated the Resident had a lot of pain and receives scheduled Norco (narcotic pain medication) twice a day as well as a topic medication for pain relief. When queried if the Resident has contractures, RN M replied, Yes. RN M was asked how long the contractures had been present and revealed the Resident had contractures for as long as they could remember. An interview was completed with the DON on 11/21/24 at 10:12 AM. When queried regarding Resident #30's ROM including the Resident not having palm protectors in place, staff verbalization of worsening ROM and pain and not completing ROM as indicated per the RNP task/plan but documenting as completed, the DON verbalized understanding of concern but did not provide further explanation. The DON was informed that Therapy Staff verbalized they would assess Resident #30 and would follow up. On 11/21/24 at 11:18 AM, an interview was completed with OT C. When queried regarding Resident #30, OT C revealed the Resident was assessed by therapy and ROM measurements were obtained. When queried, OT C revealed Resident #30 had a contracture in their right knee and also had a decrease in other ROM measurements. The measurements were reviewed with OT C at this time. OT C verbalized Resident #30's right shoulder ROM was 0-110 degrees and their left shoulder ROM was 0-120 degrees. OT C revealed the Resident's other UE ROM measurements were WFL passively. When queried regarding the Resident's BLE ROM, OT C stated, Ankles are plantar flexed (toes pointed downward away from the head) and their right knee is 80-140 degrees with contracture. OT C verbalized Resident #30's right hip external rotation was midline, and their right hip flexion was 80 degrees. When asked about the Resident's left knee, OT C stated the Resident would not allow them to assess it. OT C was asked to clarify if they were saying the Resident developed a right knee contracture and other declines in ROM at the facility, OT C confirmed. When queried why Therapy had not been informed of the Resident's decline in ROM by nursing staff prior to contracture development, OT C was unable to provide an explanation. A follow up interview was completed with the DON on 11/21/24 at 1:09 PM. When queried regarding Resident #30's ROM measurements including decline in ROM and contracture development. The DON validated concern but did not provide further explanation. Review of facility policy/procedure entitled, Restorative Nursing Program (Revised: November 2021) revealed, It is the policy of this facility to evaluate residents on an individual basis for inclusion in a restorative program to assist the resident to attain or maintain their highest possible functional level . Procedure: 1. A restorative program may be established with any of the following: a. As a continuation of therapeutic programs by a Certified Nursing Assistant following rehabilitation . b. By the clinical manager to evaluate a resident through a restorative maintenance program to ensure the resident has maintained their highest functional level . 5. The restorative program will be assessed periodically with changes or discontinuation.

Based on observation, interview and record review, the facility failed to ensure dignified Activities of Daily Living (ADL) care for one resident (Resident #6) of 3 residents reviewed for ADL care, resulting in soiled clothing, bedding and bathroom. Findings include: Resident #6: On 11/18/24, at 1:31 PM, Resident #6's doorway was shut. There was a strong urine/bowel odor noted in the hallway outside the closed door. Upon entry to the room, the odor was noted to stronger. CNA's F entered and was asked if the bedding had been changed recently and CNA's F pulled back the sheets. The mattress was in good clean repair. An observation of the bathroom revealed a large amount of bowel movement on the toilet seat. Resident #6 was not in their room. Resident #6's roommate (husband) entered the room to use the toilet and quickly left back out. CNA's F was asked if the bathroom should be dirty with bowel movement and CNA's F offered, it's usually (Resident #6) and we try to catch (Resident #6) after lunch and that they are ambulatory. On 11/18/24, at 2:30 PM, Resident #6 was ambulating in the hallway. There was an approximate 5 inch wide by 6 inch long area that was dirty with a brown residue on the backside near their bottom. On 11/19/24, at 7:59 AM, Resident #6 was sitting in the dining room for breakfast. Resident #6 had on the same clothes as the day prior. On 11/19/24, at 8:51 AM, Resident #6 was noted wandering into another resident room. They lied down on the bed on their side. Resident #6's shirt was rolled up slightly which revealed a solid brown residue noted that appeared like bowel movement. On 11/19/24, at 12:55 PM, Resident #6 was resting in their own bed with the same clothes on. There was a strong odor to the room. On 11/19/2024, at 1:15 PM, a record review of Resident #6's electronic medical record revealed an admission on 8/03/2022 with diagnoses that included Dementia, need for assistance with personal care and Alzheimer's disease. Resident #6 had severely impaired cognition. On 11/20/24, at 7:53 AM, Resident #6 was sitting in the dining room for breakfast. They had on new clean clothes and appeared to have showered as their hair was wet. On 11/20/24, at 7:54 AM, CNA's G was interviewed regarding the Activities of Daily Living (ADL) care for Resident #6. CNA's G offered at times they are resistant to changing their clothes but if you show Resident #6 the hair dryer and encourage hair care you can get (Resident #6) in the shower. On 11/20/24, at 11:57 AM, Resident #6 was resting in bed with their dirty clothes on. The resident had their shoes on and was under the covers. On 11/20/24, at 12:36 PM, the Director of Nursing (DON) was interviewed regarding the Resident #6 soiled clothing. The DON offered, that the resident can be difficult with ADL care at times. The DON was alerted of the soiled clothing the resident had on for the two days prior and that it appeared like bowel movement. The DON offered, that they did observe their dirty shirt but was unable to tuck it in. The DON was asked if they felt they were doing everything they could to assist Resident #6 with their ADL care and the DON offered, we try and if you offer hair care or have the dryer in your hand, you can usually get her in the shower. The DON offered that they had moved Resident #6's shower days to ensure the same staff to assist. A review of the Task list documentation for completed showers along with the DON revealed no missed recent showers. On 11/20/24, at 3:06 PM, the DON offered that they had Interdisciplinary Team meeting regarding Resident #6 and that they updated the care plan. On 11/21/24, at 9:00 AM, a review of the Focus (Resident #6) has the potential for altered functional mobility and ADL's related to her impaired cognition with a supporting diagnoses of Dementia . Revision on: 06/20/2023 Goal Provide oversight with dressing in clean clothes daily, assist with bathing, nurse to assist with medication set up . Interventions . Able to leave on toilet: Yes Date Initiated: 08/04/2022 ADL's DEFINE INDIVIDUAL PREFERENCES: Chooses her own clothing; prefers medications whole. Wanders throughout the facility and prefers her husband to be with here. Doorway deterrent strap across doorway intermittently as desired, to deter guests until invited. Check and change bedding daily as needed. Date Initiated: 06/20/2023 Revision on: 11/20/2024 ADL'S: Staff to anticipate needs and give physical and verbal cueing for tasks Date Initiated: 06/20/2023 . BATHING: One person assist with bathing, encouraging the resident to do as much for self as able. (Resident #6) is more accepting of bathing when (husband/roommate) is present. (Resident #6) likes the warmth of the blow dryer and she may accept a shower if she feels the warm air of the blow dryer. Date Initiated: 08/04/2022 Revision on: 11/20/2024 . COMMUNICATION ABILITY: Alert to person only . DRESSING: One assist with cueing and encourage to do as much for self as able. (Resident #6) will refuse assistance with dressing most days, frequent reproach may be necessary. If (husband/roommate) is out of sight then she may accept assistance with dressing. If she is in the restroom already she is more accepting of changing clothes and washing up. May offer a hair brush as she enjoys brushing her hair. Date Initiated: 08/04/2022 Revision on: 11/20/2024 . ELIMINATION: Independent with toilet use, staff is encouraged to assist with toileting before and after meals, HS and prn. Wears incontinence products. Check and assist (Resident #6) every shift for cleanliness and assist with peri care. Date Initiated: 06/20/2023 Revision on: 11/20/2024 . PSYCHOSOCIAL: (Resident #6) is alert, only to self and her husband . She has poor short and long term memory recall . Document behaviors in the log . On 11/21/24, at 10:09 AM, there was a strong odor of bowel movement in the hallway outside Resident #6's room. Upon entry, CNA's H was noted to be offering a change of clothes. There was a bottle of bleach wipes on the over bed table. CNA's H offered, that they had to clean the bathroom due to bowel movement all over the toilet. CNA's H offered socks and then began to put on Resident #6's tennis shoes and stopped. CNA's H cleaned bowel movement off the shoes prior to putting on the shoes. Resident #6 appeared calm and repeated, oh no over and over when CNA's H was cleaning off the bowel movement from their shoes. On 11/21/24, at 1:36 PM, CNA's H was interviewed regarding Resident #6's ADL needs and care. CNA's H offered they work with Resident #6 about once a week. CNA's H was asked why they had changed Resident #6's clothes and CNA's H offered, that (Resident #6) had soiled themselves pretty bad. They had bowel movement all over their pants, a little on their shirt and all over their socks and shoes. CNA's H was asked what the bleach wipes were used for and CNA's H offered, they used them to clean the toilet and also offered, you could see where (Resident #6) had tried to clean the bowel movement off the toilet with toilet paper. CNA's H was asked why they thought that and CNA's H stated, there was a pile of toilet paper in the trash with a large amount of bowel movement and the toilet seat had appeared to be wiped off despite the remaining bowel movement. CNA's H was asked why the bedding was removed off the bed and CNA's H offered, there was BM on the bedding/sheets. CNA's H offered they bleach wiped the bed and areas that had BM on it. CNA's H was asked how they were alerted that Resident #6 required ADL assistance and CNA's H offered, that when they were in the hallway you could smell it referring to the BM smell. CNA's H offered that Resident #6 can be difficult at times but if you catch (Resident #6) right after they eat you can usually prevent the mess. According to the HCAM Resident rights booklet, . Respect and Dignity You have a right to be treated with respect and dignity, including: . The right to reside and receive services in the facility with reasonable accommodation of your needs and preferences .

Based on interview and record review, the facility failed to respond to residents' needs timely and in a dignified manner for an anonymous group of residents, resulting in feelings of having to wait, needing to engage call lights over again to get help and call light complaints going unresolved by management. Findings include: On 11/19/24, at 10:35 AM, During the Resident Council task, the following complaints were voiced regarding staff answering call lights: They turn them off and you have to wait for them to come back My call light was on 20 minutes when they canceled it and then I it was 25 more minutes for them to come back and I had to put my light on again. If they don't come back in 10 minutes after canceling my light, I put it back on. Sometimes, they completely forget about you. They will say, I had another call light to answer first some CNA's are hard on ya; they might complain when I have to get up to go the bathroom with me, I need a Hoyer and they need two people. It's hard sometimes to get that second person. In the meantime, I am waiting with the Hoyer connected Resident Council group was asked what management has done to fix the call light response complaints. Resident council group complained that they were told to put their call light back on if staff doesn't come back in ten minutes. Resident council group also stated that management will often respond to the call light complaints we're working on it. Council members offered that they felt they didn't matter. On 11/19/2024, at 1:30 PM, Recreation Director D was asked to provide the last 6 months of resident council meeting minutes and Recreation Director D offered, that they had provided the copies to the administrator for uploading. The council meeting minutes were not provided prior to exiting the survey. According to the HCAM Resident rights booklet, . Respect and Dignity You have a right to be treated with respect and dignity, including: . The right to reside and receive services in the facility with reasonable accommodation of your needs and preferences .

Based on observation, interview and record review, the facility failed to ensure a thyroid hormone medication was given appropriately for one resident (Resident #14) of five residents reviewed for unnecessary medications, resulting in abnormal lab values and complaints of signs and symptoms of hypothyroidism. Findings include: Resident #14: On 11/19/24, at 12:57 PM, Resident #14 was resting in bed eating their lunch. Resident #14 was unsure if they were getting out of bed as they complained of feeling tired that day. On 11/19/24, at 2:23 PM, Resident #14 was resting in bed. They complained of feeling constipated at times, felt tired and wanted to stay in bed. On 11/20/24, at 7:49 AM, The Director of Nursing (DON) was alerted that the resident complained of constipation at times and didn't want to get out of bed as they felt tired in the middle of the day. The DON offered that Resident #14 started a new medication to aide in appetite. The (DON) was asked why Resident #14 was taking their thyroid hormone replacement medication with other medications and the DON offered, that they would look into it. The DON was asked to provide a detailed medication administration record for the prior week for the resident. On 11/21/24, at 9:30 AM, a record review of Resident #14's electronic medical record revealed an admission on 3/15/2024 with diagnoses that included Hypothyroidism, Dementia and Mood Disturbance. Resident #14 required assistance with Activities of Daily Living. A review of the Physician orders revealed the following: Levothyroxine Sodium 25 MCG Start Date 6/19/2024 20:00 End Date 10/15/2025 . an increase in the dosage was noted as follows: Levothyroxine . 50 MCG . Start Date 10/16/2024 06:00 Revision Date 11/20/2024 . Despite the ordered 6:00 AM administration time the resident had been receiving it in the evening. The following medications were ordered to be given at 8:00 PM: Rexult, Mirtazapine, Acetaminophen, Tamsulosin, and Atorvastatin Calcium On 11/21/24, at 10:52 AM, The DON was reminded of the need to review the detailed medication administration record for Resident #14's medications and was asked why they were taking the levothyroxine with other medications. The DON responded, oh at 8 PM. The DON offered, that they had talked to the nurse that changed the time. A record review of the Medication Admin Audit Report Schedule Date: 11/13/2024-11/20/2024 revealed the resident received their levothyroxine medication along with other medications within 10 minutes and/or routinely at the same time. For the dates of . 11/19/24 21:23 11/18/24 22:14 11/17/24 20:50 11/16/24 20:57 11/15/24 19:51 (the other medications were given 10 minutes later) 11/14/24 21:48 the resident also received their evening snack about the same time. A review of the snack intake for the previous week revealed that Resident #14 received and accepted their snack every night at 21:59. According to American Thyroid Association.com, Thyroid hormone stays in your system for a long time, it is taken once a day, and this results in very stable levels of thyroid hormone in the bloodstream. When thyroid hormone is used to treat hypothyroidism, the goal of treatment is to keep thyroid function within the same range as a person without thyroid problems. This is done by keeping the TSH level in the normal range. The best time to take thyroid hormone is typically first thing in the morning on an empty stomach. This is because food in the stomach can affect the absorption of thyroid hormone. If you are taking several other medications, you should discuss the timing of your thyroid hormone dose with your physician. Taking other medications can sometimes cause people to need an adjustment of their thyroid hormone dose. Other medications and supplements can prevent the absorption of the full dose of thyroid hormone. These include iron, calcium, soy, certain antacids and some cholesterol lowering medications .

Based on observation, interview and record review, the facility failed to provide supervision to prevent falls and implement meaningful interventions for three residents (Residents #16, Resident #36, Resident #46), resulting in injuries, pain, and hospitalization . Findings include: Record review of the facility 'Accident/Incident Report Fall management' policy, dated 6/2018, revealed the purpose was to establish a standard of accident/incident completion and to evaluate the facility responsibility to make every effort to decrease the likelihood of a recurrence by investigating incidents, understand how they occur and applying appropriate action. Record review of the facility provided form CMS-802 MDS Resident Matrix, dated 11/28/2023, revealed a census of 47. Record review of the category 'Fall (F), Fall with injury (FI) or Fall with Major injury (FMI) noted 18 residents had sustained falls while residing at the facility. That is a 38% fall rate for residents residing in the facility. Resident #16: Record review of Resident #16's Quarterly Minimum Data Set (MDS), dated [DATE], revealed an elderly female with Brief Interview of Mental Status (BIMS) score of 3 out of 15 severe cognitive impairment. Medical diagnoses included: Stroke, heart failure, hypertension, other fracture, non-Alzheimer's dementia, wedge compression of vertebra, spinal stenosis, and difficulty walking. Record review of Resident #16's fall accident/incident reports revealed: History of fall on 7/22/2023 with no injury. Incident/accident report dated 11/11/2023 at 4:12 PM revealed that Resident #16 was found lying on the floor in her room. Resident was noted to complain of pain in her right upper thigh. Record review of the 'Neurological Assessment' form dated 11/11/23 starting at 12:40 PM (4 hours earlier than the incident report noted) the resident was noted to have pain. An interview and record review on 11/30/2023 at 12:40 PM with the Director of Nursing (DON) revealed that Resident #16 did fall on 11/11/23 in her room unsupervised/unwitnessed and was found on the floor. Record review of Resident #16's fall assessment form, dated 11/11/23 at 1:45 PM, noted no assessment summary note. Record review of Resident #16's progress notes from 11/10/23 noted low blood pressure and that blood pressure medications were held for 5 days. Progress notes on 11/11/2023 through 11/12/2023 made no mention of Resident #16 having sustained a fall, no physical assessment of range of motion. Progress notes did note that Resident #16 did receive pain medications for reported pain. Record review of Resident #16's 'Neurological Assessment' form, dated 11/11/23 at 12:40 PM, noted pain. Resident #16 was noted on the form to have positive pain on 11/11/23 and on 11/12/23 until sent out to the hospital. Record review of Resident #16's Incident report, dated 11/11/2023 at 16:12 PM, revealed that the resident was assessed to have no bruising or open areas and with no pain. A few minutes after the assessment, the nurse was called back into the resident's room because Resident #16 complained of right upper thigh pain. Record review of Resident 316's in-house X-ray report, dated 11/12/2023, of the right hip with pelvis and right femur were performed with no evidence of fracture. Resident #16 continued to complain of and was eventually, 24 hours later, was sent to the hospital and diagnosed with an acute fracture of the pelvis. In an observation on 11/30/23 at 11:59 AM, a State Surveyor heard Resident #16 yelling help, help from front hall and walked towards room of Resident #16. Resident #16 was sitting on side of bed with feet on floor mat hollering out I got go to the bathroom. There was no staff in hallway. The Social worker was sitting at the nursing desk and stood up and looked at the surveyor. The State Surveyor alerted the social worker that Resident #16 was crawling out of bed. The Social worker went to the dining room and two Certified Nurse Assistants (CNA's) approached Resident #16's room in non-hurried manner with resident noted to be still yelling help, help. As the two CNA's closed the door to care for the resident surveyor overheard [NAME], you've already been to the bathroom twice. In an interview on 11/30/23 at 12:21 PM, Certified Nurse Assistant (CNA) L was asked if Resident #16 understands, and CNA L responded that no you have to repeat yourself and no she doesn't understand. In an interview Certified Nurse Assistant (CNA) M was asked if Resident #16 understands and responded that no she (Resident #16) does not understand. The State Surveyor asked CNA M if she stated to the Resident #16 You just went to the bathroom twice, and CNA M stated that yes that was her. The State Surveyor clarified if resident understands, and CNA M acknowledged that no that's why she (CNA M) said that to try and remind her (Resident #16) because she had just used the bedpan twice. The State Surveyor asked CNA M if they normally hurry when a resident is yelling out and CNA M revealed that Resident #16 does that (yelling out) about 6 to 10 times a day and cannot get up because she needs the mechanical lift to get up. Resident #36: Record review of Resident #36's quarterly Minimum Data Set (MDS), dated [DATE], revealed an elderly male with severely impaired cognitive skills. Medical diagnoses included: stoke, hypertension, aphasia, cerebrovascular accident, hemiplegia, depression, and respiratory failure. Section GG functional abilities: roll left and right with substantial/maximal assistance. Record review of Resident #36's 'Fall Risk Assessment', dated 10/6/2023 revealed that the resident was confined to a chair. Summary noted that Resident #36 had a fall when he was rolling during bed mobility with staff. Record review on 11/29/23 at 11:24 AM of Resident #36's accident report, dated 10/6/2023 at 1:52 AM, revealed that the CNA rolled the resident to the edge of the bed and the resident pulled his arm out from under himself and the CNA stepped back wards and the resident was rolled to the floor. Record review of Resident #36's care plans, pages 1-18,, noted altered functional mobility due to stroke, stiff joints, bedfast. Record review of the Falls care play, revision date 3/9/2023, revealed Resident #36 to be at risk for falls related to weakness, stroke, impaired vision, and cognitive impairment. There were no new care plan. Interventions implemented related to the 10/6/2023 fall. An interview on 11/30/23 at 10:32 AM with the Director of Nursing (DON) revealed that Resident #36 was turned in bed by one Certified Nurse Assistant (CNA) who rolled him to close to the edge of the bed and the resident fell to the floor. The CNA was educated to follow the care plan of two staff to assist the resident. 39059 Resident #46: On 11/28/23, at 9:51 AM, Resident #46 was in their bathroom. Resident #46 ambulated with a two wheeled walker towards their chair. Resident #46 moved their walker to a sideways position next to their chair and then shuffle stepped in between their walker legs and over bed table wheels. There was about a foot of floor space available. CNA T entered the room and assisted the resident to a seated position in their chair. CNA T stated to the resident oh, you need to use your call light. The soft touch call light was sitting on the bed. On 11/28/23, at 12:55 PM, a record review of Resident #46's electronic medical record revealed an admission on 7/14/2023 with diagnoses that included stroke and atrial fibrillation. A review of the care plan revealed R#46 required one person assist with a two wheeled walker to ambulate and transfer. A review of the Interdisciplinary notes (IDT) revealed the following: 11/18/2023 15:25 . Observed resident on floor on back in her bathroom . Reminded resident to use call light for assistance r/t (related to) safety. 11/18/2023 15:36 . Placed soft touch call light in place of original call light to encourage easier use of call light. Care plan updated and new copy in room. Re-educated on use of call light r/t safety. Nodded her head in agreement and smiled. On 11/30/23, at 10:58 AM, the Director of Nursing (DON) was alerted that Resident #46 was observed ambulating from bathroom in their room unassisted and the DON stated, OK.

Based on observation, interview and record review, the facility failed to prevent, assess and document the re-occurrence of a Stage III pressure ulcer for one resident (Resident #13). Findings include: Record review of the facility 'Skin at Risk Assessment, Documentation, Staging & Treatment' policy dated 1/2020, revealed it is the policy of the facility to assess resident risk factors for the development of impaired skin integrity and intervene as indicated utilizing the admission assessment, plan of care, and Minimum Data Set as formal assessment tools. It was the policy of the facility to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred. Weekly measurements are conducted on existing pressure injuries. The purpose is to provide prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors and to limit the development of avoidable pressure ulcers and provide evidence-based guidance on effective strategies to promote pressure ulcer healing. A pressure injury (ulcer) is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or as an open ulcer and may be painful. The injury occurs as a result of intense/prolonged pressure or pressure in combination of shear. Stage III: Full-thickness loss of skin, subcutaneous fat maybe visible but bone, tendon or muscle is not exposed. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. Record review of the facility Center of Medicare Service (CMS) form 672, dated 3/9/2020, revealed that there were no residents with pressure ulcers residing within the facility. Record review of the facility Matrix, printed on 3/9/2020, revealed that there were no residents identified as having any pressure ulcers. Resident #13: Record review of Resident #13's Minimum Data Set (MDS), dated [DATE], revealed an elderly female with Brief Interview of Mental Status (BIMS) score of 7 out of 15, cognitive impairment noted with no behaviors. Medical [DIAGNOSES REDACTED]. Section H: Bladder and Bowel- frequently incontinent of bladder and bowel. Section M: Skin conditions- noted no pressure ulcers/injuries. In an observation on 3/9/20 at approximately 9:13 AM, Resident #13 was lying in bed at a 45-degree angle with the bedside tray table with breakfast tray. Resident #13 was flat on her bottom and complained that it was uncomfortable to sit. In an observation on 3/10/20 at approximately 10:00 AM, Resident #13 was seated up in a brown cloth textured recliner with her legs elevated and the chair reclined. There was a slip of red dycem (anti-slip material) noted to the bottom of the chair. There was no further cushion other than the recliner seat. In an observation on 3/11/20 at approximately 8:30 AM, Resident #13 was seated up in the brown recliner with her legs elevated on the chair footrest. The state surveyor notified the Certified Nurse Assistant (CNA) W that observations of transfers and skin check needed to be reviewed. An observation was made on 03/11/20 at 9:30 AM in Resident #13's room with Certified Nurse Assistant (CNA) W. CNA W assisted the resident from recliner to use a walker to go to the bathroom. There was a thin piece of red dycem anti-slip material noted in the seat of the chair. CNA W assisted Resident #13 with ambulation with oxygen hose to the restroom and removed the brief which was wet. Resident #13 had an old dressing that came off in the process. CNA W was able to show the state surveyor the open wound that was located at the top of the buttock creases/coccyx region. Observation of the coccyx region noted an open wound with depth. CNA W notified the Registered Nurse (RN) A. An observation was made on 3/11/20 at approximately 9:35 AM with registered Nurse (RN) A. RN A gathered dressing supplies of skin prep, sterile saline wipe and a silicone 4 x 4 foam border dressing. RN A washed her hands and then came into the restroom to apply the dressing. The state surveyor had measurements taken of the wound. The wound measured 0.8 cm in length X 0.6 cm in width X 0.3 cm in depth. While in the restroom the hospice services Licensed Practical Nurse (LPN) X also observed the opened coccyx area. CNA W performed a wipe of the peri area twice and pulled up the brief. Resident #13 was assisted to back to the recliner. A record review of Resident #13's 'Short term Care Plan Wound & Skin' care plan, dated 1/9/20, revealed Stage III coccyx, excoriation right inner buttock fold. A record review of a second 'Short term Care Plan Wound & Skin' care plan, dated 3/2/20, for the same location on the body revealed that there was no further documentation of the pressure ulcer reopening. A record review of Resident #13's 'Wound tracking' documentation in Point Click Care revealed that the Director of Nursing stopped monitoring the wound area on 3/3/2020. In an interview on 03/11/20 at 10:55 AM, Registered Nurse (RN) A revealed that, in the resident's medical record, there was no documentation of an open area to coccyx after 3/3/20. RN A stated that the Director of Nursing is the wound care nurse and she does wound measurements once a week. There was not a short-term care plan found for the re-opening of the coccyx wound, which was dated after 2/11/2020. In an interview on 03/11/20 at approximately 11:34 AM, Registered Nurse (RN) K (Minimum Data Set (MDS) assessment nurse) stated that she was not aware of Resident #13 having an opened pressure ulcer. RN K stated that she had just been told about it 10 minutes ago, before speaking to the state surveyor. RN K stated that the nurses are able to update care plans and the Director of Nursing (DON) is the wound care nurse and she can also update care plans. RN K stated that she did review the wound tracker notes and there is nothing documented after 3/3/20. A record review of Resident #13's care plans, pages 1 through 17, revealed that the skin care plan stated that the pressure ulcers were unavoidable. Interventions addressed a cushion in the wheelchair, but there was no mention of a cushion or off loading/positional changes while in the recliner. Interventions were noted to perform skin inspections with AM/PM care and with showers. A record review of Resident #13's personal hygiene task report, dated 2/11/20 through 3/11/20, revealed that the resident received extensive assistance for the three days prior to the state surveyor's observation of the open wound area and there was no documentation of measurements or of notifying the physician of the re-occurrence of the Stage III pressure ulcer.

This Citation pertains to Intake Numbers MI 292 and MI 088. Based on interview and record review, the facility failed to 1) supervise 1 resident (Resident #196) who had a known history of agitating other residents with prior incidents of resident-to-resident altercations and 2) ensure the safety of 1 resident (Resident #148) who fell and acquired a fracture of 8 residents reviewed for supervision and safety, resulting in an altercation between 2 residents (Residents #196 and #41) and a fall with injury (Resident #148). Findings Include: Resident #41: Review of the Face Sheet, Minimum Data Set (MDS), resident assessment tool) dated 1/19/19, Nurses, Social Worker and Psychological Services notes dated 5/18 through 2/19, and care plans revealed that Resident #41 was 80-years-old, re-admitted to the facility on [DATE], was dependent on staff for Activities of Daily Living (ADL's) and was cognitively impaired with a BIMS of 3 (a cognitive assessment, score of 3 severely cognitively impaired). The residents [DIAGNOSES REDACTED]. Review of facility Potential for Psychosocial Distress care plan, dated 8/1/18, revealed Resident #41 had a history of [REDACTED]. physical aggression. Staff were to attempt to maintain a calm environment. This surveyor was unable to interview Resident #41 due to decreased cognitive status and no recall of the incident on 11/5/18. Resident #196: Review of the Face Sheet, Nurses, MDS- dated 4/18, Social Worker and Psychological Services notes dated 5/18 through 2/19, and care plans revealed Resident #196 was 81-years-old, admitted to the facility on [DATE], alert, had decreased mobility, received psychological services and was dependent on staff for assistance with ADL's. The residents [DIAGNOSES REDACTED]. Review of the facility Potential for psychosocial distress care plan, dated 2/25/19, revealed Resident #196 had depression and loss regarding her past roles and status of mobility. This surveyor was not able to interview Resident #196 during the survey. The resident had been discharged to the community. Review of the facility Incident report and Investigation (dated 11/5/18 & 11/8/18), revealed on 11/5/18 at 12:50 p.m., Resident #41 wheeled herself into the assist dining room and saw Resident #196 talking to a male resident. Resident #41 went up to Resident #196 and elbowed her in the face. Then Resident #196 swung and hit Resident #41 in the stomach. The investigation revealed there was no injury to either resident. The residents were separated by staff. The facility investigation said Resident #196 has no other allegation of abuse. During an interview done on 2/25/19 at 10:24 a.m., Nursing Assistant (CNA) J stated I remember I was standing by the window, I saw (Resident #41) walk in and she went up and all the sudden took her elbow and hit (Resident #196) in the head and then (Resident #196) hit her back in the stomach. She (Resident #196) sits mostly at the desk (nurses' station) so we can watch over her. On 2/25/19 at 2:05 p.m., this surveyor, the Administrator and Social Worker C reviewed Resident #196's closed record. Resident #196's history of resident-to-resident altercations found were as follows: -On 5/30/18, Resident #196 had an altercation with Resident #28. Per Social Worker C, there was an argument between the two residents and Resident #28 grabbed Resident #196's arm. No injuries were reported. Per Social Worker C, interventions done by the facility were, 15 minute checks on Resident #196, Social Worker C followed-up with the resident regarding the incident and to move Resident #196 to another room, away from resident #28's room. -On 7/7/18, Resident #196 had an altercation with Resident #11. Resident #196 grabbed Resident #11's shirt collar; no injuries were reported. Per Social Worker C, interventions done by the facility were, 15 minute checks on both residents, Social Worker C followed-up with Resident #196 and on 7/10/18, the facility started Resident #196 on [MEDICATION NAME] (antidepressant) and increased the dose on 7/18/18. Social Worker C stated, she (Resident #196) had verbal altercations with staff, family and other residents, that's why there was an increase in her [MEDICATION NAME]. -On 7/19/18, Resident #196 had an altercation with Resident #11 for the second time. Per Social Worker C, the residents both swung at each other with no injuries reported. Per Social Worker C, interventions done by the facility were, 15 minute checks on both residents, Social Worker C followed-up with resident #196 and for the second time, she was moved to another room, away from Resident #11's room. -On 10/7/18, Resident #196 had an altercation with Resident #6. Resident #196 was in her wheelchair, she asked Resident #6 to move and Resident #6 said no, so Resident #196 slapped Resident #6 on the thigh; no injuries were reported. Per Social Worker C, interventions done by the facility were, 15 minute checks on both residents and Social Worker followed-up with Resident #196 on 10/8/18, 10/17/18 and 10/18/18. During an interview done on 2/25/19 at 3:00 p.m., Social Worker C was asked by this surveyor if there had been a pattern regarding Resident #196's behaviors regarding other residents and lack of supervision. SW C stated, there's a pattern of behaviors. When this surveyor requested Social Service monthly summaries of behaviors, care plans that showed all interventions related to behaviors, a review of all aspects of the resident's behaviors as it relates to behavior management, Behavioral Team/Committee notes with recommendations and complete resident-to-resident interaction assessments regarding Resident #196's history of resident-to-resident behaviors, none were provided. Review of the facility Behavior Program, dated 8/2000, stated The Interdisciplinary team works together to identify and document target behaviors and to develop interventions and a Plan of Care so that the facility may provide continuity of care and an improved Quality of Life for resident under out care. Social Services: Completes monthly summary on behavior tracking logs. Develops care plans, incorporating recommendations made by the team and make appropriate referrals to Community Mental Health and other appropriate psychological services. Educate nursing home staff and families on problem behaviors and interventions. Provide and collect data forms and utilize this information to develop the plan.