Every finding on record at Kith Haven

This citation pertains to intake Number 3033712. Based on interview and record review, the facility failed to ensure that 3 residents (Resident #102, Resident #103 and Resident #104) had behavioral interventions and residents' responses to interventions documented for 3 residents reviewed for behaviors. Findings Include:Resident #102: Review of the Face Sheet, Nursing notes dated 7/26, and care plans dated 12/23, revealed Resident #102 was [AGE] years old, alert with confusion, admitted to the facility on [DATE], and dependent on staff for Activities of Daily Living (ADL). The residents diagnoses included stroke with hemiplegia and hemiparesis of the right side, anxiety, adjustment disorder, major depression, mild intellectual disabilities and Asperger's syndrome with behaviors. Review of the residents Behavioral care plan dated 12/29/23, stated Document behaviors, and (residents) response to interventions. During an interview done on 7/27/26 at 3:26 p.m., the Director of Nursing stated It (document behaviors, interventions and resident response to interventions) should be on the behavior symptoms task charting (in PCC-Point Click Care). Review of the resident's POC Response History documentation, dated 6/26, revealed only one behavior (resist care) on 7/4/26, and a review of the daily Behaviors PCC task charting, dated 6/26, revealed there were no behaviors all month. No documentation of interventions used regarding the behavior, nor the residents response to the intervention was found. Resident #103: Review of the Face Sheet, Nursing notes, dated 6/26 and care plans dated 5/26 to 6/26, revealed Resident #103 was [AGE] years old, alert and his own person, admitted to the facility on [DATE], and dependent on staff for ADL's. The resident's diagnoses included, diabetes, major depression, adjustment disorder with anxiety, seizures, abusive language, chronic lung disease and dependent on renal dialysis. Review of the resident's Behavioral care plan, dated 6/28/26, stated Document behaviors, and (the resident) response to interventions. Review of the resident's POC Response History documentation, dated 6/26, revealed no documentation at all of behaviors (on 6/12/26, the resident had documented behaviors in the nursing notes), no documented interventions and no resident response to the interventions. During an interview done on 7/27/26 at 11:50 a.m., Resident #103 acknowledged on 6/12/26, he was upset with a staff member because they hurt his leg. Resident #104: Review of the Face Sheet, Nursing notes, dated 7/26, and care plans, dated 11/24, revealed Resident #104 was [AGE] years old, had a guardian and was admitted to the facility on [DATE]. The resident's diagnoses included, colon cancer, psychotic disorder, anxiety, epilepsy, depression and Dementia. Review of the resident's behavioral care plan dated 11/4/24, stated attempt non-pharmacologic interventions, document behaviors, and (the resident) response to interventions. Review of the resident's Behavior sheet, dated 7/26, revealed behaviors and interventions that had been documented, however no documentation of residents response to interventions was found. During an interview done on 7/27/26 at 3:00 p.m., Social Worker C stated, They (staff) are supposed to document behaviors, behavior interventions and residents response. During an interview done on 7/27/26 at 3:40 p.m., the Administrator stated, There is an opportunity for improvement. Review of the facility Behavioral Management Program, dated 4/20/23, stated The facility staff will utilize tasks in PCC (Point Click Care) to document behaviors exhibited by the resident, including new, existing and escalating behaviors, as well as the effectiveness of interventions (frequency of the behavior exhibited, interventions, effectiveness of non-pharmacological interventions).

This Citation Pertains to Intake# 2985732Based on observation, interview and record review, the facility failed to protect the resident's (Resident #101) right to be free from abuse by Resident #102 of 3 residents reviewed for abuse, resulting in resident #101 needing hospital treatment for assault, facial contusion and closed head injury.Findings Include:Review of Resident #101's medical record revealed Resident #101 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: history of a stroke, Dementia, diabetes, history of seizures, cognitive communication deficit, anxiety, and hypertension. The MDS assessment dated [DATE] revealed the resident had moderate cognitive decline with a Brief Interview for Mental Status/BIMS score of 8/15 and needed some assistance with care.Review of Resident #102's Face sheet and MDS assessment revealed Resident #102 was initially admitted to the facility on [DATE] and had a most recent readmission on [DATE] with diagnoses: history of a gunshot wound to the back, paraplegia, history of traumatic brain injury, psychotic disorder with delusions and hallucinations, schizophrenia, depression, anxiety, adjustment disorder with mixed disturbance of emotions and conduct, history of alcohol abuse, frontotemporal neurocognitive disorder, dementia, colostomy and urinary retention. The MDS assessment dated [DATE] revealed the resident had full cognitive ability with a BIMS score of 15/15 and needed some assistance with care.A review of a Facility reported incident indicated on 3/24/2026 at approximately 11:00 AM, Certified Nursing Assistants/CNAs B and G entered the room of Residents #101 and #102 each noticed Resident #101 had blood on his face and his right eye and lip were swollen, he had bruises on his face and blood on his teeth. When CNA B asked Resident #101 what happened, he pointed to Resident #102 and said, He did it. We got in a fight.Review of the Facility reported incident investigation revealed that Nurse H said that CNA G came to the Nurses desk and said it looked like the residents had been fighting (Resident #101 and #102). When Nurse H entered the room, she asked Resident #101 if he was Ok and he said No that he wanted to go home. When she asked Resident #101 what happened he said he and his neighbor had a fight and he demonstrated how he put up his hands to try and keep Resident #102 off him. Nurse H said she assessed Resident #102 at that time, and he had no new wounds.The Facility reported incident for Resident #101 and #102 indicated both residents were transferred to the hospital on 3/24/2026: Resident #101 for injuries and Resident #102 for his aggressive behavior.A review of the Hospital emergency room discharge document revealed Resident #101 was treated in the emergency room on 3/24/2026 at 12:23 PM for Assault with a Facial contusion and Closed head injury.A review of a Wound Picture for Resident #101 that was taken after he was assaulted by Resident #102 indicated he had multiple red, raised, abrased areas on his forehead. His right eye was almost swollen shut with abrasions and swelling underneath, and his lips were swollen, red and had abrasions.Further review of the medical record for Resident #101 revealed the following:3/24/2026 at 12:07 PM, a Nurses Note Approximately 1120 am, a CNA came to me and stated that the resident in 313 had attacked the other resident and that he was bleeding. Called to room by staff; I observed the resident (R101) bleeding from the mouth, bruising to the right eye, bruising to the forehead and right jaw. Resident was visually upset and stated, He wants to go home. I asked the resident what happened and he stated, He said I cut him off. He was lying down and the resident assaulted him. per staff the attacker has been verbally abusive and agitated all morning. Per night shift nurse, stated that he called her (an obscene name) this morning and told her to get the (F.) out of his face.3/24/2026 at 6:08 PM, a Nurses Note Vs (vital signs) taken upon arrival and noted to be bp (blood pressure) 139/103 (very high) . skin assessment completed and multiple contusions noted to face.3/25/2026 at 10:07 AM, a Nurses Note IDT (interdisciplinary team) met to discuss the incident of 3-24. (Resident #101) was moved to a different (room)/unit after return from hospital. Is currently on 15 minute checks.Further review of Resident #102's medical record revealed the following:3/24/2026 at 11:15 AM, a Nurses Note This writer was called to room [ROOM NUMBER], with a complaint that (Resident #102) had beat up on his roommate. Upon arrival to the room the roommate was sitting on the edge of his bed with bruising and swelling to his right eye, red marks on his forehead, and blood and swelling around his mouth. When questioned, (Resident #102's) 1st response was, I didn't do anything. Upon further questioning he stated, He keeps scratching my mother f.) falls up. Physical exam was completed by NP (Nurse Practitioner I) and wound care nurse. No new injuries were present, only the MASD (moisture associated skin damage) that he is currently being treated for. Residents were kept apart, staff remained with both until EMS/PD arrived.3/24/2026, Encounter note Date of Service 3/24/2026 . (Resident #102) . He is being seen today after staff reported that he was in an altercation with his roommate where he was the aggressor. Upon entering the room, (Resident #102) was in his bed. When asked what happened. He stated, He kept scratching my balls and wouldn't stop so I hit him. Upon assessment with wound care nurse, there are open areas to his testicles due to moisture-related breakdown, but they have been present for a few weeks now. He also stated You can turn those microphones off that I know you all have. I'm done with them all. EMS and the police were contacted, and both parties were sent to the hospital for further assessment . Reported to be aggressive against his roommate by punching him in the face. Sent to the hospital under MD certification for psych evaluation.3/18/2026 at 4:02 PM, Psychology Follow-up visit (by Social Worker), . History of delusions, hallucinations, and extreme paranoia. admitted to multiple skilled nursing facilities over the last several years. Since admission to current facility, has had increased behaviors. rejection of care, yelling, abusive language, and threatening behaviors. History of strange and inappropriate behaviors, refusal of care, and suspected drug-seeking behavior from prior facilities. Risk Assessment: Episodes of psychosis with inappropriate and refusal behaviors. Poor judgment, poor insight, poor impulse control.3/2/2026 at 5:40 PM, SBAR Summary for Providers, The Change in Condition/ reported on this CIC Evaluation are: Behavioral symptoms. The resident appears to be under the influence. He is loud and obnoxious, blinking his eyes when eye contact is made, talking to himself and unable to self-propel in his WC (wheelchair) properly. At this time the resident has escalated with his behaviors and making threats to harm other residents.3/2/2026 at 4:47 PM, Social Services Note, SW was informed that resident return from his LOA (leave of absence) appeared to be intoxicated yelling/screaming, abusive languages, thinking disorganized, irrelevant conversation, illogical flow of ideas. while in his wheelchair running into the wall. speech was slur, rambling, difficult focusing his attentions. notified guardian via telephone regarding resident behaviors. Guardian stated resident has history: domestic violence.A review of Resident #102's Care Plans from 10/29/2025 after admission does not mention the resident's history of violent and aggressive behavior towards others.A Care Plan titled (Resident #102) has a history of substance abuse. Potential Heroin. date initiated 3/2/2026 was updated on 4/2/2026 with intervention Close observation such as q (every) 15 (minute), 1:1, as needed, date initiated 3/2/2026 and revised 4/2/2026.A Care Plan titled (Resident #102) has the potential for fluctuation in mood r/t: Mood affective disorder. Hostility. created on 10/29/2025 and revised 4/2/2026. There was no intervention to address preventing Hostility towards other residents and staff until 4/13/2026: Should (Resident #102) be expressing a desire to harm self or others provide 1:1 monitoring, follow suicide protocol and report to physician immediately. The interventions did not address that Resident #102 did not verbalize that he wanted to harm his roommate prior to assaulting him.A Care Plan titled (Resident #102) has the potential to demonstrate physical, verbal aggression, agitation, abusive language, yelling outburst. date initiated and created 3/3/2026 and revised 4/2/2026 with Interventions including: 15-minute checks for 72 hours, date initiated 3/3/2026 and resolved 3/13/2026. The resident was no longer being monitored with 15-minute checks on 3/24/2026 when he assaulted his roommate Resident #101. The Care Plan was further updated on 4/20/2026 with . (Resident #102) was involved in physical altercation with his roommate who he attacked. (Resident #102) was making threatening remarks to his 1:1 sitter stop following me before I put my hands on you. On 4/13/2026 1:1 for supervision was added. 1:1 refers to one staff member assigned to one resident. This intervention was enacted 3 weeks after the resident attacked Resident #101.On 4/29/2026 at 1:16 PM, Nurse E was interviewed about the incident between Resident #101 and Resident #102. She said she was the assigned nurse for both residents on that day 3/24/2026. Nurse E said a Nurse's Aide yelled down the hall to come quick and she went to the room for Resident #101 and #102. The nurse said Resident #101 had red marks on his face, his mouth was bleeding, teeth were bloody, and his lip was bloody. She said Resident #102 was also in the room and she sent someone to call the Director of Nursing/DON and Administrator. Nurse E said Resident #102 Had problems before and that morning he wouldn't let anyone give care. He didn't take his meds the night before. Nurse E said Resident #102 had a history of cursing, using derogatory names and he could be vulgar and disrespectful. The Nurse said when Resident #101 was assessed, his right eye was almost closed, there was bruising on his forehead, he became dizzy and was very scared. Nurse E said Nurse Practitioner I came into the room and assessed the resident and ordered for him to be transferred to the Hospital.During an interview on 4/29/2026 at 1:32 PM, Nurse Practitioner (NP) I, said she was in a morning meeting at the facility on 4/26/2026 when she was called to come to Resident #101's room. She said Resident #101 was sitting on his bed when she entered the room and there was blood on his lip and teeth and his right eye was swollen. When she asked what happened, he pointed at the bedside curtain towards Resident #102. NP I said she also assessed Resident #102 because he said Resident #101 was scratching his scrotum. NP I said Resident #102 was being treated for skin breakdown to his scrotum and there were no new areas of skin breakdown. NP I said Resident #102 had a history of abusive behavior prior to admission to the facility.On 4/29/2026 at 2:15 PM, the Director of Nursing/DON was interviewed and said after the incident between Resident #102 and Resident #101, Resident #101 was moved to a different unit on a different floor from Resident #102 and Resident #102 was moved to a private room with a private bathroom, so he would have less interaction with other residents. The DON said there were several instances at the facility that Resident #102 appeared intoxicated from alcohol or drugs. She said Resident #102 now had an around the clock 1:1 sitter, but the staff member stayed outside the resident's door to his room because he didn't like the staff to be that close to him. Resident #102 was able to motor his wheelchair and wheeled himself in the hallway and dayroom on the unit. The DON said the facility was not aware of Resident #102's violent behavior until his Guardian told them about it. The DON also said when Resident #101 returned from the hospital after the incident, the hospital medical records indicated he had additional injuries that included an imprint of a hand on his chest where he had been hit there.During the interview with the DON on 4/29/2026 at 2:15 PM, the Care Plan and Kardex (a tool for staff to provide resident care) for Resident #102 were reviewed with the DON. The Kardex said Monitors: Close observation such as (every) 15 minute, 1:1, as needed. There was no date when the intervention started. The Care Plan indicated 1:1 for supervision dated initiated 4/13/2026. The two documents did not match and could lead to confusing information for the staff. The DON said the information was not pulling over correctly into the Kardex.A record review of the facility policies identified the following: Abuse Prohibition Policy, origination date 12/1/2012 and last approved 9/9/2022 provided, Policy: Each guest/resident shall be free from abuse, neglect, mistreatment. Abuse shall include freedom from verbal, mental, sexual, physical abuse. To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents. Physical Abuse includes, hitting, slapping, pinching, and kicking. Resident Rights, origination date 9/1/2013 and last approved 5/14/2024 provided Policy: The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination.

Based on observation, interview and record review the facility failed to maintain sanitary conditions in the kitchen and proper cold holding during meal service, resulting in the potential to spread foodborne illness to all residents who consume food from the kitchen.Findings Include:On 3/17/2026 at 12:10 PM, tour of the kitchen was completed with CDM (Certified Dietary Manager) D, and following was observed:Ice Machine:Bin seal/trim was partway detached from the bottom lip of the bin.Inside white flap had orange colored residue spanning the length of it.The inside of the ice bin is blue in color but was peeling and was a white/translucent color.CDM D stated a contracted company empties and cleans the ice machine every 3 months.The bottom of the dolly cart with approximately 35 clean mugs stacked upon it was soiled with debris and other unknown food particles. CDM D stated it is cleaned weekly.The trash can was pushed against the clean and ready for use cookware, multitiered rack. The CDM stated the trashcan should not be there. Deli Cooler:Bottom left and right-side vent grates were riddled with unknown hardened substances.The entirety of the door seals had a black residue lining it.CDM D reported they have tried to clean the bottom grates to no avail. The top of a retractable pen was used to wipe the vent area and the particles loosened. On 3/18/2026 at 12:30 PM, alongside CDM D the 2nd floor dining room was observed as they prepared for lunch service. There was a large gray bin that contained resident beverages (milk and mighty shakes) that was sitting out without any type of cooling process in place for the ready to serve beverages. The dietary aide explained the beverages are brought upstairs based on the resident meal tickets. CDM D stated they are supposed to pour ice atop of the beverages and then bring them to the dining room to maintain the appropriate temperature. CDM D was asked to temp the beverages and the following was indicated:Milk: 48 Juice: 45 CDM D stated the milk, and juice should be 40 and below. The 3rd floor meal service beverages were observed and the juices were not on ice but sitting in a bin, The milk bin had some under the milk under ice and some above them that were not touching the ice. The following temperatures were indicated:Milk: 48 Juice: 42.1 1st floor dining room:Juice temperature: 43 On 3/18/2026 at 3:35 PM, an interview was held with CDM D, she reported the dietary aide stated she forgot to put ice atop the beverages prior to service. They are working on quotes to have the ice bin replaced and a company comes out every three months to clean ice machine and replace the filter. The CDM was asked if kitchen staff ever clean the ice machine if it is soiled and she stated no. She was further asked if they would have observed soiled areas within the ice machine would that have triggered them to clean it and she stated it would not as they would not have noticed it. Review was conducted of Work Orders for cleaning of the ice machine. The following was reviewed:12/23/25: .performed ice machine cleaning on ice machines, bin door messed up and door trim broke on bin, creating health dept (department) issues. (name) to quote new bin. 10/8/2025: .Clean ice machine in kitchen. Review of food/beverages temperature were reviewed for all dining rooms and it was found it was not consistent that dietary staff were temping the beverages being provided to facility residents. The following was reviewed:Breakfast from the Kitchen:3/10/2026Breakfast -no beverage temperatures 3/14/26:Breakfast -no beverage temperatures3/15/2026:BreakfastJuice: 20 Meals served from the kitchen:3/14/2026:Lunch and Dinner - no beverage temperatures 3/15/2026:Lunch and Dinner- no beverage temperatures3/17/2026:Dinner- no beverage temperatures 2nd Floor: 3/14/2026:Lunch and Dinner: no beverage temperatures3/16/2026:Breakfast and Dinner: no beverage temperatures3/17/2026:Lunch and Dinner: no beverage temperatures 3rd Floor: 3/14/2026:Lunch and Dinner: no beverage temperatures3/15/2026:Lunch and Dinner: no beverage temperatures3/16/2026:Breakfast, Lunch and Dinner: no beverage temperatures3/17/2026:Lunch and Dinner: no beverage temperatures Review was conducted of the facility policy entitled, Food Temperatures, approved 3/11/2026. The policy stated, Food will be maintained at proper temperature to ensure food safety.The temperature of holding cold foods at point of service will be 41 F. According to Food and Drug Administration Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5 C (41 F) or less. Review was conducted of the facility policy entitled, Nutritional Services Cleaning and Sanitation, last approved 3/11/2026. The policy stated, It is the policy of this facility to maintain the sanitation of the kitchen through proper cleaning and sanitizing.The Nutritional Professional will inspect the kitchen thoroughly to ensure cleaning schedules are completed as assigned.

Based on observation, interview and record review, the facility failed to ensure interdisciplinary review and revision of comprehensive care plans for one resident (Resident #65) of two residents reviewed. Findings include: Resident #65:On 3/18/26 at 11:55 AM, Resident #65 was observed in their room and an interview was completed. The Resident was noted to have Enhanced Barrier Precautions (EBP) but not Transmission-based isolation precautions in place. When queried if they were receiving any antibiotics or if they had been ill recently, Resident #65 indicated they did not know. Record review revealed Resident #65 was most recently admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), left hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), aphasia (difficulty speaking), gastrostomy, and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was rarely/never understood and was dependent upon staff for completion of Activities of Daily Living (ADLs). Review of Resident #65's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #65) is on isolation precautions related to. cough, SOB (Shortness of Breath), COVID (Initiated: 12/31/25). The care plan did not specify what type of isolation precautions were in place due to Covid. An interview was completed with MDS Registered Nurse (RN) K on 3/23/26 at 10:30 AM. When queried regarding Resident #65's active care plan related to isolation precautions and Covid, MDS RN K stated, That is not me, that is IC (Infection Control). With further inquiry, MDS RN K verbalized IC implements and discontinues all care plans pertaining to infections and isolation precautions. An interview was conducted with IC Nurse H on 3/23/26 at 10:31 AM. When queried regarding Resident #65's active care plan related to isolation precautions and Covid, IC Nurse H stated, I thought I had them all closed out and indicated they would need to review the Resident's EMR. IC Nurse H reviewed the Resident's EMR and stated, I see it (care plan). I didn't close it because it is in a custom care plan. When asked if the care plan should have been discontinued, IC Nurse H verbalized it should have been. Review of facility provided policy/procedure entitled, Care Planning (Approved: 3/3/25) revealed, Each resident. will have a person-centered Plan of Care developed an implemented that. meet a residents medical, nursing, and mental and psychosocial needs. Procedure. 9. The care plan. will be updated. with significant changes. This includes adding new focuses, goals, and interventions and resolving ones that are no [NAME] applicable as needed.

Based on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care for six dependent residents (R11, R15, R31, R50, R65, R122) of eight reviewed resulting in unkempt hair, facial hair on female residents, Resident #122 was soaked in urine for hours, unshaven male residents. Findings include:Resident #11: On 3/18/26 at 11:17 AM, a Certified Nursing Assistant (CNA) was observed exiting Resident #11's room. On 3/18/26 at 11:18 AM, Resident #11 was observed in bed, positioned on their back. The Resident was unshaven and had a disheveled appearance. The room lights were off and minimal personal items were observed in the Resident's area of the room. A urinal with dark yellow urine was hanging on a garbage can on the right side of the bed. An interview was completed at this time. When asked how long they had been at the facility, Resident #11 replied, Too long. When queried if they required assistance to get out of bed and to get cleaned up, Resident #11 responded that they are blind and indicated they required assistance. When asked if they had been assisted to complete oral care and get cleaned up, Resident #11 stated, They changed me, that it. Resident #11 was asked what they meant, and revealed staff had changed their brief due to incontinence. When asked if they liked their face shaven or if they preferred to have facial hair, Resident #11 verbalized they prefer to be shaved but cannot do it themselves because they are blind. Record review revealed Resident #11 was most recently admitted to the facility on [DATE] with diagnoses which included heart disease, schizophrenia, dementia, and vision loss in both eyes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required moderate to maximum staff assistance to complete Activities of Daily Living (ADLs). Review of Resident #11's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #11) has a functional ability deficit and requires assistance with self-care/mobility. (Initiated and Revised: 1/8/24). An interview was completed with CNA O on 3/19/26 at 3:04 PM. When queried if Resident #11 gets out of bed, CNA O responded, (Resident #11) is blind. When queried if the Resident gets out of bed frequently, CNA O verbalized they took them to the bathroom once and stated, It depends on who it is. CNA O then stated, (Resident #11) don't like to sit up. When asked if they had assisted Resident #11 to get cleaned up, CNA O revealed they had not and then stated that Resident #11 change their top every other day. Review of Resident #11's Documentation Survey Report for 3/1/26 to 3/18/26 revealed the following: -A task entitled, ADL Care Statement with the description, Have you provided routine standard care which includes. shaving and nail care as needed, turning and repositioning, oral care, washing face and hands, hair care, clean clothes and linens. dignity and respect. keeping call light within reach. encouraging and assisting to activities? Y - Yes N – No. The documentation was to be completed each shift, three times a day. There were 14 blank areas where no documentation had been completed. There was also no documentation of Resident refusal of task completion. - A task titled GG- Personal Hygiene each shift (three times a day) and detailed, The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). There were 14 blank areas where no documentation had been completed. There was also no documentation of Resident refusal of task completion. Resident #50: On 3/18/26 at 11:59 AM, Resident #50 was observed lying in bed in their room. A foul body odor was present in the room and became stronger and more prevalent closer to the Resident. The Resident was positioned on their back and noted to have bilateral Above the Knee Amputations (AKAs). When spoken to, Resident #50 responded verbally but their speech was very difficult to understand and words were unable to be discerned. A triangle shaped foam cushion was in place on the left side of the Resident's bed, under the fitted sheet. The Resident's call light was on the floor and not within the Resident's reach. Resident #50's fingernails were long and jagged with a dark colored, unknown substance present under the nails. An interview was completed with Certified Nursing Assistant (CNA) O on 3/18/26 at 12:04 PM. When queried regarding Resident #50's speech, CNA Q verbalized the Resident is normally difficult to understand when talking. CNA O was then asked about the triangle shaped foam cushion on the left side of the Resident under the sheet and replied, We rotate it because (the Resident) lean. When queried if they had provided morning ADL care to Resident #50, CNA O revealed they had not. Record review revealed Resident #50 was originally admitted to the facility on [DATE] with diagnoses which included right hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), aphasia (difficulty speaking), dysphagia (difficulty swallowing), and gastrostomy (feeding tube inserted through the abdomen into the stomach to deliver food and medications). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and dependent upon staff for completion of Activities of Daily Living (ADLs). Review of Resident #50's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #50). has an ADL Self Care Performance Deficit. has been observed to decline assistance with grooming. will say yes to one staff member who asks, then say no to another. (Initiated: 10/30/23; Revised: 1/15/25). The care plan included the interventions: - Report refusals of ADL care, personal hygiene, nail care, bathing, and showers. (Initiated: 3/12/24) - Personal Hygiene/Oral Care: (combing hair, shaving, nail care, and washing and drying face and hands) Dependent 1PA (Person Assist) (Initiated: 10/30/23; Revised: 3/3/25) Another care plan in Resident #50's EMR was titled, (Resident #50) is at risk for falls r/t (related to) poor safety awareness decreased cognition. (Initiated and Revised: 4/2/24). The care plan included the intervention, Keep environment as safe as possible with. call light within reach. (Initiated and Revised: 2/4/25) Review of Resident #50's Documentation Survey Report for 3/1/26 to 3/17/26 revealed a documentation section titled GG- Personal Hygiene each shift (three times a day). The category detailed, The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). Detailed review revealed no documentation of Resident #50 refusing care. Additionally, there was no documentation (blank) of task completion 10 times. The report also included the task, Shower/Bathing: Wednesday Saturday Day Shift and PRN (as needed). The was no documentation (blank) of Resident #50 receiving and/or refusing scheduled shower/bathing on Saturday 3/14/26. On 3/23/26 at 11:00 AM, Resident #50 was observed in their room. The Resident was in bed, positioned on their back. The Resident's fingernails remained unkempt and long with jagged edges and an unknown black substance under the nails. At 11:08 AM on 3/23/26, an interview and observation of Resident #50's fingernails was completed with Licensed Practical Nurse (LPN) P. When queried regarding the Resident's fingernails, LPN P confirmed the presence of the unknown black substance under the nails and that the nails needed to be trimmed. LPN P verbalized they would have someone take care of the Resident's nails. Resident #65: On 3/18/26 at 11:55 AM, Resident #65 was observed in their room in bed. The Resident's arms were sharply bent with their hands by their face. Resident #65's fingers appeared misshapen and contracted. Their call light was not within their reach. The Residents appearance was disheveled and unkempt. An interview was completed at this time. When queried how they are treated by facility staff, Resident #65 stated, Not good. Resident #65 was asked what they meant but did not provide further information. While speaking, the Resident's teeth were observed to have a significant amount of build up and debris on them. When queried if they required assistance to complete oral care, Resident #65 indicated they did. Resident #65 was then asked if a staff member had assisted them with oral care today and shook their head indicated they had not. When asked the last time they had received oral care, Resident #65 indicated they did not know. Record review revealed Resident #65 was most recently admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), left hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), aphasia (difficulty speaking), gastrostomy, and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was rarely/never understood and was dependent upon staff for completion of Activities of Daily Living (ADLs). Review of Resident #65's EMR revealed a care plan entitled, (Resident #65) has a functional ability deficit and requires assistance with self care/mobility. (Initiated and Revised: 10/8/23). The care plan included the interventions: - Personal Hygiene: dependent combing hair, shaving, nail care, and washing and drying face and hands (Initiated: 12/21/23; Revised: 3/12/24) - Oral Care: Dependent (Initiated and Revised: 12/21/23) - Bath/Shower: Dependent (Initiated and Revised: 12/21/23) Review of Resident #65's Documentation Survey Report for 3/1/26 to 3/18/26 revealed the following: -A task entitled, ADL Care Statement with the description, Have you provided routine standard care which includes. shaving and nail care as needed, turning and repositioning, oral care, washing face and hands, hair care, clean clothes and linens. dignity and respect. keeping call light within reach. encouraging and assisting to activities? Y - Yes N – No. The documentation was to be completed each shift, three times a day. There were 14 blank areas where no documentation had been completed and no documentation of Resident refusal of task completion. - A task entitled, GG- Oral Hygiene was also reviewed. The task included documentation sections three times a day, during each shift. Review revealed 14 blank areas where no documentation had been completed. NA was documented 10 times on the night shift from 11:00 PM to 7:00 AM. On 3/23/26 at 11:03 AM, Resident #50 was observed in their room. The Resident was in bed, positioned on their back. The significant, visible substance build-up remained on Resident's teeth. At 11:08 AM on 3/23/26, an interview and observation of Resident #65's was completed with LPN P. When queried regarding the Resident's teeth, LPN P confirmed and stated, Need to do oral care. An interview was completed with the Director of Nursing (DON) on 3/19/26 at 2:11 PM. When queried if there a blank area on daily care documentation means the care task was not provided, the DON replied, Yes. The DON was then informed of observations of Resident #'s 11, 50, and 65 as well as interviews completed. The DON did not provide further explanation. Resident #122 A record review of the Face sheet and Minimum Data Set/MDS assessment indicated resident #122 was admitted to the facility on [DATE] with diagnoses: Debility, heart disease, arthritis and osteoporosis. The MDS assessment dated [DATE] indicated the resident had full cognitive ability with a Brief Interview for Mental Status/BIMS score of 13/15, was dependent with care for toileting and was always incontinent of bladder and bowel. On 3/18/2026 at 11:15 AM, prior to entering Resident #122's room a strong odor of urine was noted in the hallway near the door. Upon entering the room, the foul smell of old urine was evident. While approaching Resident #122's side of the room near the window, the smell became much stronger. The resident was lying on her right side facing away from the left side of the bed; a blanket was covering her, but the left side of the bed was visible. On the bottom sheet was a large brownish urine stain, partially dry and partially wet and the smell was worse. On 3/18/2026 at 11:20 AM, the room was exited and Certified Nursing Assistant/CNA F was asked if she could come to the Resident #122's room, and she stated Sure. While entering the room and approaching the side near the window with Resident #122, CNA F was asked if she could smell the urine, she said Yes she could. The CNA stood at the end of the bed and she was asked if she could see the resident's bed on the left side, she stated, I see it. The CNA was asked if she could see that the brown colored urine was up near the resident's neck and the length of her body and she stated, Night shift probably didn't change her. I have all of these residents, and I am making my way through my assignment. I haven't got to her yet. On 3/18/2026 at 1:45 PM, Resident #122 was observed sitting in her bed. She appeared clean, with clean clothes. The bed linens appeared clean and there was still a slight smell of urine in the room. The resident was smiling and talking to a visitor. On 3/19/2026 at 11:34 AM, Resident #122 was observed lying in her bed awake and watching TV; there was no smell of urine. The resident was asked if she received timely assistance with incontinence care and she said she was not changed the previous night (3/19/2026), but was now clean and dry with dry bedding, When asked about yesterday (3/18/2026), she said she had not been changed that night either and stated, Sometimes they don't get to it because they don't have enough people. I just wait for them. Sometimes it takes a long time. A record review of the Care Plans for Resident #122 identified the following: (Resident #122) is incontinent of (bladder &/or bowel) r/t (related to). This was left blank with no explanation, dated 9/26/2025 and revised 10/20/2025 with Interventions including: Brief Usage: Resident uses disposable briefs. Change q (every) 2 hours and prn (as needed), date initiated 9/26/2025 and revised 10/20/2025; Check q 2 hours and prn for incontinence. Wash, rinse and dry perineum. Change clothing after incontinence care as needed, date initiated 9/26/2025. (Resident #122) has a functional ability deficit and requires assistance with self care/mobility r/t: decreased mobility, disease process, date initiated 9/26/2025 and revised 9/30/2025 with Intervention including: Toilet Hygiene: (Resident #122) is dependent for toilet hygiene, date initiated 9/30/2025. A review of the Kardex for Resident #122 provided, Bladder/Bowel/Toileting: Brief Usage: Resident uses disposable briefs, Change q 2 hours and prn; Check q 2 hours and prn for incontinence. Wash, rinse and dry perineum. Change clothing after incontinence. On 3/23/2025 at 3:15 PM, during an interview with the Director of Nursing/DON, she said there had been staffing issues with call ins and a lack of scheduled staff. Reviewed with the DON both the residents and staff were verbalizing there were not enough staff and Resident #122 was not changed after being incontinent during the night shift on 2 occasions and on the day shift until after 11:30 AM after being wet all night. The DON said the facility was trying to hire more staff. A review of the facility policy titled, Resident Dignity & Personal Privacy, date effective 3/12/2025 provided Policy: The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality. groom appropriately and to resident's desire. A review of the facility policy titled, Routine Resident Care date effective 3/12/2025 revealed, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Incontinence care is provided timely according to each resident's needs. Resident's call lights are answered timely and resident's requests are addressed. Resident #15: R15 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include dementia, anxiety, schizophrenia and hyperlipidemia. On 03/17/2026 at 12:16PM, R15 was sitting on the edge of the bed, observed with long chin hairs and other long hair on her face. On 03/19/2026 at 3:00PM, R15 was resting in bed, R15 was again observed with chin hairs and long facial hair on her cheeks. R15 was asked if the staff offers to help her with facial hair removal. R15 stated, no, I have to ask staff for help, and they take their time getting it done. R15 was asked when the last time was the staff helped you with hair removal on your face. R15 stated, that is has been about two weeks. R15 stated that she does not like having facial hair and that she would ask her son to do it if the staff won't do it. On 03/19/2026 at 3:04PM, an interview was conducted with certified nursing assistant (CNA) A. CNA A was asked if the staff offers to help R15 with facial hair removal. CNA A stated, yes, but sometimes she will refuse. I gave her a shower on 3/13/26 and she refused to let me shave her chin at that time. CNA A stated that she would go down and see if R15 needed any assistance. On 03/19/2026 at 3:15PM, record review of care plans for R15 revealed that she is a one person assist for personal hygiene. On 03/23/2026 at 10:32AM, observation this morning revealed some chin hair and facial hair were still present. Resident #31: R31 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include muscle wasting, chronic obstructive pulmonary disease, anxiety and depression. On 03/17/2026 at 1:05PM, R31 was resting in bed, observation revealed her hair was greasy and not combed. On 03/19/2026 at 2:54PM, R31 stated she gets two showers a week, most weeks. R31 stated there is a staff member that doesn't like to help her with showers, but she cannot recall the name of the employee. R31 was asked when the last time she had a shower. R31 wasn't sure when she had a shower last. R31's hair was observed to be greasy and not combed again. Record review of the task list for bathing revealed that R31 did not receive a shower on 3/19/26, as scheduled in the electronic medical record (EMR) to be completed on the first shift. On 03/19/2026 at 2:56PM, an interview was conducted with CNA B. CNA B was asked if R31 refuses showers. CNA B stated, I honestly don't know, her showers are on second shift and I work first shift. CNA B stated, I have tried to give her a shower before and she would tell me no, that it is too cold. CNA B was asked what R31's shower days are. CNA B stated that R31 is scheduled for Wednesday and Saturday, second shift showers. CNA B was made aware that the EMR shower task indicates that R31 is scheduled for showers on Monday and Thursday, first shift. CNA B was made aware that the EMR does not match the shower book at the nurse's station. On 03/19/2026 at 3:00PM, record review of the most recent minimum data set (MDS) assessment dated [DATE], revealed that R31 is a max assist for bathing and moderate assist for personal hygiene care. Review of the policy titled, Routine Resident Care, revealed, Residents receive the necessary assistance to maintain good grooming and person/oral hygiene. Guidelines: 3. Daily personal hygiene minimally includes assisting or encouraging residents with washing their face and hands, shaving, nail care, combing their hair each morning, and brushing their teeth and/or providing denture care. Any concerns will be reported to the nurse.

Based on observation, interview and record review, the facility failed to provide enteral tube care per professional standards of practice for four residents (R50, R65, R81, R115) of four residents reviewed. Findings include:Resident #50: On 3/19/26 at 11:13 AM, Resident #50 was observed in their room. The Resident was in bed, positioned on their back. The Head of the Bed (HOB) was elevated to 15 degrees, and they were receiving tube feeding via infusion pump at a rate of 59 milliliters (mL) per hour. On 3/19/26 at 3:40 PM, Resident #50 was observed in their room in bed. The Resident's tube feeding was infusing via pump at 59 mL per hour and the HOB was elevated 24 degrees. An interview was completed with Licensed Practical Nurse (LPN) M on 3/19/26 at 3:48 PM. LPN M was asked how high the HOB should be when a Resident is receiving tube feeding and replied, 30 to 40 degrees. LPN M was asked check how high the head of Resident #50's bed was elevated. After exiting Resident #50's room, LPN M was queried regarding the HOB and confirmed the HOB was not elevated 30 degrees. Record review revealed Resident #50 was originally admitted to the facility on [DATE] with diagnoses which included right hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), aphasia (difficulty speaking), dysphagia (difficulty swallowing), and gastrostomy (feeding tube inserted through the abdomen into the stomach to deliver food and medications). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and dependent upon staff for completion of Activities of Daily Living (ADLs). Review of Resident #50's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #50) an alteration in nutrition and/ or hydration status. (Initiated 6/22/16; Revised: 1/7/26). The care plan included the intervention, (Resident #50) needs the HOB elevated 45 degrees during and 1 hour after tube feed (Initiated: 6/22/16; Revised: 6/4/24). On 3/23/26 at 10:57 AM, on observation of Resident #50 was completed. The Resident was in bed, on their back with tube feeding solution infusing via pump at 59 mL per hour. The head of the Resident's bed was elevated less than 20 degrees. Upon exiting Resident #50's room, LPN N was observed in the hallway. When queried if they were Resident#50's assigned nurse, LPN N verbalized they were. LPN N was asked what the HOB should be elevated to when a resident is receiving tube feeding and replied, 20 to 25 degrees. LPN N was asked to enter Resident #50's room and what their HOB elevation was. LPN N entered the Resident's room and proceeded to raise the head of Resident #50's bed. When queried, LPN N verbalized the head of Resident #50's bed was elevated less than 20 degrees. No further explanation was provided. Resident #65: Record review revealed Resident #65 was most recently admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), left hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), aphasia (difficulty speaking), gastrostomy, and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was rarely/never understood and was dependent upon staff for completion of Activities of Daily Living (ADLs). On 3/23/26 at 10:41 AM, Resident #65 was observed in their room in bed. The Resident was positioned on their back with the HOB elevated at 20 degrees. Tube feeding administration set was hanging via pump and connected to the Resident. The tube feeding container was empty and Feed Error was displayed on the tube feed pump message screen. The tube feeding container was noted to contain approximately 1000 mL of feeding solution and was dated 3/22 at 2000 (8:00 PM) with a rate of 80 mL/hour written on the container. No staff were present in the hallway. At 3/23/26 at 10:51 AM, Certified Nursing Assistant (CNA) O was walking past the Resident's room. CNA O was stopped. When queried regarding the error message on Resident #65's tube feeding pump, CNA O indicated they did not know and would have to find the nurse. CNA O verbalized Hospice staff had just left. When queried how high the HOB should be elevated when a Resident is receiving tube feeding, CNA O did not provide a response. Review of Resident #65's EMR revealed a care plan entitled, (Resident #65) has alteration in nutritional and/or hydration status. (Initiated: 9/19/23; Revised: 9/4/25). The care plan included the intervention, Elevate HOB 30-45 degrees during tube feeding administration (Initiated: 9/19/23; Revised: 2/16/24) Resident #81 A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #81 was admitted to the facility on [DATE] with diagnoses: history of a stroke, left-sided weakness, history of cranial surgery after a stroke/craniotomy with skull flap, heart disease, neuropathy, Frontotemporal neurocognitive disorder, and hypertension. The MDS assessment dated [DATE] indicated the Resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 14/15 and needed assistance with care. On 3/18/2026 at 10:39 AM, Resident #81 was observed lying in bed, awake and readily answered questions. She was observed to have a soft helmet on, and she said she had previously had a stroke and had surgery on her head and wore the helmet for protection. She said she was supposed to have surgery again at some point. Resident #81 said she had a feeding tube but she also received a meal tray with a diet. The resident said tube feeding might be restarted, but she wasn't sure. The resident showed there was a gauze dressing on her abdomen over the feeding tube insertion site. She said the staff usually changed the dressing in the morning. A review of the physician orders for Resident #81 identified the following: Flush PEG (feeding tube) with 60cc H2O (water) every 6 hours, start date 12/13/2025. Cleanse Peg tube site with wound cleanser and apply dry dressing every night shift as needed, start date 12/15/2025. No added salt diet, regular texture, Thin consistency (fluids) for diet, start date 12/12/2025. Further review of Resident #81's MDS Comprehensive assessment dated [DATE] section K: Swallowing/Nutritional Status did not indicate the resident had a feeding tube or that she was receiving water flushes/fluid intake via the feeding tube. A review of the progress notes revealed the following: 3/16/2026 at 4:31 PM, a Skin check, provided . Resident does not have an external device. There was no mention of the feeding tube inserted into the resident's stomach. 3/09/2026 at 11:11 PM a psychiatric note provided, . Anoxic brain injury secondary to CVA (stroke). s/p (status post) PEG tube placement. 2/17/2026 at 1:00 AM, a provider Encounter note revealed, . PEG tube placement. 2/2/2026 at 1:00 AM, a provider Encounter note revealed, . Keep PEG tube patent with routine flushes. Keep area clean and dry. 1/10/2026 at 3:36 PM, a Nurses Note provided, Tube feeding patent with flushes done each shift per order. Will continue to monitor. The resident was noted to have multiple Skin checks that mentioned no external device. It did not identify the feeding tube. The feeding tube was not being routinely monitored. A review of the Medication Administration Records/Treatment Administration Records (MAR/TARs) for Resident #81 identified the following: Flush PEG tube with 60cc H2O every 6 hours for patency, start date 12/13/2025. Enhance barrier precautions every shift for peg, start date 12/13/2025. There was no entry on the MAR/TAR for changing the gauze dressing on the PEG tube insertion site or to monitor the site. A review of a Nutritional Re-evaluation assessment dated [DATE] did not identify Resident #81 had a feeding tube or that she was receiving water flushes every 6 hours. A review of the Care Plans for Resident #81 identified the following: (Resident #81) has a peg tube r/t (related to) inadequate nutrition, date initiated and revised 12/13/2025 with 1 Intervention: Use enhanced barrier precautions, date initiated 12/13/2026. (Resident #81) has potential alteration in nutritional and/or hydration status. date initiated 12/15/2026 and revised 3/21/2026. There was no mention that the resident had a feeding tube or that she was receiving water flushes. On 3/23/2026 at 11:21 AM, Dietary Manager D was interviewed related to Resident #81's feeding tube, she said it was the Registered Dietitian who ordered the water flushes, but she had resigned the prior week. The Dietary Manager said it was her understanding it was not being used. On 3/23/2026 at 1:42 PM, Nurse Practitioner/NP G was interviewed related to Resident #81's feeding tube. She was asked why the resident still had a feeding tube, since admission [DATE], without being used, as it could be an infection risk or develop complications. The NP was asked what the plan for the feeding tube was as there was no documentation found in the chart clarifying this. She was also asked about monitoring of the abdominal insertion site, as there was no identified routine monitoring. NP G said she would check on it. On 3/23/2026 at 2:21 PM, NP G was interviewed and she said she spoke with Resident #81's son as he was visiting the resident. She said the son said his mom would need another craniotomy when the swelling in her brain subsided and he would like the feeding tube to stay in until after that surgery. NP was asked about documentation for the feeding tube as there was nothing that explained that and NP G said she would make a note about it. She said there should have already been a note. Resident #115: R115 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include dysphagia, anxiety, depression and traumatic subdural hemorrhage. On 03/19/2026 at 9:08AM, the medication administration task was conducted with Licensed Practical Nurse (LPN) C. R115 has a Percutaneous Endoscopic Gastrostomy (PEG) tube, medication orders revealed they are to be administered via PEG tube and some via mouth. LPN C did not verify placement of the PEG tube prior to the administration of medication and did not properly flush the PEG tube after medication administration. On 03/19/2026 at 9:35AM, an interview was conducted with LPN C. LPN C was asked what the process is for verifying placement of a PEG tube. LPN C stated, we usually take the residual gastric content and make sure it doesn't go over a certain amount (200ml) then we push it back in. LPN C was asked if they should have verified placement of the PEG tube before giving medication. LPN C stated, yes, I should have verified placement, but I didn't. The water was flowing freely, so I knew it was in place. LPN C was asked how much you should flush the tube with after medication administration. LPN C stated, usually we put in 150-200cc of water, I put about 150cc in the end to flush the tube. On 03/19/2026 at 9:46AM, an interview was conducted with the Director of Nursing (DON). The DON was asked if R115 is supposed to have anything by mouth. The DON stated, no, I don't believe that he is able to have anything by mouth. His oral meds were to be put on hold until he had a video swallow. The DON was made aware that R115 has physician's orders both by mouth and by PEG tube. The DON was asked what the process is for verifying PEG tube placement. The DON stated, I believe it is verified once a shift and we verify residual. If it is under the threshold then we re-feed it and we know it is in place. The DON was made aware that placement was not verified prior to medication administration. Review of the policy titled, Medication Administration-Enteral,' revealed: Procedure: 11. Verify placement of tube by using a piston syringe to aspirate stomach contents. Fasting gastric secretions are clear, grassy green or brown. Replace gastric contents after aspirating. If unable to obtain gastric secretions, hold medication and tube feeding and notify physician for further orders. Re-clamp tube if present. Verify Dobhoff and Jejunal placement per policy. Once placement in verified release clamp from tube, if present, and instill at least 15ml of water into the tube through the syringe to check for patency via Gravity Flow. If water flows in easily, tube is patent. If it flows in slowly, raise the syringe to increase pressure. If water does not flow properly, stop the procedure and notify the physician. 16. After giving all the medication, instill at least 15ml of water to irrigate the tube.

Based on interview, and record review the facility failed to ensure residents were 1) consistently assessed for Influenza and Pneumococcal vaccinations on admission, per Standards of Practice; 2) provided an educational vaccination information sheet for each vaccination, 3) and document vaccination information in the residents' medical record, including consent or declination of the vaccinations, which could potentially effect all residents, including Residents (#5, #15, #61, and #74) reviewed for vaccinations, resulting in the potential for exposure to Influenza and Pneumococcal disease, and severe illness. Findings Include: CDC/Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report (MMWR), Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices- United States, 2025-26 Influenza Season, Weekly/ [DATE]. Routine annual influenza vaccination is recommended for all persons aged >= 6 months who do not have a contraindication to vaccination. For most persons who require only 1 dose of influenza vaccine fo the season, vaccination should ideally be offered during September or October. However, vaccination should continue after October and throughout the influenza season as long as influenza viruses are circulating and unexpired vaccine is available. CDC/Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report (MMWR), Expanded Recommendations for Use of Pneumococcal conjugate Vaccines Among Adults >=50 Years: Recommendations of the Advisory Committee on Immunization Practices- United States, 2024, Weekly/[DATE]. Streptococcus pneumoniae (pneumococcus) is a common bacterial cause of respiratory tract infections, bacteremia, and meningitis. Pneumococcal pneumonia, accounting for 12%-13/5 of all hospitalized pneumonia cases, has been estimated to result in approximately 225, 000 U.S. adult hospitalizations annually. CDC Pneumococcal Vaccination, [DATE]: CDC recommends pneumococcal vaccination for people based on their age or if they have certain risk conditions. Pneumococcal vaccines help protect against pneumococcal infections, including invasive disease. Invasive disease means the bacteria invade parts of the body, such as blood, that are normally free from germs. Invasive disease is usually very serious and can sometimes result in death. Pneumococcal disease is common in young children, but older adults are at greatest risk of serious illness and death. CDC: Long-term Care facilities (LTCF's), [DATE], Viral Respiratory Pathogens Toolkit for Nursing Homes: Preventing the spread of respiratory viruses in nursing homes requires a comprehensive approach that includes not only vaccination, but also testing, treatment, and the prompt implementation of proven infection prevention and control measures. Taken together, these actions can protect residents and staff from respiratory viruses. Vaccinate: Provide recommended vaccines to residents and HCP (Healthcare Providers); Recommended vaccines help prevent severe illness, hospitalization, and death from respiratory viruses. On [DATE] at 2:10 PM, the facility Infection Control Program was reviewed with Infection Control Practitioner/ ICP H. Vaccinations including Influenza/Flu, Pneumonia and Covid-19 were reviewed. The ICP H said the facility had a vaccination clinic in the fall 2025 for residents and planned to have another vaccination clinic in [DATE]. She said she would be catching up on new residents. The ICP H said usually residents were assessed for vaccinations on admission. Their history of vaccinations was reviewed with the residents and responsible parties. She said at the initial care conference, vaccine information was provided to the new residents but consent or declination for the vaccinations was not provided at that time.During the interview with ICP H on [DATE] at 2:10 PM, she said since [DATE] to the current date, she said she had not offered the Flu, Pneumonia or Covid vaccinations to the residents. The ICP said there was a large Covid-19 outbreak in the facility with 36 residents and staff testing positive between [DATE] to the beginning of [DATE]. When asked why the residents were not being offered vaccinations and offered the opportunity to consent or decline the vaccinations, the ICP said she had been very busy with the outbreak. The ICP had been observed working as a staff nurse on the floor during the survey and when asked how often she worked as a nurse on the floor instead of working in her role as the ICP she said she often worked several days a week as a nurse on the floor. The census during the survey was 132 residents and when she worked on the floor, her duties as an ICP were not completed.A record review of resident vaccinations identified the following:Resident #5A record review of the Minimum Data Set/MDS assessment and medical record indicated Resident #5 was admitted to the facility initially on [DATE] and the most recent admission was [DATE] with diagnoses: Heart disease, diabetes and arthritis. The MDS assessment dated [DATE] identified a memory problem with a Brief Interview for Mental Status Score/BIMS of 7/15.A review of the resident's vaccination status revealed Flu [DATE], Pneumonia [DATE] and Covid-19 [DATE]vaccinations were documented as received. There was no additional consent or declination for vaccinations after then.Resident #61A record review of the MDS assessment and medical record indicated Resident #61 was admitted to the facility [DATE] with diagnoses: Cancer, heart disease, history of a stroke and Peripheral vascular disease. The MDS assessment dated [DATE] identified the resident had a memory problem.A review of the resident's vaccination status revealed the resident refused Flu, Pneumonia and Covid-19 vaccinations in the vaccination tab on the electronic medical record/emr, but no consent or declination form providing educational information about the vaccinations was identified.Resident #74A record review of the MDS assessment and medical record indicated Resident #74 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Heart disease, diabetes, and respiratory failure. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS score of 15/15.A review of the resident's vaccination status indicated: Flu refused [DATE], Pneumonia refused [DATE] and Covid-19 refused [DATE]. The only consent or declination was for the Covid-19 vaccination. There was no indication Flu or pneumonia vaccinations had been reoffered.Resident #15A record review of the MDS assessment and medical record indicated Resident #15 was admitted to the facility on [DATE] with diagnoses: Hypertension, Dementia and Schizophrenia. The MDS assessment dated [DATE] identified a BIMS score of 14/15 indicating full cognitive ability.A review of the resident's vaccination status indicated: Flu, Pneumonia and Covid-19 vaccinations were all refused on [DATE]. There were no consent or declination forms.Consent or declination forms for vaccinations that included information on the risks and benefits were not identified for the residents reviewed. The residents or representatives were not able to make an informed decision on whether they wanted to receive the vaccinations or not.A review of the facility policy titled, Infection Prevention Program Overview, dated effective [DATE] provided, Infection Prevention Program: Mission of Program- The infection prevention and control program (IPCP) must include, at a minimum, the following elements: The facility establishes a program under which it: Investigates, identifies, prevents, reports and controls infections and communicable diseases for all residents. Is based upon facility assessment; follows accepted national standards. Staff and resident education will focus on risk of infection and practices to decrease the risk. Policies, procedures and aseptic practices are followed. Immunizations are offered as appropriate to residents and staff to decrease the incidence of preventable infectious diseases.

Based on interview and record review the facility failed to specify indication for usage and provide a clinical rationale for duplicate therapy of antipsychotic medication for one resident (Resident #88) of five residents reviewed for unnecessary medications.Findings include:Resident #88;On 3/23/2026 at 11:50 AM, a review was conducted of Resident #88's medical record and it revealed the resident initially admitted to the facility on [DATE] with diagnoses that included, Adjustment Disorder, Anxiety Disorder, Dementia, Psychotic Disorder with Delusions and Psychophysiologic Insomnia. Further review of her chart yielded the following:;Paliperidone (Invega) ER Oral Tablet Extended Release 24 Hour 1.5 MG (milligram)- give one tablet by mouth one time a day for antipsychotic. Ordered on 3/7/2025. Quetiapine (Seroquel) Fumarate Oral Tablet 25 MG- Give one tablet by mouth two times a day for psychotic disorder. Ordered on 4/9/2025. Both above medications are classified as antipsychotics. Mental Health Provider Progress Notes:Review was completed of progress notes from June 2025- March 2026 and there was no documentation located regarding clinical rational dual antipsychotic therapy for Resident #88. On 3/23/2026 at 2:10 PM, an interview was conducted with Social Worker E regarding Resident #88's antipsychotics (Seroquel and Invega). Review was completed of her chart, and she stated antipsychotic is not an appropriate indication for usage for Invega. Social Worker E stated her behaviors have been decreased as she has stabilized on her current medication regime. She was queried if the clinical rationale for duplicate antipsychotic therapy was clearly documented within Resident #88's chart and she stated she did not believe it was explicitly addressed within the practitioner's charting. Review was completed of the facility policy entitled, Psychoactive Medication Management, last approved 1/28/2026. The policy stated, The facility will provide appropriate treatment and services for residents who display or are diagnosed with a mental disorder or psychological adjustment difficulty.When pharmacological interventions are indicated, the licensed staff will verify that the physician order includes the appropriate clinically supported diagnosis.

Based on interview and record review, the facility failed to ensure timely completion of a significant change Minimum Data Set (MDS) assessment for one resident (Resident #65) of one resident reviewed. Findings include:Resident #65:Record review revealed Resident #65 was most recently admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), left hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), aphasia (difficulty speaking), and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was rarely/never understood and was dependent upon staff for completion of Activities of Daily Living (ADLs). The MDS further detailed the Resident was receiving Hospice care. Review of Resident #65's Health Care Provider (HCP) orders revealed an order to admit to hospice services on 6/23/25. Further review of Resident #65's Electronic Medical Record (EMR) revealed the Resident's payor source was changed to Hospice on 6/23/25. Review of Resident #65's MDS assessments in the EMR revealed a Significant Change MDS assessment pertaining to decline and Hospice admission was completed on 8/11/25.Review of Resident #65's care plans revealed a care plan related to Hospice Services was initiated 6/23/25 and revised 8/13/25. An interview was completed with the Director of Nursing (DON) on 3/19/26 at 2:09 PM. When queried if a significant change MDS should be completed when a resident is admitted to hospice services while at the facility, the DON replied, Yes. Resident #65's HCP orders, payor change date, and Significant Change MDS dates were reviewed with the DON at this time. The DON was then asked if it was a concern that a Significant Change MDS had not been completed until August 2025 when the Resident was admitted to Hospice in June, and responded, Yes. An interview was completed with MDS Registered Nurse (RN) K on 3/23/26 at 10:25 AM. MDS RN K was asked if a Significant Change MDS should have been completed when Resident #65 was admitted to Hospice in June 2025 and stated, Let me find out. MDS RN K proceeded to contact Regional MDS Nurse L via phone. After speaking to Regional Nurse L, MDS RN K stated, Yeah, one should have been done and wasn't. When asked why the MDS assessment was not completed, no further explanation was provided.

Based on observation, interview and record review, the facility 1) failed to ensure that skin was assessed and monitored beneath a soft helmet for 1 resident (Resident #81) of 6 residents reviewed for skin care; and 2) Ensure that a resident received peak and through (max/min concentration of drug in bloodstream monitoring to maintain therapeutic medication levels by not obtaining timely laboratory testing for vancomycin antibiotic therapy for one resident (Resident #139) of one resident reviewed for IV therapy, resulting in the potential for sub therapeutic care and prolonged therapy. Findings Include:Resident #139 (R139): According to a review of R139's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diagnoses including: chronic heart failure, Fracture of vertebrae (back), infection following surgical procedure; On 03/09/2026 R139 was re-admitted after hospital stay with a diagnoses of: Sepsis due to Methicillin Resistant Staphylococcus Aureus, Pneumonia (PNA), with peripherally inserted central catheter (PICC) place for IV therapy through 04/22/2026. The Minimum Data Set (MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13/15 indicated the resident had intact cognition. On 03/19/2026 at 11:10 AM, Resident observed laying in bed eyes closed under blanket and was unable to interview. A record review of R139's progress notes post hospital transfer on 02/19/2026 revealed resident was sent out for fever and decreased level of consciousness; resident had been being treated in facility for PNA and acute kidney injury (AKI) with peripheral IV fluids and Levofloxacin (antibiotic).A record review of R139's hospital discharge to facility record revealed medical diagnoses of Septicemia with MRSA, elevated tropins (cardiac markers), PNA with the last Peak and trough lab collection date of 03/09/2026 at 9:01 AM resulting in 17.7 UG/ML value (10-20 UG/ML) reference range. The next weekly lab draw would be due on 03/16/2026. A review of discharge prescription written by the hospital infectious disease (ID) doctor dated 03/09/2026 revealed orders: 'Vancomycin 1.25 grams 250ML in NaCl 0.9% (normal saline) intravenous solution, to be given 1.25g (gram) via IV piggyback Q24H (once every 24 hours) for 35 days through 04/12/2026. PICC care: Catheter care. Heparin flushes. Cathflo if needed. Labs: CBC with differential, BUN, Cr, WSR, C-reactive protein (QNT), Vancomycin though Q week.' On 03/19/2026 at 1:10 PM, R139 was asked and agreed to interview. During the interview he was asked about his IV and PICC site viewed and dated 03/17/2026. R139 said he had an infection but couldn't identify why or where it was located, he said he needed medication for a long time. He was asked if the staff drew blood for his medications levels and he said No, further said that hurts like hell and agreed that he did not like to have bloodwork done but would do it if he had to. A record review of R139's lab results at the facility revealed he had last had labs done at the facility on 02/18/2026, prior to his transfer to the hospital on [DATE]. A record review of R139's readmission order set revised on revealed: 'placed on 03/18/2026 for Laboratory; 03/18/2026 -03/20/2026 (directions one time only for 2 days)' for the following tests: CBC (complete blood count), CMP (complete metabolic panel), Vitamin D level, Lipid panel lab draw. There was no order for Vancomycin Peak and through placed. On 03/23/2026 at 9:39 AM, During an interview with ICP Nurse J was asked about R139 hospitalization, she said R 139 had PNA with worsening symptoms and was sent out to be evaluated, he was hospitalized from [DATE] and returned to the facility on [DATE] in the afternoon. ICP Nurse J said that R139 returned with a PICC line in place and received IV antibiotic Vancomycin 1 dose a day for Septicemia. ICP Nurse J was queried on no labs ordered for R139 on re-admission and she said the admission nurse would have put in the orders, she said the admission nurse called her because she needed help to put in the orders, ICP Nurse J said that she put in the (contracted lab) lab order. When asked where that order in the chart was, she agreed it was not present. When asked to review the lab order she put into (contracted lab) she produced an order dated 03/18/2026 stat (now order- one time) for CBC with differential, CMP, Lipid panel and Vitamin D. there was no order for Vancomycin peak and trough (P&T) attached. ICP Nurse J said she placed a separate order for standing orders, but she could not find it in the (contracted lab) system so she would have to call and see why and said it must be a glitch in their system. ICP Nurse J was confirmed there was an order from the hospital ID doctor and acknowledged none from the facilities existed in the medical record. ICP Nurse J said R139 refused his blood draw on 03/18/2026 and that they attempted again on 03/20/206 in which he did get the labs drawn. ICP Nurse J was asked what the last day R139 had his P&T drawn she was unable to answer, ICP Nurse J was asked if she was going on the day R139 returned 03/09/2026 as the last draw then what was the date the next draw would be due, she said 03/16/2026. ICP Nurse J acknowledged that even though R139 had declined the stat lab on 03/18/2026, that it was ordered 2 days later that its scheduled time. ICP Nurse J said that the NP G went and talked to R139 and explained why he needed the lab and that was why he had it done on 03/20/2026. On 03/23/2026 at 11:18 AM, During an interview with Nurse I she confirmed that she was the nurse who was R139 nurse on readmission. She said she was very busy at the time the resident was being readmitted and that she reached out to ICP Nurse J and the DON for help putting in orders. Nurse I said that ICP nurse J handled the Vancomycin and labs and that DON placed the batch orders for that admission. Nurse I confirmed this with medical chart review that revealed order for Vancomycin placed by ICP Nurse J with no labs, and batch orders placed by DON. On 03/23/2026 at 11:29 AM, During an interview with ICP Nurse J she was asked about Nurse I 's call for help on date of admission for R139 and that she placed the Vancomycin order but no lab ordered, she said it was a miscommunication because she only put the lab order in (contracted company) system and not the medical chart for Nurse I. ICP Nurse J was asked to confirm the date of readmission on [DATE], yes. When asked to confirm the date the order was placed in [NAME], she said 03/18/2026 was the only one she could validate and that she was expected a call back from the (contract company) about standing order labs that she believed she placed. On 03/23/2026 at 11:45 AM, During an interview with NP G, she was queried about R139's admission orders that had not included an order for P&T with IV Vancomycin. NP G stated I asked the '(medical director)' who works at '(hospital)' and was advised that this was a standard dose for Vanco and they didn't need P&T from ID perspective. NP G was asked to review the ID doctor prescription with specific instructions to the facility on discharge. After NP G reviewed it out loud she stated Oh, I missed that, it should have been monitored.NPG said R139 had a P&T drawn, after queried about timing NPG admitted the order was placed 9 days after R139 returned on 03/18/2026 and only to the contracted company it was not in R139's chart until today after multiple conversations with staff, and that R139's initial refusal due to his needed explanation, prolonged obtaining levels another 2 days. A record review of R139's orders revealed on 03/23/2026 an order was placed in R139's chart for Weekly labs: CBC with diff, BUN, CR, WSR, C-reactive protein (QNT), Vanco trough. Hold Vanco from being administered until lab is drawn.A record review of R139's care plan revealed: dated 03/09/2026 Focus: R139 is on isolation precautions related to: Specify DX: bacteremia with interventions: Administer medication as ordered. Observe for effectiveness and side effects, report abnormal findings to the physician; Obtain labs as ordered and report abnormal findings to physician. A record review of facility provided medication sheet on Vancomycin therapy revealed: Nursing considerations: . carefully monitor vancomycin level to adjust IV dosage requirements and patient teaching: Teach about the use of the drug and its administration.According to the Infectious Disease Society of America (IDSA) Vancomycin guidelines 2020 Update, The guidelines recommend an AUC/MIC (Area Under Curve/Minimum Inhibitory Concentration) ratio (parameter to assess effectiveness of an antibiotic) of 400–600 mg*hour/L to achieve clinical efficacy and ensure safety for patients being treated for serious methicillin-resistant Staphylococcus aureus infections and according to the IDSA clinical practice guideline recommendation achieving a trough (parameter to assess effectiveness of an antibiotic) concentration of 15-20 mg/L (milligram per liter) for complicated infections. Resident #81 A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #81 was admitted to the facility on [DATE] with diagnoses: history of a stroke, left-sided weakness, history of cranial surgery after a stroke/craniotomy with skull flap, heart disease, neuropathy, Frontotemporal neurocognitive disorder, and hypertension. The MDS assessment dated [DATE] indicated the Resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 14/15 and needed assistance with care. On 3/18/2026 at 10:39 AM, Resident #81 was observed lying in bed, awake and readily answered questions. She was observed to have a soft helmet on, and she said she had previously had a stroke and had surgery on her head and wore the helmet for protection. She said she had a skin flap where bone had been removed, and she was supposed to have surgery again at some point. The resident said the helmet caused her head to feel hot, itchy and sweaty at times and she removed it to show her hair underneath. She said her hair was starting to grow back in the area where she had surgery. Resident #81 said she also had a different soft helmet that had holes in it for aeration and she wore it in warm weather. A record review of the physician orders identified the following: Head helmet to be worn at all times. Nursing to inspect skin around Helmet each shift, every day and night shift, start date 12/13/2025. A review of Resident #81's Medication Administration Record/Treatment Administration Record (MAR/TAR) for March 2026: Head Helmet to be worn at all times. Nursing to inspect skin around Helmet each shift. Every day and night shift for protection, start date 12/13/2025. A review of the Kardex for Resident #81 revealed there was no mention of wearing a soft helmet or monitoring the skin beneath the helmet. The Skin section of the Kardex had 1 entry Cue to reposition self as needed. A review of the progress notes and Skin Checks revealed no mention of assessing or monitoring the skin underneath the resident's helmet. A review of the Care Plans for Resident #81 identified the following: (Resident #81) is at risk for fall related injury and falls r/t (related to): stroke; (Resident #81) is supposed to wear her helmet at all times. She frequently chooses to take it off, created 12/12/2025 and revised 12/22/2025 with 1 Intervention mentioning the helmet: Encourage (Resident #81) to wear her helmet for her own safety. Encourage her to put it back on if observed that she has taken it off, date initiated 12/22/2025. There was no mention in the Fall Care Plan or other Care Plans for the resident that mentioned assessing and monitoring the skin under the helmet. On 3/23/2026 at 9:44 AM, Wound Nurse C was interviewed related to Resident #81's helmet. The physician's order dated 12/23/2025 for nursing assessment related to Resident #81's helmet, said to assess around the helmet each shift. There was no mention of assessing beneath the helmet. Reviewed there was no mention of assessing and monitoring beneath the helmet on the MAR/TAR or Care Plans for Resident #81. The Wound Nurse C said the nurses should assess under the helmet each shift.

Based on observation, interview, and record review, the facility failed to provide care and services to ensure that communication was completed in an understandable language including availability of adaptive equipment and translation devices for one resident (Resident #88) of one resident reviewed, resulting in lack of implementation of planned interventions for communication with a resident who does not speak English. Findings include: Resident #88:On 3/18/26 at 12:51 PM, Resident #88 was observed walking unassisted in their room. The Resident had a Croc style shoe on their left foot and a gripper sock on their right. An interview was attempted to be completed at this time. When asked how they were doing, Resident #88 made eye contact but did not respond. Upon repeating the question, Resident #88 replied, No English. There were no communication and/or translation boards/devices present in the room. An Activity Calendar, with written words in English, was hanging on the wall. The question, How are you? was written and shown to the Resident. Resident #88 shook their head and stated, No English. An interview was conducted with Licensed Practical Nurse (LPN) Q on 3/18/25 at 12:52 PM. When queried regarding Resident #88, LPN Q stated, (Resident #88) only speaks Romanian. When asked how facility staff communicate with the Resident if they only speak Romanian, LPN Q responded the Resident had communication boards and a translator device they use. Record review revealed Resident #88 was most recently admitted to the facility on [DATE] with diagnoses which included heart disease, diabetes mellitus, psychotic disorder with delusions, and dementia. Review of Resident #88's Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to moderate assistance to complete Activities of Daily Living (ADLs) with the exception of set up assistance for eating. The MDS specified the Resident's preferred language was Romanian and Yes was selected as the response to the question, Do you need or want an interpreter to communicate with a doctor or health care staff? Review of Resident #88's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #88) has impaired communication r/t (related to) Language barrier as evidenced by not speaking English. does not speak English. primary language is Romanian. (Resident) uses a pocket talker to communicate and son is able to communicate for (Resident) when he is visiting. (Resident) will at times refuse to use the pocket talker to communicate. will sometimes just stare at you and say nothing. Due to dx (diagnosis) of dementia and word salad, the pocket talker has trouble picking up (the Resident's) words as speaks in broken Romanian, and the communication comes out broken (Created: 11/9/22; Initiated: 11/9/24; Revised: 3/3/26). The care plan included the interventions:- (Resident #88) is able to communicate via picture board and gestures. Pocket talker can be used to translate (Created and Initiated: 11/10/22)- Ensure availability, functioning and effectiveness of adaptive communication equipment pocket talker (Created, Initiated, and Revised: 11/09/22) A second care plan entitled, I, (Resident #88) am alert oriented an ambulate without assistance. I am Romanian and my primary language is Romanian. I use a talk box translator to assist me with making my wants and needs known to others that do not speak my language. (Created and Initiated: 11/9/22; Revised: 3/3/26) was present in the Resident's EMR. This care plan included the interventions:- Staff will encourage me to utilize my communication board to assist me with communicating my wants and needs (Created and Initiated: 12/2/24)- Staff will use my talk box translator to assist with communication as it relates to language barrier (Created and Initiated: 11/9/22) Review of Resident #88's Visual/Bedside Kardex used by Certified Nursing Assistant (CNA) staff to guide care revealed, Resident Care. (Resident #88) is able to communicate via picture board and gestures. Pocket talker can be used to translate. Communication. A sign in (Resident #88's) primary language (Romanian) was put on their assign room to help provide redirection. The Sign was made more noticeable/colorful for better appearance. Ensure availability, functioning and effectiveness of adaptive communication equipment pocket talker. Use communication techniques to enhance interaction: Allow adequate time to respond, Repeat as necessary, Do not rush, Request feedback, clarification from the resident, to ensure understanding, Face when speaking and make eye contact, Turn off TV/radio as needed to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and picture. On 3/19/26 at 11:52 AM, Resident #88 was observed in their room in bed. The lights were off in the room and the Resident's eyes were closed. A communication board and/or translation device were not observed in the room. A sign was observed outside of the Resident's room that was written in a language other than English. The words on the sign were entered into Google Translate. Per Google Translate, the language was Romanian and said, Welcome (Resident #88) this is the room. An interview was completed with Certified Nursing Assistant (CNA) R on 3/19/26 at 12:02 PM. When asked how they communicate with Resident #88, CNA R stated, I use a translator app on my phone. (Resident #88) speaks Russian. When asked to clarify if Resident #88 spoke Russian or Romanian, CNA R indicated they speak Romanian. CNA R verbalized they were not supposed to have and/or use their personal cell phones when working but they do not have any other way to communicate with Resident #88. When asked if the Resident had a translator box, CNA R responded that they did but it was missing and were not sure what had happened to it. CNA R was then queried if the Resident has a communication board in their room and replied, I haven't seen one. An interview was completed with Resident #88 on 3/19/26 at 12:13 PM in their room using google translate. When asked how they were doing using google translation, Resident #88 smiled and initially responded before the translation software was set to Romanian to English. Once the software began translating, Resident #88 stated, I miss him and I can't do it without him. After switching Google translate back to English to Romanian, Resident #88 was asked who they were talking about but did not provide a response. A conversation regarding their clothing and room was completed with the Resident using Google Translate. Resident #88 was noted to speak quickly, and not all words were captured due to delays with Google Translate in switching back and forth from English to Romanian and proximity of the laptop to the Resident. An interview was completed with LPN S on 3/19/26 at 12:14 PM. When queried regarding Resident #88, LPN S stated the Resident has a translator device. LPN S was then asked how long the translator device had been missing and replied, It's not missing. When asked where the translator device is, LPN S stated, It might be in the (medication) cart. LPN S was observed looking in the medication cart and then going into the medication room on the unit. LPN S returned and stated the translator device was not there. LPN S verbalized they were going to ask the social work. The Social Worker revealed they did not know where the translator device was and told LPN S to ask Activity staff. LPN S was asked how long the translator device had been missing and revealed they did not know. LPN S stated, Not sure what happened to the translator. LPN S indicated they were going to ask Unit Manager LPN T and would be right back. LPN S returned and stated that Unit Manager LPN T said Resident #88 is supposed to be using a (communication) board now. LPN S was asked how the Resident was supposed to use a communication board for language translation when there was no communication board in their room. LPN S indicated they would check the Resident's room for a board. LPN S confirmed a communication board was not present in Resident #88's room but did not provide further explanation. An interview was completed with Unit Manager LPN T on 3/19/26 at 12:20 PM. When queried regarding Resident #88's translator device and how staff are able to communicate with the Resident, LPN T stated, We was using a translator but as dementia progressed it was not accurate. When asked how they knew it was not accurate, LPN T did not provide a response. When queried regarding a communication board, LPN T stated, Supposed to be in there. LPN T was asked if the words on the communication board were written in Romanian. LPN T verbalized the communication board included pictures but did not provide a response to the question asked. When queried what happened to the translator device, LPN T stated, Not sure if the DON (Director of Nursing) has it. Review of prior MDS assessments revealed documentation of the Resident's primary language not being Russian in 2023 and requesting a translator at that time. At 12:22 PM on 3/19/26, LPN S approached and stated, The DON took (translator device) away. When asked how they are able to communicate with Resident #88 without the translator device or a communication board in a language the Resident can understand and indicated they point at things and gesture. LPN S was then asked how they communicate more complex thoughts with the Resident without the translator device and replied, I get what you are saying and confirmed they cannot. A follow-up interview was conducted with Unit Manager LPN T on 3/19/26 at 12:24 PM. When asked how staff are able to communicate complex thoughts/processes with Resident #88 when they do not speak Romanian and do not have access to the translator device to communicate to the Resident in Romanian. LPN T stated, (Resident #88) can understand English. When asked how they know the Resident can understand English, LPN T indicated the Resident was able to understand and speak some English when they were initially admitted to the facility. With further inquiry, LPN T verbalized that as Resident #88's dementia progressed, they were only able to communicate in Romanian. LPN T was asked again how they know the Resident was able to understand English if their dementia had progressed to a point where they were only able to communicate in their primary language of Romanian, LPN T did not provide an explanation. When queried what language Resident #88's family use to communicate with the Resident when visiting, LPN T responded that family members speak to the Resident in Romanian. An interview was attempted to be completed with Resident #88's Family Member Witness U on 3/19/26 at 1:28 PM. A voicemail message with return number was left but a return phone call was not received by the conclusion of the survey. An interview was conducted with the DON on 3/19/26 at 1:31 PM. When queried regarding Resident #88's translator device, the DON verbalized that the device was taken from the Resident. When asked the reason the translator device was removed, the DON replied that it was no longer working due to the Resident's advancing dementia. When asked why the translator device was still on the Resident's care plan, the DON stated, I don't know. The DON was then asked to explain how the translator device was not working and indicated that Resident #88's responses were non-sensical with the device. When queried why staff were not aware that the translator device had been removed, the DON was unable to provide an explanation. The DON was then asked if they were aware that facility staff were using translation apps on their personal devices in order to communicate with the Resident. The DON responded that staff are not allowed to have/use personal devices while working. When queried what their expectations are for communication with Resident #88 when the translator device is on the Resident's care plan and Kardex but not available and the staff do not speak Romanian. The DON responded that the device was not effective due to the Resident's dementia. The DON was then informed that I was able to have a conversation with Resident #88 using Google translate. When queried how the translation device was ineffective when I was able to converse with the Resident using Google Translate, even with the ineffectiveness of the application, the DON did not provide an explanation. The DON was then asked how staff are able to speak to the Resident and explain things in a language they can understand without a translation device and/or application available and did not provide any additional information. A review of Resident #88's documentation in the EMR did not reveal any documentation pertaining to discontinuation of the translator device. On 3/19/26 at 2:47 PM, Resident #88 was observed in the room, packing all of their clothing and toiletry items in a blanket on the bed and folding up the edges of the blanket to make a sack. Using Google Translate, Resident #88 was asked what they were doing and the Resident replied, Packing to go home. Resident #88 was then asked if it would be okay if I got a staff member to help them and replied, Okay. A policy/procedure related to communication was requested from the DON during interview on 3/19/26 at 1:31 PM but not received by the conclusion of the survey. Review of policy/procedure entitled, Resident Dignity & Personal Privacy (Approved 3/12/25) revealed, Policy. The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality. Information. Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth.

Based on observation, interview and recorded review, the facility failed to ensure that one resident's (Resident #104) Behavior Care Plan, dated 01/14/25, had interventions which were implemented consistently for Resident #104, who had a history of poor impulse control and aggression, of 4 residents reviewed. Findings Include: Resident #104:Review of Face Sheet, care plans dated 1/2025, nursing progress notes dated 1/7/26 and 1/8/26, revealed Resident #104 was [AGE] years old, alert and able to make own decisions, admitted to the facility on [DATE], required staff to assist with Activities of Daily Living, had a below knee left leg amputation, was wheelchair bound, and received dialysis treatments. The residents' diagnosis included end stage 5 kidney disease, alcohol use, post-traumatic stress disorder, anxiety disorder, schizoaffective disorder, chronic migraine, diabetes, depression disorder, and heart failure.Review of the resident's potential for aggression care plan dated 1/14/25, revealed staff were to avoid confrontation, and adjust plan of care to reduce incidents of aggression where possible.During an interview done on 1/13/26, at 8:00 a.m., the Director of Nursing said on 1/8/26, at 11:41 a.m., and per observation of the facilities video of the incident on 1/8/26, revealed Resident #104 exited the building to go on LOA (On leave of Absence-outside to smoke). The facility was aware Resident #103 was already outside smoking (on LOA). When Resident #104 wheeled past Resident #103, Resident #103 hit Resident #104 with his grabber. The two residents then were hitting each other and Resident #104 hit Resident #103's face; his ring cut the side of his (Resident #103) face. Resident #104 then started coming back onto facility through the main door with Resident #103 following him. The police were contacted and took Resident #103 in handcuff's (Fought with police) to jail. Resident #104 will be discharged back to his apartment next week (1-19-26); neither resident will be re-admitted to the facility.Review of the contracted mental health note dated 1/13/26, stated Today's visit was requested by the medical team due to a physical altercation occurring between this patient (Resident #104) and another resident (Resident #103). The provider discussed the incident at length with the facility Administrator today as well as with the NP (nurse Provider). Apparently, the altercation began the day prior (on 1/7/26) with the other resident (Resident #103) accusing this patient (Resident #104) outside the building with an object (grabber), the patient then hitting the other resident (Resident #103 hit Resident #104 with grabber, then Resident #104 hit Resident #103 in face). The other resident (Resident #103) came back into building and made several verbal threats. Police were called; there was much confusion.During an interview done on 1/13/26 at 11:00 a.m., the Administrator and Director of Nursing/DON said Resident #104 had been put on 15-minute checks on 1/7/26, due to the argument between both residents regarding resident #104 stealing Resident #103's planner. Review done on 1/13/26, of the resident #104's facility 15-minute check sheet dated 1/7/26 and 1/8/26, confirmed this information. Resident #104 signed out on the LOA sheet to smoke on 1/8/26 at 11:41 a.m., rolled past resident #103 on the sidewalk, when Resident #103 started hitting him with his grabber. At this point Resident #104 hit him in the face and wheeled back into the facility and signed back in at 11:47 a.m. The Administrator and DON both said the facility had been aware that Resident #103 had also signed out and was outside prior to resident #104 signing out on 1/8/26. Resident #104's 15-minute check sheet had documented they had observed him at 11:45 a.m., while he was outside. The DON said they should not have let Resident #104 outside to smoke the same time Resident #103 was also outside smoking. The Administrator stated, We did not follow that care plan (the aggression care plan dated 1/25-avoid confrontation and adjust plan of care to reduce incidents of aggression where possible). The DON stated We did not follow it (the aggression care plan dated 1/25). The Administrator and DON both said the facility did not avoid confrontation and adjust Resident #104's plan of care to reduce incidents of aggression when possible.The facility Care Plan policy dated 6/24/21, stated the care plan must be specific, resident centered, how to manage risk factors (includes behaviors-aggression), and have a comprehensive assessment.

This Citation Pertains to Intake Numbers: 2575687, 2577971, and 2580349. Based on interview and record review, the facility failed to develop and implement policies and procedures to ensure effective and appropriate communication and documentation for transfer to the hospital and failed to ensure readmission to the facility for one (#701) of three Residents reviewed for discharge rights and planning. Findings include: Review of documentation revealed three separate intakes with allegations pertaining to the facility refusing to readmit Resident #701 back to the facility after being in the hospital. Per the intake information, Resident #701 had a legal Guardian, was a long-term Resident of the facility, and was not provided with a bed-hold policy and/or eviction notice prior to being transferred to the hospital. An interview was completed with Resident #701's Guardian Representative Witness A on 8/12/25 at 10:38 AM. Witness A was queried regarding Resident #701's transfer to the hospital on 7/22/25 and revealed they received a phone call from the facility Administrator the day after Resident #701 had been sent to the hospital. When asked why they were not informed prior to the Resident being transferred, Witness A stated, They often forget to call. It is what it is. Witness A added that the facility did not call their cell phone or their office and did not leave a message. When queried what the Administrator told them when they called, Witness A replied, (The Administrator) said (Resident #701) was petitioned and (the hospital) decided they were not going to keep (Resident #701) and sent them back (to facility) but then (Resident #701) eloped. When queried why Resident #701 was petitioned and sent to the hospital, Witness A responded they were told that (Resident #701) was aggressive and wouldn't get off the elevator. Witness A then stated, I think (Resident #701) had some aggression and I don't know if they were trying to leave or something but it didn't seem like something that was really petition-able but I did not argue with them (facility staff). Witness A revealed the hospital evaluated Resident #701 and determined the Resident did not need inpatient mental health treatment and discharged them back to the facility via a transportation van. Witness A stated, (Resident #701) got mad and out (of the transport van) in the middle of [NAME]. When asked what happened after Resident #701 got out of the back of the van, Witness A stated, (Resident #701) went missing. Witness A continued, They (Administrator) called me to tell me (the Resident) was missing but that it wasn't their fault because they discharged (Resident #701) and that was the (transport companies) fault. Witness A verbalized they were only concerned with finding the Resident and bringing them back to the facility. When queried what happened, Witness A stated, So like 12 hours later, (Resident #701) was found on the side of the road with a crack pipe, passed out. With further inquiry, Witness A stated, The Administrator called me and said they found (Resident #701) and the police wanted them to just take (the Resident) back to the facility. Witness A verbalized they told the Administrator they wanted the Resident to go to the hospital be checked out and that Resident #701 could return to the facility after that. Witness A stated the Administrator responded, We discharged (Resident #701) and Witness A said they told the Administrator, I understand but, in the morning, you can do a readmit and (the Administrator) said we'll get (the Resident) to the hospital to be checked out. Witness A verbalized they did not know what the concern was as the Administrator agreed Resident #701 should be evaluated at the hospital. When asked about the Administrator telling them Resident #701 had been discharged , Witness A responded that they understood that to mean that the Resident was discharged from the computer when they were sent to the hospital and would need to be readmitted which is difficult to do during the night shift. When queried why Resident #701 did not return to the facility, Witness A revealed Resident #701 was evaluated in the Hospital ER and medically cleared to return to the facility but when the hospital called the facility to send the Resident back, the facility informed the hospital they were not taking (Resident #701) back. When queried why the facility would not take Resident #701 back, Witness A revealed they contacted the facility and the facility refused to take (Resident #701) back. Witness A verbalized they told the facility staff they were dumping (Resident #701) and they said that was not what they were doing. Witness A continued, I said (Resident #701) doesn't have a place to do and lives with you guys. Witness A stated they told the facility that not taking Resident #701 back did not seem right. When asked how the facility staff responded, Witness A verbalized the Director of Nursing (DON) told them that the facility discharged (Resident #701) to the hospital and we (guardian) were okay with that. Witness A reiterated they were not notified of the Resident's transfer and specified they were fine with the Resident going to the hospital ER for treatment not as a new placement. Witness A said they told the DON, It wasn't like you discharged (Resident #701) to the emergency room forever. That's not an appropriate discharge. When asked, Witness A revealed Resident #701 ended up being in the hospital for several days without a medical reason to be there because the facility would not readmit them and the hospital had to find a different long-term care facility for the Resident to go. Witness A stated, Now (Resident #701) is down in Detroit and revealed Detroit was far from their home and family as they were from [NAME]. A list of residents who were sent to the hospital and did not return was requested from the facility Administrator and Director of Nursing (DON) on 8/12/25 at 11:00 AM. An interview a review of the list of discharged Residents who did not return to the facility was completed with the Administrator on 8/12/25 at 1:30 PM. When queried regarding the disposition of the transferred Residents on the list, the Administrator stated, I can tell you the only one who we did not take back was (Resident #701) because they were discharged . Record review revealed Resident #701 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease and schizoaffective disorder: bipolar type. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, was independent with ambulation using a wheelchair or walker, and displayed no behaviors. Review of Resident #701's Census documentation detailed the Resident was discharged on 7/22/25 and did not return. However, the MDS assessment dated [DATE] specified discharge with return anticipated. Further review of Resident #701's Electronic Medical Record (EMR) revealed the Resident had a court appointed full legal guardian. Review of progress note documentation in Resident #701's EMR revealed the following: - 7/22/25 at 9:30 AM: Psychiatry Follow up. When this provider arrived to the facility today police were at the facility for this patient and EMS were on their way. The patient was in the process of being PIT (petitioned)/Certed (certified)by the social worker and medical director for a psych eval at (Hospital). Apparently, staff reported the patient was not feeling well this morning and when medical PA (Physician Assistant) arrived at the floor to evaluate. (Resident #701) was on the elevator; when they attempted to redirect (Resident) off the elevator they would not leave. When (Medical PA) asked if (Resident) was feeling weak or lethargic they started to jump around and play box to show was feeling okay however then (Resident #701) stated I will F all of you up. At that point (Resident #701) began to become more aggressive towards staff when they tried to redirect and encourage them to leave the elevator. Apparently, (Resident #701) also made several delusional statements towards staff, such as stating that was a white man. (Resident) is African American. referred to (themselves) as a white police officer and as an RN (Registered Nurse). The patient was in a very delusional and agitated state. This provider met with (Resident #701) on way to the ambulance when the police officer was present to talk with them for a bit and to make sure they stayed calm. (Resident #701) stated had meatballs for dinner last night and it made them very jumpy and could not sleep and has just felt out of sorts since that. After (Resident #701) left via EMS. provider called the charge nurse in the ER . talked at length regarding the medication regimen, patient's noncompliance, patient's past and current delusions. As well as aggression, and aggression being new as patient has a history of delusions however not normally aggressive. Explained that the plan would be to take patient off of Risperdal (atypical antipsychotic medication) . start on paliperidone long-acting injection (Invega - atypical antipsychotic medication) . Later in the afternoon, a social worker. called from the behavioral care team (at hospital) . explained that (Resident #701) had been calm the whole afternoon while in the hospital and (hospital behavioral health services) felt that Rexulti (atypical antipsychotic medication) by mouth would be appropriate for (Resident #701). due to a diagnosis of Alzheimer's, regardless of his schizophrenia. - 7/22/25 at 10:00 AM: Nurses Notes. DON was called to 3rd floor to speak with (Resident #701). Upon arrival, (Resident #701) was on the elevator. stated, ‘I am going home to Oklahoma. I have a house there and I don't belong in this State Run Hospital. has intermittently been refusing mental health medications. Managing PA and Psych NP aware. exhibiting flight of ideas today. Multiple different staff attempted multiple times to redirect and encourage (Resident #701) to leave the elevator. (Resident #701) replied I am never leaving this elevator unless you call the police and arrest me. Physician and PA attempted on 2 separate times to intervene and redirect. Police arrived and were able to successfully get (Resident #701) off the elevator and into the ambulance. He was PIT/Certed per Dr Cherry for psych eval. Sent to (Hospital). -7/22/25 at 6:50 PM: Nurses Notes. Approx 6:50 pm, ambulance service called regarding resident stating res left out of ambulance and started walking. They followed (Resident #701) while on phone with this facility and while waiting for police. They somehow lost resident when police arrived. Police stated there was nothing they could do without resident being petitioned. Meanwhile nursing updating administrator of situation. Resident's family was called and informed. - 7/22/25 at 7:54 PM: Social Services Note. Resident was attempting to leave assigned floor, and when staff and provider attempted to redirect back agitated and swung at the provider. Resident appeared very delusional. When Police arrived, (Resident) told the police was waiting for the police and did not believe that was actually the police. Resident exhibited paranoia. PCP completed Clinical Cert. SW completed Petition for Mental Health Evaluation. Resident was petitioned to (hospital) for psych eval. - 7/23/25: Health Care Provider Note Date of Service: 7/23/25. Follow up. Patient . being seen today for increased behaviors. Patient was upset this AM complaining of an internal chill and is shaking upper torso like. shivering ever since he ate the meatballs for dinner last night. Patient admits to increased agitation and is exit seeking. walking around the unit with a bag packed, stating. is leaving and going home. Patient is arguing with nursing staff this morning and will not get off of the elevator to be redirected. [NAME] police contacted the patient was petitioned out by SW (Social Worker), MD today. Patient willingly went with [NAME] police to [NAME] for further management of symptoms after arguing for extended period of time with staff and police. - 7/29/25 at 8:00 AM: Health Care Provider Encounter. Date of Service: 7/29/25. Visit Type: Others. After being hospitalized with mental illness, patient was being transported back to (facility), via the transportation service, being ran (sic) from the providers after exited from the automobile. guardian was contacted. was later found by the police, then transported back to the hospital. Review of Assessment/Evaluation documentation in Resident #701's EMR revealed the Resident did not have a change in condition, transfer and/or discharge assessment completed prior to being transferred to the hospital ER on [DATE]. A care plan entitled, (Resident #701) has a potential for verbal aggression yelling/screaming and become combative. R/T (Related To): Dx (diagnoses): Schizophrenia, Manic Episode without Psychotic Symptoms, Delusional Disorders, Schizoaffective Disorder, Bipolar Type. observed washing my clothes in my room per my preference. will refuse to shower at times. often say I want to go home and when I am told I have a guardian who makes my decisions, I get agitated and do not like this answer and become argumentative . at times is not able to be redirected. had a verbal altercation with a fellow resident. (Initiated: 10/27/22; Revised: 6/27/25) was active at the time Resident #701 was transferred to the hospital emergency room. The care plan included the interventions:- Anticipate and meet needs (Initiated: 10/27/22; Revised: 1/11/23)- Avoid changes in environment and confrontation (Initiated: 10/27/22)- Document behaviors, and resident response to interventions (Initiated: 10/27/22)- Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes (Initiated: 10/27/22)- Offer reassurance, support, redirections and diversionary activities as needed (Initiated: 10/27/22)- Provide gentle redirection (Initiated: 10/27/22) A second care plan entitled, (Resident #701) requires 24-hour care/LTC placement at this time related to (diagnosis/condition). (sic) Resident/family/legal decision maker has verbalized acceptance of plan to remain in the facility (Initiated: 12/2/21; Revised: 3/14/22) Review of Resident #701's Documentation Survey Report for July 2025 revealed the only documented behavior demonstrated by the Resident was rejection of care during the day shit on 7/5/25. A review of the scanned documentation section in Resident #701's EMR revealed no documentation that a bed hold policy was provided the Resident and/or guardian. The following was noted in the scanned documentation section of Resident #701's EMR:- Petition for Mental Health Treatment form dated 7/22/25. The Petition form was completed by SW B and specified Resident #701 was experiencing Paranoia, delusions and they were requesting a combination of hospitalization and assisted outpatient treatment.- Report on Examination and Clinical Certificate form completed by Physician C. The form specified Physician C spent 15 minutes with Resident #701 on 7/22/25 beginning at 10:05 AM and determined they required treatment and hospitalization. The Clinical Certificate Facts in Support detailed, Patient has a history of schizophrenia and delusional disorders. Patient is delusional and not in touch with reality.On 8/12/25 at 3:25 PM, an interview was completed with Nurse G. When queried if they were working when Resident #701 was transferred to the hospital on 7/22/25, Nurse G revealed they did not recall. When asked about Resident #701, Nurse G revealed the Resident was typically pleasant, did not always want to take their pills and would walk around all the time. When asked why Resident #701 did not return from the hospital when they went on 7/22/25, Nurse G revealed they did not know. An interview was conducted with Nurse H on 8/12/25 at 3:30 PM. When queried regarding Resident #701, Nurse H verbalized the Resident was never mean but wanted to do their own thing. When asked why Resident #701 did not return from the hospital when they went on 7/22/25, Nurse H was unable to provide a reason.An interview was completed with CNA J, CNA K and CNA I on 8/12/25 at 3:40 PM. When queried regarding Resident #701, all three CNA staff verbalized the Resident was nice, pleasant, and liked to walk around the facility. An interview with Transportation Company Staff D was completed on 8/13/25 at 11:50 AM. When queried regarding Resident #701, Staff D confirmed their company provided non-emergency transport from the hospital to the facility in a wheelchair can on 7/22/25. When asked what happened, Staff D verbalized the Resident exited the van and the police were notified. Staff D revealed there was nothing else in the record due to being a wheelchair transport. An interview was conducted with Social Worker (SW) E on 8/13/25 at 3:20 PM. When queried regarding Resident #701, SW E replied, (Resident #701) was here a couple of years, had a guardian, and was open to psych services. When queried regarding behaviors, SW E responded that the Resident could have behaviors and delusions. SW E was asked if the Resident was in the facility for long term care and replied they were and that they had a guardian. SW E stated, (Resident #701) didn't understand that they had a guardian and would say they didn't. When asked what happened on 7/22/25 when Resident #701 was transferred to the hospital, SW E revealed they were the Social Services staff member assigned to Resident #701 but were not working the day the Resident was transferred to the hospital. When queried why the Resident did not return from the hospital, SW E stated, From my understanding, the facility did not deny them coming back. When asked if Resident #701 had a planned discharge, SW E stated, No, (Resident #701) was long term. There was no plan for them to go anywhere. When queried if the Resident was a good fit for the facility and was able to receive all the care they needed, SW E replied, Yeah, I would say they were. On 8/13/25 at 3:41 PM, an interview was completed with SW B. When queried what occurred on 7/22/25 when Resident #701 was transferred to the hospital, SW B replied, (Physician C) and the NP (Nurse Practitioner) were there. (Resident #701) was very delusional and wouldn't get off the elevator. They called me to come up to fill out a petition for a psych eval. SW B revealed the police came and were able to convince the Resident to go to the hospital. When queried why it was a concern that the Resident would not get off the elevator, SW B replied, (Resident #701) had a wander guard on and the elevator won't move with the alarm going off. SW B was then asked if Resident #701 said what they wanted and replied, (Resident #701) said they didn't want to be here and has been here to long. When asked what interventions were attempted prior to calling the police, SW B indicated several staff had attempted to get Resident #701 to get out of the elevator. SW B then stated, Our psych NP was here, and they spoke to the hospital a few times and recommended to the ER that (Resident #701) have an injection to calm behaviors. When asked why Resident #701 did not return to the facility, SW B replied, There was no reason that (Resident #701) couldn't come back when we sent them out. An interview was conducted with the DON on 8/13/25 at 3:52 PM. When queried why Resident #701 did not return to the facility from the hospital ER, the DON replied, (Resident #701) didn't want to come back. When queried what the Resident's legal guardian wanted, as the Resident was unable to make their own decisions, an explanation was not provided. The DON was asked to explain what occurred and stated, We sent (Resident #701) to (hospital ER) for eval. (Resident #701) left the ER and (the hospital ER) put (Resident #701) in a wheelchair van. (Resident #701) got out of the van and walk to the area of [NAME] they wanted to be. With further inquiry, the DON stated, Found (Resident #701) a day or two later and then they went back (Hospital ER). The DON continued, (Resident #701) wanted to go live with a friend. A staff member saw him lying under a tree. The DON was asked if the Hospital contacted them for the Resident to return after the Resident was found laying under a tree in [NAME] and confirmed they had. When asked why the facility did not readmit the Resident, the DON stated, We meet as a team and decided that it was not our responsibility to take (Resident #701) back. When queried if a nursing assessment/evaluation transfer form should be completed when a Resident is transferred to the hospital, the DON replied, Should be. A review of Resident #701's EMR was completed with the DON and the DON confirmed a transfer assessment/evaluation form was not completed. When asked the reason the documentation was not completed, an explanation was not provided. When queried if a bed hold form was completed and provided to Resident #701 and their Guardian, the DON stated, I don't know that one was done. When asked if Resident #701's guardian was notified prior to the transfer, the DON verbalized there was no documentation of communication with the Resident's legal guardian prior to and/or immediately following the transfer to the hospital ER. When queried how facility bed hold information is communicated to the Resident/guardian, the DON stated, I don't know. Let me review the policy. When queried Resident #701 had personal items at the facility and if the items were still at the facility, the DON replied, I don't know. A copy of the facility policy/procedure related to transfers and bed holds were requested at this time. An interview was completed with the Administrator and DON on 8/14/25 at 10:41 AM. The timeline of events involving Resident #701's transfer was discussed. Per the Administrator and DON, Resident #701 left the building on 7/22/25 at 10:38 AM. On 7/22/25 at 6:50 PM, the transportation company called to notify the facility that the Resident had exited their vehicle. Resident #701's guardian was notified on 7/22/25 at 7:22 PM that the Resident was missing and facility staff looked for the Resident until approximately 11:00 PM and included homeless shelters. Facility staff continued to look for the Resident on 7/23/25. Facility Staff M found Resident #701 on 7/23/25 at 7:58 PM on King Street in downtown [NAME] under a tree and the Resident was sent back to the Hospital ER at this time. The Administrator and DON were asked when the facility was contacted by the Hospital ER related to readmitting Resident #701 and the Administrator verbalized the referral was received from the hospital on 7/24/25. When asked if the Hospital contacted them prior to 7/24/25, the Administrator revealed the hospital services called them on 7/23/24. The Administrator exited the room. The DON was asked if the Hospital contacted the facility after 7/24/25 and stated, On 7/25/25, (hospital) discharge planning called, and I told them no because I got that directive from Regional. The DON then revealed they had checked and Resident #701 did still have personal items at the facility. An interview was attempted to be completed with Hospital SW F on 8/14/25 at 12:35 PM. SW F was not currently working and a message with return phone number was left. On 8/15/25 at 8:53 AM, a return phone call was received from Hospital SW F and an interview was completed. When queried regarding Resident #701, SW F stated, (Resident #701) was seen the day before in ER for a psych eval. SW F revealed the Resident was evaluated and it was determined they did not need inpatient psychiatric treatment and were discharged back to the facility on 7/22/25 at 6:37 PM via a medical transportation company in a van. When asked what happened after the Resident left the hospital, SW F stated, At a stop light (Resident #701) got out of the (transport) van, went and did drugs and came back (to the ER) that night. SW F was asked when Resident #701 returned to the ER and stated, 7/23/25 at 9:30 PM. SW F verbalized the Resident was medically cleared to return to the facility on 7/23/25. SW F stated, We (hospital) tried to send (Resident #701) back (to the facility) on 7/23/25 and they would not take (the Resident) back because they had to wait to talk to the DON. SW F was queried if they knew who was contacted at the facility and the time and replied, At 11:41 PM (on 7/23/25), spoke to the (Administrator). (The Administrator) said (Resident #701) was discharged from the facility on 7/22/24 per documentation. SW F revealed they returned to work on 7/24/25 and tried to discharge Resident #701 back to the facility again. SW F stated, I spoke to (Resident #701's) guardian and (the facility) were trying to not take (the Resident) back. When asked if they spoke to anyone at the facility, SW F revealed they spoke to the DON and stated, (Facility DON) said (Resident #701) was discharged to (Hospital ER), and they were not taking (the Resident) back. SW F continued, They didn't provide 24-hour or 30 day discharge notice and you can't discharge a long-term patient to the ER. When queried if Resident #701 wanted to return to the facility, SW F stated, (Resident #701) lived there and had a legal guardian who wanted them returned there. SW F revealed Resident #701 had to be held in the hospital for several days before an appropriate alternate placement was able to be found. Review of Resident #701's hospital documentation revealed the following:- 7/22/25 at 10:49 AM: ED Provider Note. Psych was consulted, and they recommended no inpatient psych admission, and as soon as patient is medically clear can de-certify and discharge. determined medically clear. safe for discharge home.- 7/23/25 9:17 PM: ED Provider Note. At-risk Social Status. discharged yesterday, staff from facility stated was supposed to be brought to them yesterday by (transport company) after discharge, patient ran out of (transport) van and has been missing. [NAME] PD had a [NAME] (Be on Lookout) for them from the facility and dropped (Resident #701) off here today after finding them on the side of the road with a crack pipe. ED Course.:. Social work service was consulted regarding disposition recommendations. They contacted (facility) who states that patient is prohibited from returning to the facility at this time due to their behavior. Review of facility provided policy/procedure entitled Discharge Planning (Last Revised: 9/2023) revealed, The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of the resident to be an active partner in their care. 4. The discharge plan will be discussed with the resident and/or the resident representative.Review of facility policy/procedure entitled, Notification of Change (Last Revised: 2/14/24) revealed, The facility must inform the resident. and notify, consistent with his or her authority, the resident representative (s) when there is a change in status.

This citation pertains to intakes MI00153289 and MI00153294. Based on interview and record review, the facility failed to provide supervision for three residents (R5, R6, R7) of three residents reviewed for supervision, resulting in multiple resident to resident altercations. Findings include: Resident #5: R5 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include Huntington's disease, adjustment disorder with anxiety, cognitive communication deficit and schizoaffective disorder, bipolar type. R5 has a brief interview for mental status (BIMS) score of 8, indicating mild cognitive impairment. Resident #6: R6 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include alcoholic cirrhosis of liver with ascites, adjustment disorder with depressed mood, chronic diastolic heart failure and pulmonary hypertension. R6 has a BIMS of 0, indicating severe cognitive impairment. Resident #7: R7 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include unspecified disorder of adult personality and behavior, adjustment disorder with depressed mood, bilateral above the knee amputations and anxiety disorder. R7 has a BIMS of 15, indicating they are cognitively intact. Record review of an Incident and Accident Investigation Form and progress note revealed that on 05/16/2025 at around 4:47pm, R5 and R7 were involved in a resident to resident altercation. The facility conducted a review of their camera system to aid the investigation. R7 was sitting at the front reception desk and signing back in to the building. R5 was observed to be walking towards the front door, at this time the receptionist approached R5 and redirected him away from the front door. R7 appeared to say something to R5 and that upset him, and he pushed the wheelchair and right shoulder of R7. R7 hit R5 on the arm and R5 walked away until they were escorted by the Director of Nursing (DON). R6 was present during There were no injuries noted during this interaction. R5 was directed out on to the back patio placed on every 15-minute checks. Record review of an Incident and Accident Investigation Form and progress note revealed that on 05/16/2025 at around 5:30pm, R5 and R6 were involved in a resident-to-resident altercation. The facility conducted a review of their camera system to aid the investigation. R5 re-entered the building from the back patio and walked up and down the hall and then eventually to the dayroom. R6 was observed sitting in the hallway and then got up and went to the dayroom. R5 exited the dayroom appearing upset and knocked over a mop bucket. The facility conducted an interview with a resident who observed the incident, and he stated that R5 swung at R6 multiple times and hit him once in the face. R6 stated that he approached R5 to scold him for the incident prior to this one where he hit R7 by the front door. R6 stated he stood up eye to eye with R5 and that R5 clocked him in the face four times, R6 stated he sat back down and went back outside. R5 was placed on 1:1 monitoring, R6 had a skin assessment completed and it revealed a small abrasion near his left eye. On 06/04/25 an interview was conducted with the DON. The DON was asked about R5. The DON stated that R5 has Huntington's disease and schizoaffective disorder, he is truly good if he is left alone. On the day in question, he was trying to go out the front door and the receptionist was handling it, R7 started shaking her finger at him and scolding him, this upset him and he open hand shoved her in the right shoulder. R7 then hit him on the arm. The DON was asked what intervention was put in place at the time of the incident to prevent further incidents. We put R5 on 15-minute checks for 72hours. The DON was asked about the second resident altercation that occurred after that. The DON stated that after the second incident that occurred, R5 was placed on 1:1 monitoring for 72 hours after that he had an escalation of behavior and was placed on 1:1 monitoring full time. The DON was asked about the mood of R5 during the 15-minute checks after the first incident. The DON stated that during the first three 15-minute checks R5 was out on the patio with the activities director and then R5 came back in the building and had an incident with R6. Was the activity director aware that R5 was on 15-minute checks and why R5 was on them. The DON stated, yes, the activity director was aware he was on 15-minute checks. We were aware he was coming back in the building on his own. The DON was asked why someone didn't accompany R5 back in the building after he had just had an incident with R7. The DON stated that the 15-minute checks were more to run interference to stop other residents from provoking R5. The DON was asked if someone should have been with R5 once he came back in the building. The DON stated we were in between 15-minute checks so someone wouldn't have necessarily been with R5 at the time. Documentation of the 15-minute checks were requested from the DON. The DON stated that there is no documentation of the 15-minute checks in the EMR. On 06/04/25 an interview was conducted with Activity Director A. Activity Director A was asked if they knew why R5 was on every 15-minute checks. Activity Director A stated, I was not aware that R5 had an incident prior to him coming to the back patio, I told the DON that I didn't witness anything. But I came to the front reception area and took him out of the situation and out to the barbecue on the back patio. Activity Director A stated, when R5 was done at the barbecue I escorted him back into the building, I think R5 wanted something to drink, and I went and got that for him. When I returned with the drink, I was made aware that another incident had occurred with a resident. I have never seen him act out like that, I have seen him be frustrated in the past and knock stuff over. On 06/04/25 an interview was conducted with Receptionist B. Receptionist B was asked about the incident that occurred by the front door. Receptionist B stated that R5 was trying to go out the front door, I redirected him to come back in, he was mad at me at this time. R6 and R7 were sitting at the front desk, and I think one of them said something to R5. R5 then hit R7and she hit R5 back. Receptionist B stated, I'm thinking that R5 might have been mad that he couldn't go outside. R6 and R7 could have been talking together but R5 might have thought they were saying something to him. R7 knows better to say anything to provoke him, she is always encouraging him and being nice. When I redirected R5 from the door we had to walk in between R6 and R7 to get out of the area. That could've been why R5 thought R6 and R7 were saying something to him. On 06/04/25 an interview was conducted with Social Worker (SW) C. SW C was asked to tell me about R5 and his behavior in the facility. SW C stated that R5 is a very nice person, he has poor impulse control due to his Huntington's and psych diagnosis. When they did his Level 2, we were going to see if he could have specialized care, but they couldn't determine which diagnosis is more prevalent. SW C stated R5 can get upset, he does not like to be told no. He loves pop and will ask you for pop constantly and he enjoys watching Nascar. Does R5 have a history of physical aggression without being provoked? There was an incident on 9/10/24, where R5 and R7 had an altercation when R7 attempted to redirect him from eating out of the garbage can, R5 hit her on the shoulder at that time. SW C was asked what kind of services does R5 receive here. SW C stated R5 sees Behavioral Care Solutions (BCS), which includes the nurse practitioner and the social worker. SW C stated that R5 also has a case manager that visits him from the Department of Health and Human Services (DHHS). SW C was asked, if based on R5's history of past incidents, do you think someone should have been with him when he came back in the building from the barbecue after his previous incident? SW C stated, yes, someone should have been with him. SW C was asked what their role is during investigations. SW C stated, I follow up with the residents, follow up with psych and update care plans to address the changes. On 06/03/25, R5 was observed resting in bed, being monitored 1:1 by staff in the room. Attempts were made to interview R5, but he would not respond. An interview was conducted with Dietary Aide D, who was providing 1:1 care at the time. Dietary Aide D was asked if R5 leaves his room. Dietary Aide D stated, yes, when he does, I walk with him. He mostly just walks around. He doesn't really interact with any other residents and will sit in the lobby area. Dietary Aide D was asked if R5 seems confused when he talks. No, he seems pretty good to me. An interview was attempted with R6 to discuss the incidents and R6 refused to be interviewed. An interview was conducted with R7. R7 was asked about the altercation with R5. R7 stated that R5 thought I was talking to him, and he hauled off and hit me in the breast. R7 stated she was yelling at another resident (R6). R7 was asked if they thought R5 was purposeful in hitting her. R7 stated, yes, I believe it was, he knows better than that and he knows exactly what he is doing. He is much smarter than people give him credit for. When he sees me, he always calls me by name, he is more aware than they think. I have not had any issues with R5 since the incident. I told the DON that I would not interact with R5 for a while. R7 stated prior to this R5 elbowed me really hard in the right collar bone/shoulder area. R7 stated this happened a few months prior but could not recall when. I told the facility, and I don't think they did anything about. I believe they actually just threw the information out. Record review of the policy titled, Abuse Prohibition, revealed: Procedure: D. Identification: 5. The facility supervisory staff will integrate into the supervisory process monitoring the behavior of staff members and guest/residents that are indicative of high stress levels that lead to abuse/neglect or may escalate a continuum of aggression. F. Protection of Guests/Residents during the Investigation. 4. f. Accompany the guest/resident to an area away from the environment in which the behavior has occurred. Use interventions identified by the interdisciplinary team to calm the guest/resident.

This Citation pertains to Intake Number MI00149971. Based on observation, interview and record review, the facility failed to address hospital discharge recommendations for blood glucose monitoring and insulin administration and follow parameters for insulin administration for two residents (Residents #1 and Resident #3) of three residents reviewed for glucose monitoring. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE] and re-admission on 2/19/25 with diagnoses that included end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with ketoacidosis. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 11/15 that indicated moderate cognitive impairment. The Resident went out of the facility for dialysis treatments. On 3/27/25 at 1:01 PM, an observation was made of Resident #1 dressed and sitting on the side of the bed with their lunch tray on the overbed table. The Resident had Visitor C seated in a chair by the Resident. The Resident answered questions and engaged in limited conversation; the Visitor assisted the Resident with answers. The Resident reported not going to dialysis today but had gone yesterday. The Resident was asked if they ate breakfast at dialysis. The Resident stated, I usually get it when I come back, don't eat at dialysis. When asked about blood sugar monitoring, the Resident reported that it goes up and down. On 3/27/25 at 1:10 PM, an interview was conducted with Resident #1's Nurse D. The Nurse was asked if the resident received insulin with her breakfast yesterday. The Nurse stated, No she was gone to dialysis. The Nurse was asked if the Resident had a blood sugar check after returning from dialysis and before eating breakfast, and the Nurse reported that she receives insulin when her blood sugar is high. The Medication Administration Record (MAR) was reviewed with the Nurse for 3/26/25 with documentation on the MAR of 5 that indicated hold see nurses note. The nurses note revealed, dialysis, and the Resident did not get the blood sugar checked or insulin given as per sliding scale. The Nurse reported that the Resident does come back and either eats a sack lunch or will get a tray and stated, Eats either her sack or the tray, it's either/or. A review of the orders revealed the Resident had a recent hospitalization where the Resident was sent out to the hospital from dialysis. The Progress Note dated 2/10/25 at 12:50 PM revealed, Dialysis called and they sent patient to hospital for ams (altered mental status) and bs (blood sugar) of over 900. The Resident was readmitted to the facility on [DATE]. A review of Resident #1's discharge hospital records of the Discharge Summary Notes revealed .Labs showed hyperglycemia with BG (blood glucose) >920 and acidosis PH 7.19 with pseudohyponatremia of 122 and AG of 19 with lactic acid of 4.2. She was started on insulin drip and fluid per DKA protocol . DKA (diabetic ketoacidosis-a complication of diabetes that can be life-threatening when there is a lack of insulin causing blood to become acidic). A review of Resident #1's discharge hospital records revealed medication list that had the directions, START taking these medications: insulin aspart U-100 100 unit/mL (milliliter) vial, Commonly known as: Novolog. Inject 0-8 Units into the skin 3 (three) times daily before meals. A review of Resident #1's discharge hospital records revealed a FAX Cover Sheet dated 2/20/25 with a Medication List: START taking these medications insulin aspart . Inject 0-8 Units into the skin 3 (three) times daily before meals: 100-140= 0 Units Subcutaneous; 141-200= 1 Unit Subcutaneous; 201-250= 2 Units Subcutaneous; 251-300= 3 Units Subcutaneous; 301-350= 4 Units Subcutaneous; 351-400= 5 Units Subcutaneous. A review of the medical record revealed an order dated 3/14/25 for Insulin Aspart Subcutaneous Solution Cartridge 100 Unit/ML (Insulin Aspart). Inject as per sliding scale, three times a day before meals with the sliding scale of 100-140= 0U (unit), 141-200=1 U, 201-250=2 U, 251-300=3 U, 301-350= 4 U, 351-400=5 U. The medication was started on 3/15/25 but was not given in the morning on the Resident's dialysis days. The Resident went out to dialysis on Monday, Wednesday, Friday. Further review of the medical record revealed a lack of documentation of why the hospital discharge recommendations for medication were not followed, no progress note made that the recommendation was discussed with the doctor upon readmission. On 2/27/25 at 2:11 PM, an interview was conducted with Director of Nursing (DON) regarding Resident #1's hospitalization with treatment for DKA and the discharge orders for insulin sliding scale. The resident's return on 2/19/25 but the insulin sliding scale not ordered until 3/14/25 was reviewed with the DON. The notation on the hospital records of Physician Assistant A for 3/14/25 was reviewed. The DON was unsure why the medication orders from the hospital discharge were not followed and reviewed the medical record and revealed no documentation of why. The DON indicated that if the hospital discharge instructions were not going to be followed, there should be documentation of the rational and the nurse should document discussions with the practitioner if it had occurred. The lack of following the physician order to monitor the blood glucose and give insulin as needed per sliding scale with meals was reviewed with the DON and Nurse B who had been the interim DON prior to the DON. It was determined that the Resident ate breakfast when they returned from dialysis. The DON reported the Nurse should be checking the blood glucose and following the sliding scale for insulin after the resident returned from dialysis. It was reported that when the nurse identified the Resident was out for dialysis treatments, the glucose monitoring and sliding scale insulin would not show back up on the MAR to be given. The medication schedule for the glucose monitoring and insulin was not adjusted to accommodate the Resident's dialysis treatment schedule. On 3/28/25 at 10:37 AM, an interview was conducted with Physician Assistant (PA) A regarding Resident #1's order for blood glucose monitoring and sliding scale insulin. The hospital records were reviewed with the written note sent 3/14/25 and the PA signature. The PA reported that she had came upon a pile of paper in the office that had not been reviewed and that it could have been it that pile. The PA indicated that the medication orders should be addressed when the Resident came back form the hospital. When asked if the recommendations were not going to be followed, the PA indicated that there should be documented rational why it will not be followed. A review of facility policy titled, Diabetic Management, revised 9/22/23, revealed, . Evaluation: Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure: orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician . Blood glucose measurements are taken per the physician order . Anti-diabetic agents (insulin or oral anti-diabetic agents) are administered per physician order . 49944 Resident #3 (R3): R3 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include type 2 diabetes, anxiety, depression and alcohol abuse. On 03/28/25, record review revealed a physician's order Insulin Glargine, inject 10 units, subcutaneously two times a day for diabetes mellitus (DM). Hold for blood glucose (BG) less than 100. The start date for this order 03/09/2025. On 03/28/25, record review of the medication administration record (MAR) for March 2025 revealed that on three occasions the 10 units of insulin glargine was given outside of the parameters of administration. -03/14/25- Blood glucose was 79 and the medication was administered. -03/18/25- Blood glucose was 57 and the medication was administered. -03/22/25- Blood glucose was 71 and the medication was administered. Record review of the policy titled, Diabetic Management, revealed: Evaluation: -Orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician. Routine Care: -Blood glucose measurements are taken per the physician order. Results outside of ordered parameters are communicated to the physician immediately.

This Citation pertains to Intake Number MI00151298. Based on interview and record review the facility failed to update care plans and implement interventions to prevent falls for one resident (Resident #2) of three residents reviewed for incidents and accidents, resulting in repeated falls. Findings include: Resident #2 (R2): R2 is [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses that include above the knee amputation on the right leg, dementia, anemia and chronic obstructive pulmonary disease. R2 has a brief interview for mental status (BIMS) score of 5, indicating severe cognitive impairment. On 3/28/2025, a review of falls was completed for R2, it was revealed that R2 had sustained multiple falls in the facility. -On 1/5/25 at 04:03 AM, R2 was observed lying on his left side on the floor beside his bed. The fall was unwitnessed, and the care plan intervention was to perform a three-day sleep study. Results of the sleep study were unable to be located in the electronic medical record. -On 1/31/25 at 11:30 PM, R2 was observed holding onto the bed post and sliding off the left side of the bed, the care plan was not updated with a new intervention. -On 2/28/25 at 11:30 AM, R2 was found lying on the floor next to the bed. The care plan was not updated after the fall. -On 2/28/25 at 05:30 PM, R2 was observed sitting on his bottom next to his bed with his back up against the other bed (bed 2) in the room. The care plan was updated to perform checks on R2 every 15 minutes. Documentation of the 15-minute checks could not be located in the electronic medical record. -On 3/3/25 at 02:15 AM, R2 was observed on the floor, laying on his left side. The care plan was not updated in the electronic medical record. On 03/28/25 an interview was conducted with the Director of Nursing (DON). The DON was asked what the expectation is with updating care plan after falls. The DON stated, this will require education for the nursing staff, at the time of the fall I expect the nurse to put something (an intervention) in right away, the next day we can review the falls with the team and see if we can come up with an intervention based on what the root cause of the fall is. Going forward these incident forms will be filed in one spot so we can find them and ensure they get updated. The electronic medical record has a nice system in place to keep track of incidents and we plan to fully use that going forward. The DON was asked if they think the interventions should be meaningful and pertaining the fall. The DON stated, yes, the interventions should be meaningful and relevant to the fall. Review of the policy titled, Incidents and Accidents for Guests/Residents or Visitors, revealed: Policy: Incidents or accidents involving a guest/resident or visitor will be documented and reported to meet the regulatory requirements. The administrator and the director of nursing will be notified as outlined in this policy. Procedure: 7. For incident and accidents involving guests/residents, pertinent clinical information and observations must be recorded in the medical record. Documentation: 5. Record the relevant facts regarding the guest/resident in the medical record, e.g. where guest/resident was found, evaluation conducted, care provided, follow-up care provided, etc.

Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food, foodborne illness and improper kitchen sanitization, potentially affecting all residents who consume meals from the kitchen. Findings Include: On [DATE] at approximately 10:00 AM, a tour of the kitchen was started with Assistant Administrator Q and concluded with Dietary Manager AA upon entering the kitchen, dietary staff were actively cleaning out the walk-in cooler. The following expired and/or unsanitary conditions were observed during the tour: Walk-in Cooler: -Floors had spills in different areas of what appeared to milk, and the floor was sticky in some areas. -There were miscellaneous items strewn across the floors such as lids and onion peelings. -18 cups of orange juice inside an extended white tray- some of the juices lids were off and there was spilled juice in the bottom of the tray. It was dated [DATE]. -1 gallon of jalapenos with expiration date of [DATE] -Both fan covers in the walk-in cooler were riddled with build on dirt and debris. The fans itself also were observed with grayish particles on the fan blades. The encapsule containing the fans had unknown dust/debris/particle buildup around the perimeter. Maintenance Director BB reported it was unknown the last time the fans in the cooler or freezer were cleaned but he would provide the logs for it. Walk-in Freezer: -10-pound ham with no expiration date -Small container of purer meat- expired [DATE] -,d+[DATE] pounds of Spaetzle Dumplings- no expiration date -5-pound bag of Pepperoni- expired [DATE] -7- biscuits in unsealed bag with no expiration date -5-pound hamburger - with no expiration date -3- pound bag of chicken with no open/use by date -Both fan covers were riddled with build on dirt and debris. The fans itself also were observed with grayish particles on the fan blades. Dry Storage: -18- Evaporated milk cans- expired ,d+[DATE] -20 pack or tortillas- expired [DATE] -1 box- pasta- expired [DATE] -35 oz box of raisins - expired [DATE] 35 oz container of Frosted Flakes- no use by date. Manager AA reported those items should have been discarded and she's unsure how they were missed in her walkthroughs. Kitchen Area: -Underneath both pop machine spigots was a black/brown dried substance and other unknown splattered substance. -Underneath pop machine was a dried brown substance that was circular in shape -Inside individual toaster was brown/blackened particles at the bottom. -20-pound container of thickener expired [DATE] -20-pound container of sugar expired on [DATE] Dishwashing Area: The top of dishwasher had observable debris in multiple areas and the entrance to the dishwasher had a white/beige clumpy build up around the edges. Manager AA reported it appeared to be calcium build up, but she was not 100% certain. Manager AA was asked to run a test strip to verify if the appropriate temperature was reached for sanitization. As the 1st cycle was completing the wash temperature was at 140 and 3rd cycle- wash temperature at 140 and rinse temperature at 180 . On [DATE] at 11:30 AM, an interview was conducted with Dietary Manager AA regarding the kitchen tour. The manager reported she started in [DATE] and is working toward maintaining structure within the kitchen. Review was completed of the kitchen cleaning logs with many of the daily tasks being blank. She explained they are cleaning in the kitchen but have not initialed them. Manager AA stated cleaning atop the dishwasher and the white buildup observed at the entrance of the machine, is not on the cleaning log so it's nothing they would complete. When asked if she could provide cleaning logs from the prior month, she stated they would be incomplete like the current ones. Everything that was found in the cooler and freezer should have at least had an open date at the very least. Review was completed of the cleaning log from [DATE] to [DATE] and it showed of the four pages of tasks they rarely were completed daily. The log was 85% blank. Review was completed of the facility policy entitled, Use by Date Storage Chart, revised ,d+[DATE]. It stated, All unopened prepackaged processed products should be used or discarded by the Manufacturers expiration date .Meat and poultry - 30 days in freezer .Hard sausage- pepperoni slices-6 months in freezer . Review was completed of the facility policy entitled, Dish Machine Usage and Sanitation, revised [DATE]. The policy stated, .the dish machine will be cleaned inside and out after each meal. Dish Machine will be de-limed, as needed .Minimum wash temperature ,d+[DATE] . final rise temperature must be at least 180 F.

This Citation pertains to Intake Number MI00149049. Based on observation, interview and record review, the facility failed to ensure that residents' rights/dignity was maintained for Resident #'s 6, 38, 60, 81, 82, 94, 97 and 127, of a sample of 26 reviewed for residents' rights, dignity and ADL (activities of daily living) care, and two residents in room [ROOM NUMBER], resulting in long call light wait times, Resident complaints of food served at an unpalatable temperature, menu not followed, lack of assistance with dressing, lack of ADL care, long and jagged fingernails, complaints of staff rudeness with Resident interaction and the potential of unmet care needs, weight loss and dissatisfaction with care, services and meals. Findings include: Resident #6: A review of Resident #6's medical record revealed an admission into the facility on [DATE] and recent admission on 1/3/24 with diagnoses that included end stage renal disease, dependence on renal dialysis, acquired absence of right leg below knee, and anxiety disorder. A review of the Minimum Data Set assessment revealed intact cognition, and the resident was independent for most activities of daily living but needed setup or clean-up assistance for bathing. On 1/29/25 at 10:20 AM, an observation was made of Resident #6 seated in a wheelchair, in the hallway, with a towel over top his lap, and his legs were bare. The towel was small and did not cover the resident past mid-thigh. The Resident was asked questions, responded with answers and engaged in conversation. The Resident was upset and indicated he could not find any sweatpants. When asked if he had let staff know, the Resident reported he had told the nurse earlier today and reported they were going to call down to laundry and get them but has not gotten any yet. The Resident is holding a tee shirt and a blue sweatshirt and reported he got them for his birthday and now the pants were missing as well as his orange pants and another pair of pants. On 1/29/25 at 10:35 AM, an observation was made of Resident #6 seated in a wheelchair with a towel over his lap and legs bare in the hallway. The Resident remains upset over his clothing missing and Certified Nursing Assistant (CNA) R came down the hall and told the Resident that laundry was called but there was no answer. The Resident was upset and told the CNA he had no pants and that he was also missing other pants and expressed frustration. The CNA left the Resident in the hall with a towel across his bare legs. On 1/29/25 at 10:45 AM, an interview was conducted with Resident #6 in his room. The Resident answered questions and engaged in conversation but was not always understandable in some of his explanations. The Resident indicated the facility does his laundry and he got his sweatshirt back but did not get his sweatpants back that match. The Resident indicated that he was missing three pairs of pants. The Resident had boxes of personal belongings stacked on the floor across from his bed. When asked if staff came to look for other clothes, the Resident indicated they had not, and he wanted his ones back that matched his sweatshirt. The Resident was in his room at this time and continued to have a hand towel over his lap and his legs were bare. Resident #38, Resident 81: On 1/29/25 at 11:28 AM, an interview was conducted with Residents #38 and #81 who shared a room together. The Residents were interviewed, answered questions and engaged in conversation. The Residents were asked if there were any issues with care. Both Residents voiced complaints of food being cold when received in the room. The Residents reported they liked to eat in their room, and it will often be cold. Resident #81 expressed that it did not matter which meal because they would come cold for all three meals. Resident #81 reported that the trays will come up and sit in the hall, and pointed outside the door, indicated sometimes seeing or hearing the cart but will not get their tray for a while after. Resident #81 reported breakfast was at 8:00 in the morning but they don't get it sometimes until 9:00 or 9:30 am. Resident #38 reported, when it's like that, I just leave it. When asked when the food was not warm, she did not eat it, the Resident stated, I can't eat it like that. Resident #60: A review of Resident #60's MDS revealed intact cognition, and the Resident needed substantial/maximal assistance with shower/bathe, upper body dressing, lower body dressing and needed partial/moderate assistance with personal hygiene. On 1/29/25 at 11:05 AM, an interview was conducted with Resident #60 who was in bed with the head of the bed elevated. The Resident answered questions and engaged in conversation. The Resident was observed to have very long fingernails. The Resident stated, They are too long, and indicated that his daughter was coming and will take care of them. When asked if staff offered to trim his nails, the Resident stated, They are too busy to do them. When asked if they offered with his shower, the Resident indicated he had a shower yesterday and stated, They didn't get done, they are starting to curl, and showed the edges of the nails are starting to curl under. The Resident reported I scratch myself; they are too long right now. Resident #82: On 1/30/25 at 10:03 AM, an interview was conducted with Resident #82. The Resident was asked questions and engaged in conversation. The Resident had been in the bathroom, came out and had her breakfast tray on her bedside table. When asked if the food was still warm, the Resident reported that it was cold. The breakfast consisted of scrambled eggs, toast that was well done and very dark, and oatmeal. The Resident reported there was no jelly, no butter and the toast was burnt and stated, I can't eat that. The Resident reported not wanting the oatmeal either with no sugar to go on it. There was no sugar on the tray, no jelly and the toast did not look like it had been buttered. During the interview, staff came by and handed out a menu. The staff did not check on the Resident's breakfast tray, offered to warm the tray or removed the tray. The Resident looked at the menu and reported they were to have biscuits and gravy and scrambled eggs. The Resident did not receive the biscuits and gravy. Resident #97: A review of Resident #97's medical record revealed an admission into the facility on [DATE] with diagnoses that included anxiety disorder, depression, lymphedema, and open wound of lower leg. A review of the MDS revealed the Resident had intact cognition and needed substantial/maximal assistance with shower/bathing, partial/moderate assistance with personal hygiene and transfers. On 1/30/25 at 9:32 AM, an interview was conducted with Resident #97 who was lying in bed with the head of the bed elevated. The Resident answered questions and engaged in conversation. The Resident was asked about bathing and the Resident reported she liked to shower and that her days to shower were on Tuesday and Friday. The Resident reported that the staff don't always offer a shower, that she must remind them and had recently missed a shower that was not offered at another time having to wait for the next shower day. The Resident reported that staff can be rude or have an attitude towards her or disrespectful. The Resident had reported they had long call light wait times and had incontinence when waited for assistance with the call light on. The Resident reported problems with cold food and stated, 50:50 chance the meal is cold. The Resident reported that the menu was not always followed, the alternative was not always available if it was not ordered ahead of time, but the menus are passed out late and you don't know what you are going to get, so how would you know to order something else. The Resident reported not getting a menu today to know what was on the menu for breakfast. Resident #38, Resident 81: On 1/29/25 at 11:28 AM, an interview was conducted with Residents #38 and #81 who shared a room together. The Residents were interviewed, answered questions and engaged in conversation. The Residents were asked if there were any issues with care. Both Residents voiced complaints of food being cold when received in the room. The Residents reported they liked to eat in their room, and it will often be cold. Resident #81 expressed that it did not matter which meal because they would come cold for all three meals. Resident #81 reported that the trays will come up and sit in the hall, and pointed outside the door, indicated sometimes seeing or hearing the cart but will not get their tray for a while after. Resident #81 reported breakfast was at 8:00 in the morning but they don't get it sometimes until 9:00 or 9:30 am. Resident #38 reported, when it's like that, I just leave it. When asked when the food was not warm, she did not eat it, the Resident stated, I can't eat it like that. On 1/30/25 at 2:40 PM, an interview was conducted with Dietary Manager H regarding complaints of food not at a palatable temperature for residents. When asked about complaints, the DM indicated they have had some complaints regarding cold food. When asked if they had done any audits, she reported she had not done a test tray, but the Dietician had. An observation of breakfast passed in the 300 hall area at 9:22 AM this morning was reviewed. The DM reported breakfast started to be served about 8 AM in the dining room, then room trays were assembled after that and that the trays were passed depending on when the aides were available. The DM indicated that breakfast was a slower meal with them (residents) just getting up, and reported that they were working on getting the trays out earlier. On 1/31/25 at 11:15 AM, an interview was conducted with the Director of Nursing (DON) with a review of multiple concerns. Resident #97's shower/bathing was reviewed with a shower documented as given on 1/7/25 and then 10 days later on 1/17/25. There was no documentation that the Resident had refused. The DON indicated that had staff documented that the Resident refused, they would have gotten an alert and it would have been addressed by finding out issue and reschedule the shower. The DON reported because it had not been charted at all, that they did not get the alert. The DON reported that a grievance form had been filled out with all the Resident's concerns and the concerns were addressed. The grievance/complaint form had been requested earlier in the survey and was not received by the facility. The DON was asked for the form and the DON reported that they should have a copy. The DON was asked about nail care and reported that the nails were offered during bathing and as needed. The DON was informed of the Resident complaints of cold food. The DON reported that they serve in the dining room first then put the trays together, put on the tray cart and they go to the hall for the Residents that eat in their room. On 1/31/25 at 1:48 PM, an interview was conducted with the Assistant Administrator (AA) Q regarding complaints voiced by Resident #97. The AA indicated that the Resident had voiced concerns, and they had filled out a concern form and had provided follow through with the concerns. The facility Grievance form for Resident #97 was not received prior to the exit of the survey. Residents in room [ROOM NUMBER]: On 1/29/25 at 1:07 PM, an observation was conducted with Resident in room [ROOM NUMBER]-1 of long fingernails with debris underneath the fingernails. The Resident was asked when their last shower was, but they reported they were unsure. When asked if staff had offered to trim their fingernails, the Resident indicated staff had not offered and they would not refuse. The Resident in 328-3 reported having a recent shower but had not been offered nail care. An observation was made of the Resident nails being long and jagged. A review of facility policy titled, Resident Rights, effective 5/14/24, revealed, Policy: The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . 22927 Hydration/Water Pass: Observation and interview on 01/30/25 at 08:19 AM with the Director of Nursing (DON) of Resident #41 revealed the call light on the floor. The surveyor had the DON go into the resident room and give it to the resident, there is no clip to his call light. Resident #41 was lying in bed and stated that he still had Third shift water dated 1/29/2025 with no ice, and why was there no fresh water that morning. Resident #41 stated that the staff are lazy, they are good when they work, but they don't want to work. They talk to us like we live on the street, there's no respect, very rude to the way they talk to us. The DON stated that there was No clip on the call light, they break, and we have replaced them. Fresh Water passes are done at the end of each shift, night shift should have passed the fresh water for this morning before 7:30 am at the end of their shift. Observations and interview on 01/30/25 at 08:30 AM the Surveyor reviewed resident rooms 304, 303, 302, 301, for fresh waters, all were dated 1/29/25 3rd. room [ROOM NUMBER]-2 water was dated 1/27/2025. room [ROOM NUMBER]-1 dated 1/29/25 3rd, 305-2 undated, 306-2 water dated 1/29/2025 3rd, 311-1,2,3,4 all had water not dated and with no ice. The Resident in bed 311-4 stated that's last night's water when asked why his roommate had no ice in his water. Observation on 01/30/25 at 08:36 AM of Resident #102 in room [ROOM NUMBER]-2 noted that the call light was on the floor, and white Styrofoam glass with water dated 1/29 3rd. In an interview on 01/30/25 at 02:42 PM with the Certified Dietary Manager (CDM) H stated that the aides pass the water at the end of their shift, 3 times a day. Record review of the facility 'Oral Hydration' policy dated 12/10/2024 revealed it is the policy of the facility to assist residents to maintain adequate hydration whenever possible Procedure: (5.) Each resident will be provided bedside water unless contraindicated . Dining Observation: Observation and interview on 01/30/25 at 08:45 AM on the 3 North unit of resident rooms when checking for [NAME] pass, revealed that the residents complained of no breakfast yet this morning. Multiple rooms reviewed for water pass with no breakfast trays noted at 8:45 AM. Observed the 3 North dining with steam table set up in progress while waiting for the elevator. During the ride in the elevator down, The Certified Dietary Manager (CDM) H got on the elevator at the second floor, and was asked what time breakfast was served? she stated 8:00 AM. Observation on 01/31/25 at 08:42 AM on the 3 North unit revealed the First breakfast tray to the hallway from the dining room, by Certified Nurse assistant (CNA) I took the meal tray to room [ROOM NUMBER]-2. Dignity: Resident #94: In an interview on 01/29/25 at 01:08 PM with Resident #94 revealed that the facility staff on the 3 south unit are rude and disrespectful. If Resident #94 goes over to the 3rd floor south unit side of the building the staff tell the resident to get out of there and are nasty to the resident. Resident #127: In an interview on 01/29/25 at 09:42 AM with Resident #127 during the initiate screening task of the survey revealed the resident had concerns stating: 'they are so disrespectful, they yell at us residents, they don't care about us, they will ignore the residents and stand around and talk. Call lights take over 15 minutes to get answered. Here's an example, last night I took a nap, and I woke up to a chemical smell in my room, and asked the staff if they could smell it, they said no, and walked out. They just walk away and don't address the issues. Record review of the facility 'Certified Nursing Assistant' job description undated, revealed the position requires patience, compassion and a desire to care for the residents in a gentle and empathetic manner. essential functions included: record fluid intake and output, assist with eating and hydration, make routine rounds on each assigned resident every two hours, provides and reinforces other behavior consistent with the resident's dignity. Resident Rights: Promotes and protects resident's rights; treats residents with dignity and respect .

Based on observation, interview and record review, the facility failed to ensure that two Residents (#21, #83) received consistent pre and post dialysis weights, and failed to ensure that two Residents (#22, #107) received medications post dialysis when the residents returned to the facility from dialysis, resulting in the potential for decline in condition, lack of medication therapy, and prolonged health issues. Findings include: Record review of the facility 'Hemodialysis' policy dated 9/26/2023 revealed residents receiving hemodialysis will be assessed pre and post treatment and receive necessary interventions Record review of the facility 'Medication Administration' policy dated 10/17/2023 revealed resident medications are administered in an accurate, safe, timely and sanitary manner. Procedure: (6.) Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility Resident #107: Record review of Resident #107's December 2024 Medication Administration Record (MAR) noted that on 12/3/24, 12/5/24, 12/7/24, 12/10/24, 12/12/24, 12/14/24 and 12/17/24 Resident #107 did not receive medications of Norvasc 10 mg (blood pressure), pantoprazole 40 mg (GERD), Valsartan 160 mg (blood pressure), Coreg12.5mg (blood pressure), Eliquis 2.5 mg (blood thinner), Nepro 2 times daily (dialysis), Reglan 5 mg (nausea), and sevelamer carbonate 2.4 grams (dialysis) were not administered on those dialysis days as ordered by physician. Record review of Resident #107's January 2025 Medication Administration Record (MAR) noted on 1/25/25, 1/28/25 that Aspirin 81 mg, Folic Acid 1 mg, Norvasc 10 mg (blood pressure), pantoprazole 40 mg (GERD), Valsartan 160 mg (blood pressure), Coreg12.5mg (blood pressure), Eliquis 2.5 mg (blood thinner), Nepro 2 times daily (dialysis), and sevelamer carbonate 2.4 grams (dialysis) were not administered on those dialysis days as ordered by physician. An interview and record review on 01/31/25 at 01:52 PM with the Director of Nursing (DON) revealed Resident #107's December 2024 and January 2025 Medication Administration Record (MAR) of missed medications. The DON stated that she could not explain why the nurses are not giving the resident medications on dialysis days before going to dialysis or why after the resident comes back. The DON stated that she will have to educate the nurses on changing med times. 37666 Resident #21 Dialysis A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #21 was admitted to the facility on [DATE] with diagnoses: history of a stroke with left-sided weakness, Dementia, diabetes, chronic kidney disease, need for dialysis, feeding tube, history of seizures. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 0/15 and the resident needed assistance with all care. ON 1/30/2025 at 10:33 AM, Resident #21 was observed lying in bed, awake. He did not verbalize answers to questions, but would point or make gestures. Nurse aide M was with him and said she was going with the resident to dialysis and they were waiting for the transport to arrive. The nurse aide said the resident went to dialysis on Monday, Wednesday, and Friday and needed someone to go with him because he would become restless and try to get out of the chair and fall. The resident was asked where his dialysis catheter was and he pointed to his left groin; the nurse aide confirmed that was where his catheter was. The resident pointed to his abdomen and a feeding tube was observed. On 1/30/2025 at 2:51 PM, Registered Dietitians/RD F and G were interviewed about Resident #21's weight. He weighed 120.8 lbs. on 1/6/2025. RD G said the resident had experience a weight loss over several months. RD G said she used the resident's weights on the Dialysis Communication Forms to determine the resident's nutritional status. The weight was obtained pre and post treatment on Monday, Wednesday and Friday when the resident went to dialysis. The RD G said the dialysis center did not always document the weights on the resident's Dialysis Communication Form and the last weight in the Weights and Vitals section of the electronic medical record for Resident #21 was dated 1/6/2025. A record review of the electronic medical record for Resident #21 indicated the most recent Dialysis Communication Form was dated 12/27/2024. A review of the Dialysis Communication Forms indicated they were not consistently completed. Many were missing pre or post or pre and post dialysis weights. Some of the forms were mostly blank. Resident #83 Dialysis A record review of the Face sheet and MDS assessment indicated Resident #83 was admitted to the facility on [DATE] with diagnoses: Diabetes, end stage kidney disease, need for dialysis, anxiety, depression, absence of left leg below the knee due to amputation, and heart failure. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS score of 15/15 and needed some assistance with care. On 1/30/2025 at 9:05 AM, Resident #83 was observed sitting in his wheelchair in the hallway. He said he went to dialysis on Monday, Wednesday and Friday. A record review of the electronic medical record for Resident #83, revealed there was one Dialysis Communication Form in the medical record dated 11/11/2024. A review of the weight for Resident #83 indicated they were obtained less than weekly at the facility and the last weight was dated 1/21/2025 with a weight of 208.2 lbs. The resident had gained 8.6 lbs. from the prior weight on 1/9/2024. A review of the Care Plans for Resident #83 identified the following: (Resident #83) is at risk for complications related to needs dialysis due to : possible infection, CKD/chronic kidney disease, date initiated 11/7/2024 and revised on 11/8/2024 with Interventions: Dialysis, with pickup time of 11 am and chair time 1130 am, dated 12/2/2024; For Hemodialysis: Facility will utilize the Dialysis Communication form to communicate with the dialysis center . date initiated 11/12/2024; For Hemodialysis: Obtain daily weights as ordered. Notify physician of weight changes per physician ordered parameters, date initiated 11/12/2024; Observe for signs of fluid retention: peripheral edema, weight gain . dated 11/7/2024. On 1/30/2025 at 3:26 PM, RD F was interviewed about Resident #83. He said the resident was monitored for weight loss or gain, but the weights were not consistently obtained. The dialysis center did not always provide pre and post dialysis weights and the facility did not obtain pre and post dialysis weights. He said the resident had experienced a weight gain possible related to fluid build up. 37771 Resident #22: A review Resident #22's medical record revealed an admission into the facility on [DATE] and readmission on 1/22/25 with diagnoses that included chronic kidney disease with dependence on renal dialysis, dementia, bradycardia, seizure disorder or epilepsy, and hypertensive chronic kidney disease. A review of the Minimum Data Set assessment dated [DATE] revealed the Resident had severely impaired cognition and needed substantial/maximal assistance with eating, toileting hygiene, bathing, dressing, roll left and right, sit to lying, lying to sitting. A review of Resident #22's medical record revealed the Resident went to dialysis on Tuesday, Thursday and Saturday. The Resident had been transferred to the hospital on 12/31/24 and returned to the facility on [DATE]. A review of Resident #22's Medication Administration Record (MAR) revealed medications scheduled in the morning at 9:00 am and 11:00 am were not always given on the days the Resident was scheduled for dialysis and not documented as given before leaving or after returning to the facility. The facility did not accommodate the Resident's dialysis treatments in the medication regimen. Review of the January 2025 MAR included the following: -Doxazosin 2 mg (milligram), give 2 tablets one time a day for hypertension, scheduled at 9:00 am on 1/8 then changed to 11:00 am. The following days were documented with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Escitalopram Oxalate 10 mg, given 1 tablet one time a day for depression, scheduled at 9:00 am on 1/8 then changed to 11:00 am on 1/9. The following days were documented with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Furosemide 20 mg, give 1 tablet by mouth one time a day for diuretic, scheduled at 9:00 am on 1/8 then changed to 11:00 am on 1/9. The following days were documented with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Losartan 50 mg, give 1 tablet one time a day for hypertension, scheduled at 9:00 am on 1/8 then changed to 11:00 am on 1/9. The following days were documented with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Colace 100 mg, give 1 capsule two times a day for bowel regimen, scheduled at 11:00 am and 9:00 pm. The following days were documented on the 11:00 am administration with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Levetiracetam 250 mg, give one tablet two times a day for epilepsy, scheduled at 11:00 am and 9:00 pm. The following days were documented on the 11:00 am administration with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Midodrine 5 mg, give one tablet two times a day for hypotension, scheduled at 11:00 am and 5:00 pm. The following days were documented on the 11:00 am administration with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Nifedipine Extended Release 60 mg, give one tablet by mouth two times a day for hypertension, scheduled at 11:00 am and 9:00 pm. The following days were documented on the 11:00 am administration with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. -Quetiapine Fumarate, 25 mg, give one tablet by mouth two times a day for depressive disorder, scheduled at 11:00 am and 9:00 pm. The following days were documented on the 11:00 am administration with a 3, which indicated Absent from Home, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30. On 1/31/25 at 11:33 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #22 and the lack of accommodations of medication regimen with dialysis treatments. The DON indicated that the medications should be given when returned or earlier in the mornings. The DON indicated that the Resident was picked up at 8:15 for a chair time at dialysis at 9:00 am and gets back about 1:00 pm.

Based on interview and record review, the facility failed to ensure that pharmacist medication regime reviews (MRR) were reviewed, acted upon and addressed in the residents' clinical record for five (#27, 40, 42, 86, 102) of five residents reviewed for MRR. resulting in medications not being adjusted with physician response to accept or decline the pharmacy recommendations. Findings Include: Resident #27 On 1/29/2025 at approximately 2:15 PM, a review was conducted of Resident #27's medical record and it indicated the resident admitted to the facility on [DATE] with diagnoses that included Alzheimer's, Adjustment Disorder, Delusional Disorder, Dementia, Adjustment Disorder and Major Depressive Disorder. On 1/30/2025 at approximately 4:00 PM, a review was conducted of Resident #27's monthly pharmacy recommendations from May 2025 to December 2024. The pharmacist noted an irregularity on 9/24/2024 but the specifics were not in the resident medical record. On 1/31/2025 at 10:13 AM, an interview was conducted with the DON (Director of Nursing) regarding monthly pharmacy recommendations. She explained contact was made with their pharmacist who emailed the recommendation which was addressed timely for Resident #27 in early October 2024; but they do not have the signed copies of them within the medical chart nor is there a subsequent binder for other residents MRR. Resident #86 On 1/30/2025 at approximately 4:15 PM, a review was conducted of Resident #86's monthly pharmacy recommendations from May 2025 to December 2024. The pharmacist noted irregularities in March 2024, May 2024 and October 2024 but the specifics of their recommendations were not located in Resident #86's medical record. The facility provided pharmacy consultation reports that were unsigned by the physician and DON: 3/26/2024: .Please consider discontinuing Senna and docusate and adding PEG 3350 17 gms qd and titrating to BID if needed . 5/28/2024: .Please monitor for involuntary movements now and at least every 6 months or per facility protocol. It is recommended that monitoring frequency increase following dose adjustments . 10/29/2024: .Please monitor for involuntary movements now and at least every 6 months or per facility protocol. It is recommended that monitoring frequency increase following dose adjustments . 37666 Resident #40 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #40 indicated an admission to the facility on [DATE] with diagnoses: Diabetes, kidney disease, anemia, hypertension, anxiety, depression, psychiatric disorder. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 1/15 and needed assistance with care. On 1/30/2025 at 1:53 PM, during a record review of the Medication Regimen Reviews/MRR for Resident #40, it was identified there were 4 MRR recommendations from the monthly MRR reviews over the past year. The recommendation dates identified by the facility pharmacist included: 3/11/2024, 5/28/2024, 10/30/2024 and 1/30/2025 (which was newly completed). Of the 3 recommendations in 2024, the Director of Nursing was able to provide a copy of the pharmacy recommendation for one date: 10/30/2024. The recommendations for 3/11/2024 and 5/28/2024 were not located by the facility and it could not be determined what they were or if the physician/provider reviewed them and acted upon them. Resident #42 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A record review of the Face sheet and MDS assessment indicated Resident #42 was admitted to the facility on [DATE] with diagnoses: Alzheimer's, depression, COPD, Heart Disease and Non traumatic brain injury. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS score of 15/15. On 1/30/2025 at 1:23 PM, the monthly Medication Regimen Reviews/MRR reviewed indicated 2 of the reviews had recommendations: 1/28/2025 (newly completed) and 12/31/2024. Neither recommendation could be located in the medical record for Resident #42. On 1/30/2025 at 2:30 PM, the Director of Nursing/DON was asked about the pharmacy reviews for Resident #40 and Resident #42. She said she would look for them. On 1/31/2025 at 10:30 AM, the DON said she found 1 pharmacy review for Resident #42 dated 12/31/2024. The recommendation from the pharmacist was Please obtain a BMP (bloodwork) on the next convenient lab day and every 6 months thereafter. The provider signed the document with I accept the recommendations above, please implement as written, on 1/3/2025 and the DON signed on 1/8/2025. During a review of the medical record for Resident #42, a laboratory result with a BMP (basic metabolic panel- which included electrolytes, glucose and tests for kidney function), were not located. The last blood work in the resident's chart was dated 6/12/2024. 22927 Resident #102: Record review of Resident #102's January 2025 Medication Administration Record revealed that the resident received: Ativan 0.5 mg tablet twice daily for anxiety and agitation; Depakote sprinkles 125 mg twice daily for psychotic disorder and delusions. Zyprexa 7.5 mg tablet twice daily for restlessness and agitation. Record review on 01/30/25 at 01:36 PM of Resident #102's pharmacy reviews from April 2024 through January 2025 revealed there to be no reviews for the months of June 2024 and August 2024 found for the resident. An interview on 01/31/25 at 12:53 PM with the Director of Nursing (DON) of Resident #102's Medication regimen review for a year look back revealed there were no June 2024 or August 2024 reviews found in the computer. The DON stated that at this point 6 months past those months the medication reviews should have been there (in the computer system). The DON stated that she did learn about looking up the monthly reviews. The Pharmacy consultant does the monthly and/or admission reviews. The DON stated that she could not know if there were any pharmacy recommendations for those months of June 2024 or August 2024 for that resident.

This Citation Pertains to Intake Number MI00138869. Based on interview and record review, the facility failed to ensure adequate supervision to prevent physical abuse and ensure appropriate reporting and comprehensive investigations of abuse allegations for one resident (Resident #76) of two residents reviewed. This deficient practice resulted in Resident #76 suffering three separate incidents of physical abuse perpetrated by two separate residents (Resident #71 and Resident #376), the need for emergency medical treatment, and the likelihood for psychosocial distress utilizing the reasonable person concept. Findings include: Review of intake documentation detailed concerns that the facility was not providing adequate supervision to ensure Resident #76's safety. The intake specified Resident #76 was physically assaulted on more than one occasion by other facility residents including being hit and having their surgically placed medical devices forcefully pulled out. Resident #76: On 1/30/24 at 12:07 PM, Resident #76 was observed sitting in a geri-chair (reclining, high back wheeled chair used for positioning) in their room. When spoken to, Resident #76 made eye contact and stated, To much pressure on my stomach. When asked questions, Resident #76 did not provide meaningful responses. Record review revealed Resident #76 was most recently admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, colon tumor, dysphagia (difficulty swallowing), and gastrostomy (surgically created opening in the abdominal wall to the stomach for the introduction of nutrition- commonly called a PEG or G-tube). Review of the Minimum Data Set (MDS) assessment, dated 1/10/24, revealed the Resident was moderately cognitively impaired, had impaired Range of Motion (ROM) in both upper and lower extremities, required a feeding tube for nutrition, and required maximum-to-total assistance to complete Activities of Daily Living (ADL). Note: A PEG (Percutaneous Endoscopic Gastrostomy) or G-tube is inserted through the surgically created opening in the abdomen wall to the stomach and held in place by an inflated balloon or a bumper device in the stomach as well as an external bumper and/or securement device on the abdomen. A review of requested Incident and Accident (I and A) Reports and Investigations for Resident #76 revealed documentation pertaining to Resident-to-Resident altercations on 6/27/23 and 8/5/23. Review of documentation related to the Resident-to-Resident incident on 6/27/23 involving Resident #71 included the following documentation: - 6/27/23 at 2:32 PM, I and A Form: Other . Incident Description: This nurse was setting up resident's tube feeding . set up in day room . was notified . that peg tube was pulled out by another resident. Resident Description: Resident Unable to give Description . Immediate Action Taken . Resident was removed from dining room and placed into another area and assessed for any new injuries . New orders given to send to hospital for peg tube replacement . No injuries observed at time of incident . Mobility: Bedridden . No witnesses . - 6/27/23 at 2:32 PM: Incident and Accident Investigation Form . Location: 2 South Dining Room . Resident (s) . (Resident #76) and (Resident #71) . Made aware by the nurse on the unit. To Whom was it reported: DON (Director of Nursing) . Additional Interviews . (LPN C) . Date: 6/27/23 . Signature of Interviewee indicating that he/she been interviewed, reviewed the interview summary, and did not give a written statement . (Blank/Unsigned by LPN C) . Conclusion: The resident whose peg tube was dislodged likes to sit in the window and sing in a loud voice. This was a trigger to (Resident #71) who pushed (Resident #76's) chair causing the peg tube to become dislodged. (Resident #71) states (Resident #76) was too (sic) but there was no intent to harm resident . Brief description of the plan to avoid this situation in the future . (Resident #76) likes to sit up in chair in the day room during the day, enteral feeding time changes to the evening. (Resident #71 was moved to another unit . A form entitled, Quality Assurance Interview Summary . was included with Investigation Form. The form detailed, Resident Interviewed: (Resident #71) . Date: 6/27/23 . Summary of Statement/ Interview: Asked why they pushed (Resident #76's) chair and (Resident #71) stated, 'They was too loud' and I was watching TV . Staff Member Interviewed: (LPN C) . Date: 6/27/23 . Nurse stated they started resident's enteral feeding and put them in the day room because they like to sit in there . states stated out and when came back in (Resident #71) was pushing (Resident #76's chair which caused the peg tube to become dislodged . The interview statements were not signed. The documentation did not include an interview with Resident #76. Resident #71: Record review revealed Resident #71's was originally admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder; bipolar type, anxiety, major depressive disorder, catatonic disorder (abnormal movements, communication, and/or behaviors) due to known physiological condition, and vascular dementia with behavioral disturbance. Review of Resident #71's MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and displayed verbal behavioral symptoms towards others one to three days and other behavioral symptoms daily which significantly interfered with care and participation in activities and/or social interactions. Review of progress note documentation in Resident #71's EMR revealed the following: - 3/25/23 at 3:15 PM: Nurses Notes . Resident alert with confusion most times . seen by staff attempting to take (another) residents g-tube apart. Resident stopped by staff and redirected to another area . - 6/27/23 at 2:42 PM: Nurses Notes .Resident pushed another resident out of day room causing the other residents peg tube to become displaced. Residents immediately taken to different areas. No further incidents noted. - 6/28/23 at 12:42 PM: Social Services Note . Late Entry: SW (Social Worker) was informed that resident caused another resident's peg-tube to come out. Resident was observed sitting in the day room . SW inquired why they pulled on the resident's wheelchair. Resident stated, 'I don't know what you're talking about'. Resident did not recall this situation happening. This is baseline for cognition. Resident often does not recall . SW attempted to discuss with resident things to do when other residents might be bothering them. However due to low cognition and inability to retain information. This most likely will not be helpful . Staff reported no concerns . Further review of Resident #71's EMR revealed the Resident had a history of sexually inappropriate behaviors including kissing and touching male residents as well as verbal and physical behaviors directed towards others. On 6/28/23 at 7:20 PM, Resident #71 pushed another Resident in the threshold of the day room causing them to fall and experience injuries. Review of Resident #71's care plans revealed a care plan titled, I, (Resident #71) has a potential for physical aggression R/T: Dementia, Schizoaffective disorder (bipolar type). On 3/4/22 I was accused of hitting a male resident and told psych nurse that I liked him more than a friend and I expose myself to get attention because that's how I 'get people to talk to me' . 8/18/2022 (Resident #71) was accused of hitting a fell ow male resident on the shoulder . Due to my cognition, I do not retain information on education about my inappropriate behaviors. I will often bang on the wall, counters and table . (Initiated: 9/26/21; Revised: 12/28/22). Review of provided documentation pertaining to the Resident-to-Resident altercation with Resident #376 on 8/5/23 detailed the following: - 8/5/23 at 05:20 AM, I and A Form: (Type) Verbal . Location: Resident's Room . Nursing Description: Resident was observed getting punched in upper body by another resident., The resident that was showing aggression was assisted out of the room immediately into day room. (Resident #76) was assessed . no injury noted . Resident Unable to give Description . Immediate Actions Taken: Resident was assessed . The Resident that was the aggressor . was removed from room and assessed as well . No injuries . Mobility: Wheelchair bound . Mental Status: Orientated to Person (only) . baseline . No Witnesses . - 8/5/23 at 2:32 PM: Incident and Accident Investigation Form . Location: (Resident #76 Room) . Resident (s) involved . (Resident #376)/ (Resident #76) . Description . (Resident #376) was observed to hit (Resident #76) . Under what circumstances did the reporting person become aware of the incident? CNA (Certified Nursing Assistant) responded to the noise from the room while doing rounds . To whom was it reported: Administrator . 8/5/23 . 3:46 PM . Was the resident involved in the alleged incident questioned? Yes . Date: 8/7/23 . (Resident #376), (Resident #76) . Additional Interviews . (CNA G) . 8/8/23 . Conclusion . Residents did not have any recollection of the incident/Staff responded appropriately and separated residents and reported to the nurse . The Quality Assurance Interview Summary . included with Investigation Form detailed, (Resident #76/Resident #376) . Unable to Interview. Date of Interview: 8/7/23 . Residents were unable to recall the incident . Staff Member Interviewed: (CNA G) . Date of Interview: 8/7/23 . Summary of Statement/Interview: CNA states at the start of shift . was doing walking (sic) and heard noise coming from (Resident #76's) room. When they went into the room, (Resident #376) was standing over (Resident #76) and was hitting them . states they separated the residents. Removed (Resident #376) from (Resident #76's) room and reported the incident to the nurse on the unit . Resident #376: Record review revealed Resident #376 was originally admitted to the facility on [DATE] with diagnoses which included psychotic disorder with delusions, adjustment disorder with disturbance of conduct, and dementia with behavioral disturbance. Review of the MDS assessment, dated 9/29/23, revealed the Resident was severely cognitively impaired and displayed behaviors including wandering, physical and verbal behaviors directed towards others, and other behaviors not directed at others. Review of progress note documentation in Resident #376's EMR revealed the Resident punched another resident in the face on 7/22/23 as well as hit staff and displayed verbal behaviors throughout their stay at the facility. Review of care plans in Resident #376's EMR revealed a care plan entitled, (Resident #376) has a actual behavior problem . I'm not redirectable at times. I will try in get into other beds, while other residents are in them. I will not stay in bed when staff put me there. Staff reports that I touched another residents feces. I will go to my roommate, pull covers off, stand over them, and go into other resident's rooms messing with their stuff and getting in their beds. I will touch people with unwanted touching but due to my cognition and dx (diagnosis) of dementia. I also attempt to pick things up from the floor or wall that are not there . appears to see things that are not there. I had an episode where I smeared my feces all over my room like paint, and on my roommate's side (Created: 7/3/23; Revised: 12/5/23). An interview was conducted with Social Worker A on 2/1/24 at 12:02 PM. When queried regarding Resident #76, Social Worker A revealed Resident #76 was moved from the memory care unit of the facility to their floor. When asked the reason Resident #76 was moved out of the memory care unit, Social Worker A revealed they did not know and would need to check with the Unit Manager. When queried regarding altercations with other Residents, Social Worker A indicated they were not aware of any altercations. When queried regarding Resident #76's cognition and lack of meaningful responses when asked questions, Social Worker A revealed that is the Resident's baseline cognition. On 2/1/24 at 12:29 PM, an interview was completed with Family Member Witness D. When queried regarding Resident #76's stay at the facility, Witness D verbalized concerns regarding the Resident's safety and adequacy of staff supervision. When asked why they had these concerns, Witness D revealed Resident #76's PEG tube got pulled out twice by the same Resident. Witness D was asked what happened and replied, There was nobody (staff) in the room with the TV (day room) and the other Resident just pulled it right out. When asked to clarify if they were saying the other Resident pulled the PEG tube out of Resident #76's abdomen, Witness D confirmed that was what they were saying. With further inquiry, Witness D revealed Resident #76 had to be transferred to the hospital both times to have the PEG tube reinserted. When asked about Resident #76's PEG tube, Witness D replied that Resident #76 did not eat or drink and obtained all their nutrition and fluid intake via the feeding tube. Witness D then stated, I got another call that a (different) Resident was on top of (Resident #76) beating their ass. When queried what had occurred, Witness D revealed they were informed that Resident #76 was in their room in bed and a staff member found another Resident on top of them hitting them. Witness D stated, There was some nasty stuff on that floor. They (staff) don't communicate. Witness D was asked to explain what they meant and indicated they do not believe the staff always tell the truth and do not communicate timely. An interview was completed with the facility Administrator on 2/1/24 at 2:19 PM. When queried what occurred on 6/27/23 when Resident #76's PEG tube became dislodged, the Administrator stated, (Resident #71) just pushed (Resident #76). When asked if Resident #76 was sitting in a wheelchair or Geri chair, the Administrator replied they assumed they were. When asked how far they were pushed in the chair, the Administrator revealed they did not know. The Administrator was asked the likelihood of a surgically placed PEG tube becoming dislodged from the abdomen from having their wheel chair pushed, the Administrator did not provide an explanation. When asked if the tube feeding had been disconnected from the PEG tube, the Administrator reviewed the investigation documentation and revealed they did not know. When asked if it was logical that the tubing would become disconnected rather than being pulled from the abdomen by being pushed in a chair, the Administrator indicated they were not a nurse and did not know. On 2/1/24 at 2:37 PM, an interview was completed with Witness D. Witness D was queried how many times another Resident had pulled out Resident 76's feeding tube (PEG) and replied, Two. With further inquiry, Witness D reiterated it was the same Resident who had pulled the tube out both times and stated, (Resident #76) was very fearful of them. When queried if they recalled the specific dates in which the tube had been removed, Witness D replied that facility staff were aware of the dates. Witness D was asked if they remembered the dates, due to the facility on ly providing one I and A form related to the Resident's PEG tube, Witness D revealed they were at work but would attempt to locate the information. Witness D disclosed they were at the facility, meeting with Social Worker J in their office when (Resident #71) pulled it out the second time. Witness D verbalized Social Worker J confirmed Resident #71 had pulled out Resident #76's PEG tube previously. Witness D was then asked how they knew Resident #76 was fearful of the other Resident and indicated they had told them. When queried regarding Resident #76 not responding and/or not providing meaningful responses when this Surveyor asked them questions, Witness D indicated the Resident does not always talk to people they are not familiar with. A follow-up interview was completed with Witness D on 2/2/24 at 1:36 PM. When queried if they recalled the dates Resident #76's PEG tube had been pulled out the first time by the other Resident, Witness D revealed they thought it was in April 2023. Witness D stated, They did call me and say it came out. When asked if they recalled anything else about the phone call, Witness D stated, I think it was at night it was after 9:00 PM and revealed they recalled the time because they were working different shifts at the time. Witness D stated, They said it come out when (Resident #76) was sleeping. When asked if Resident #76's PEG tube became dislodged when they were sleeping or if it was pulled out by another Resident, Witness D revealed they found out the next time they went to the facility to visit Resident #76 while talking to a CNA in the elevator. Witness D stated, (The CNA) was talking to me like I knew. (The CNA) was talking about the Resident who took the PEG tube out. (The CNA) said (Resident #71) said give me a kiss and then pulled it out. When asked if they spoke to Resident #76's nurse about the other Resident pulling out Resident #76's PEG tube, Witness D revealed they talked to multiple facility staff members. Review of Resident #76's note documentation in the Electronic Medical Record (EMR) revealed the following: - 4/24/23 at 3:20 PM: Resident alert with confusion . Resident was in dining room when large noise was heard. Another resident pushed resident in wheelchair and g-tube that was connected disconnected completely from entrance. Resident was removed away from resident and assessed. Small blood noted but area cleaned and covered . EMS called . - 4/24/23 at 4:07 PM: e INTERACT SBAR Summary for Providers . Situation . Trauma . - 4/24/23: Physician Encounter . Nurse advised (Resident #76) was pushed while in Geri chair and PEG tube . came out . Recommend sending to ER . - 4/25/23 at 12:56 AM: Nurses Notes . Resident returned from hospital with new . tube feed . - 4/25/23: Physician Progress Notes . Patient was evaluated . seen for evaluation of peg tube placement after accidental dislodgment. Patient also noted with a recent ileus (lack of movement within bowels) . Patient does have mild tenderness at insertion site of peg tube . - 6/27/23 at 2:32 PM: Nurses Notes . This nurse was setting up resident's tube feeding for afternoon feeding. Resident was set up in dining room. This nurse went to finish another assignment and was notified . that peg tube was pulled out by another resident. Area is not bleeding at this time. Resident was removed from dining room and placed into another area. (Family) made aware of findings and social worker as well as hospice nurse. New orders given to send to hospital for peg tube replacement . Note: The same progress note was present in the EMR and dated 6/27/23 at 3:24 PM. - 6/27/23 at 10:49 PM: Nurses Notes Resident returned from Hospital . from getting a Peg-tube replacement . - 8/5/23 at 5:25 PM: Nurses Notes . Resident (family), DON (Director of Nursing), administrator, on call Dr all notified of resident being punched on by another resident. Resident has no injuries or signs of pain noted at this time . - 8/7/23: Physician Progress Notes . Patient was evaluated today s/p (status post) altercation with another resident. It was report that patient was either hit or choked by another resident, unclear per notes and verbal report . Review of EMR documentation revealed LPN C provided care to Resident #76 on both 4/24/23 and 6/27/23. An interview was completed with LPN C on 2/5/24 at 3:12 PM. LPN C was asked what occurred on 6/27/23 involving Resident #76's feeding tube. LPN C stated, (Resident #76) was in the day room and the tube feeding was running. I heard (Resident #76) making noise and getting louder. I walked in their and (Resident #71) had the PEG tube in their hand. (Resident #71) had pulled it out. When queried if Resident #71 was holding the actual PEG tube from Resident #76's abdomen, LPN C confirmed Resident #71 was and reiterated they had pulled it out. When asked why Resident #71 had pulled out Resident #76's PEG tube, LPN C revealed they asked Resident #71 and they replied, Because (Resident #76) wouldn't be quiet. LPN C was asked what Resident #76 was sitting in when this occurred and revealed Resident #76 was in their wheelchair. When queried regarding the position of Resident #76's wheelchair in the room after the PEG tube had been pulled out by Resident #71, LPN C stated, (Resident #76's) wheelchair was in the same spot. LPN C was asked if Resident #71 had pushed Resident #76 in their wheelchair causing the PEG tube to become dislodged, LPN C reiterated Resident #71 had pulled out the PEG tube and specified Resident #71 was holding the PEG tube when they entered the room. When queried if the PEG tube was still running when they entered the day room, LPN C indicated it was and stated, Wasn't a lot of tube feed (solution) all over. LPN C was asked who was working with them and indicated they did not recall. When queried what happened after they found Resident #71 holding Resident #76's PEG tube in their hand, LPN C replied, I removed (Resident #71) from the area and assessed (Resident #76). I think I took (Resident #76) to their room and then I called the (Health Care Provider). LPN C stated, (Resident #76) did go out (to hospital) to get a new one (PEG tube) put in. When queried if Resident #71 and Resident #76 were alone in the day room, LPN C replied, There were other residents in there. When asked if the other Residents present in the day room were cognitively intact, LPN C replied it occurred on the dementia unit. LPN C was then asked if Residents are usually unattended in the day room, without staff supervision and replied, Yes, sometimes. Activities is not always in there. When queried if Resident #71 had a history of behaviors, LPN C stated, Yes, banging on tables and kiss people. Like full on kiss and touch them. When asked if this behavior was directed at other residents, LPN C revealed it was. LPN C was then asked what happened when another resident did not want (Resident #71) to kiss them and indicated Resident #71 would become upset. When queried if Resident #71 was supposed to be or should be left alone with other residents, LPN C stated, Probably not. Particularly tries to kiss men so probably definitely not safe to leave (Resident #71) alone with them. LPN C was asked if Resident #71 had tried to kiss Resident #76 prior to pulling out their PEG tube and revealed they did know as there were no staff present in the room. LPN C repeated Resident #71 just that (Resident #76) wouldn't be quiet. LPN C then added, (Resident #76) wasn't singing, was making their regular noises. When queried if there is an adequate number of staff to monitor and provide supervision to the number of residents on the dementia unit, LPN C replied, We could use more because it is not safe over there (dementia unit) to leave them by themselves and there is only one aide (CNA) and a nurse. When queried if they had provided a written statement and/or statement as part of the investigation, LPN C revealed they had not provided a statement. When queried if Resident #71 had pulled out Resident #76's PEG tube prior to 6/27/23, LPN C replied, That was the first time that (Resident #76's) PEG tube came out for me. When queried regarding EMR documentation dated 4/24/23 indicating the feeding tube had been disconnected completely from the entrance . after being pushed by another Resident in their wheelchair and Resident #76 having to go the hospital, LPN C indicated they did not recall the incident. When queried what disconnected completely from the entrance . meant, LPN C reiterated they did not recall but assumed they meant the feeding tube had come out of the hole in the abdomen. On 2/5/24 at 3:42 PM, an interview was completed with Social Worker J. When queried regarding Resident #76's PEG tube being pulled out by Resident #71 on 6/27/23, Social Worker J revealed they were not present at the time but were aware it had occurred in the day room. When queried if Resident #71 had a history of behaviors including physical behaviors towards others, Social Worker J revealed they did. When asked about Resident #71's behaviors, Social Worker J revealed the Resident was Sexually inappropriate and verbally inappropriate. Social Worker J was asked about physical behaviors and replied, Yes, kissing. Social Worker J indicated Resident #71's physical behaviors were directed towards men. When queried if Resident #71 should be left alone with male residents, Social Worker J replied, No. Social Worker J then stated, If (Resident #71) is in the day room, they should be supervised. Social Worker J was asked if direct supervision when in the day room and not being unattended around male residents was included on Resident #71's care plan, Social Worker J revealed they did not believe that was a care plan intervention. When asked why it was not, an explanation was not provided. Social Worker J was asked if Resident #71 had pulled out Resident #76's PEG tube prior to 6/27/23 and stated, Yes. When queried regarding the date that Resident #71 pulled out Resident #76's PEG tube prior to 6/27/23, Social Worker J revealed they did not know the specific date but that it had to be before 6/27/23. When asked what happened the first time Resident #71 pulled out Resident #76's PEG tube, Social Worker J replied, I don't know. Social Worker J was then asked what interventions were implemented following the first occurrence to prevent it from happening again and stated, I don't know and indicated Resident #76's family was aware of what had occurred. When queried regarding Resident #376, Social Worker J stated, (Resident #376) wandered everywhere. They were very hard of hearing and had very poor eyesight. When asked what occurred on 8/5/23 involving Resident #76 and Resident #376, Social Worker J stated, They (staff) heard (Resident #76) yelling and went down there (Resident #76's room). When queried if Resident #376 had a history of behaviors, Social Worker J replied, Yes. (Resident #376) was aggressive. Mostly with staff and some occasionally with other residents. When queried if Resident #376 was supposed to have supervision when up due to their history of behaviors and aggressiveness, Social Worker J replied, Yeah, monitoring. Social Worker J was queried how Resident #376 entered Resident #76's room and began punching them if they were being supervised/monitored when out of their room and was unable to provide an explanation. At 4:14 PM on 2/5/23, an interview was conducted with Unit Manager LPN B. When queried if Resident #71 pulled out Resident #76's PEG tube twice, LPN B stated they were unsure and would need to review Resident #76's EMR. When asked if an I and A should be completed if a Resident pulls out another Resident's PEG tube, LPN confirmed staff should complete an I and A. A follow-up interview was conducted with Unit Manager LPN B on 2/5/24 at 4:28 PM. When asked, LPN B revealed there was an occurrence in April or May (2023) where Resident #71 pushed Resident #71 in their wheelchair and dislodged their PEG tube. When queried if Resident #71 had grabbed and/or pulled on Resident #76's PEG tube at that occurrence, LPN B indicated they did not know and stated, I didn't see it. Resident #76's progress note documentation was reviewed with LPN B at this time. When queried if the progress notes for Resident #76 on 4/24/23 were pertaining to another incident involving Resident #71, LPN B stated, It was in April and confirmed the documentation was referring to Resident #71 pushing Resident #76. When queried regarding an I and A, LPN B stated, An incident report was not completed. LPN B was then asked about interventions implemented following the incident on 4/24/23 to protect Resident #76 and stated, (Resident #71) was moved off the unit on 6/29/23. When asked if Resident #71 was moved due to pulling out Resident #76's PEG tube on 6/27/23 or because they pushed a different Resident on 6/28/23 causing them to fall and sustain injuries, LPN B did not provide a response. On 2/5/24 at 4:58 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding Resident #76's PEG tube removal by Resident #71 on 6/27/23 including the facility investigation, the DON stated, I did interviews. When queried if facility cameras were reviewed to determine what had transpired, the DON stated, I did not because I do not have access and (the Administrator) was on vacation. The DON was asked how they determined Resident #71 pushed Resident #76's wheelchair which caused their PEG to become dislodged. The DON indicated they interviewed the nurse who was working and reviewed documentation in the Resident's EMR. When queried regarding Residents being unattended in the common day area of the dementia/memory unit, the DON stated, We don't have the staff to dedicate a staff to the common area (day room). An explanation was not provided by the DON when asked how supervision is provided to residents who require supervision for behaviors and safety. When queried regarding Resident #76's PEG tube being pulled out by Resident #71 twice, in April 2023 and in August 2023, the DON stated they were not aware of the tube being removed in April. No further explanation was provided. An interview was completed with the Administrator on 2/5/24 at 5:15 PM. When queried regarding staff supervision of residents in the common areas of the dementia area, the Administrator stated, We try to keep someone down there (common area/day room) but we can't watch them (Residents) 24/7. The Administrator was asked if there was an I and A and/or investigation completed for Resident #76's PEG tube being pulled out on 4/24/23 and revealed there was not. The Administrator indicated they were unaware of the incident on 4/24/23. The Administrator was queried why they were not made aware of the incident but did not provide an explanation. When asked if there was any additional information such as witness statements for Resident #76's I and As dated 6/27/23 and 8/5/23, the Administrator replied, That's all there is. When queried if a review of the facility video cameras was completed when Resident #76's PEG tube was pulled out by Resident #71 on 6/27/23, the Administrator replied, I don't know. The Administrator was then asked if the cameras were reviewed for the occurrence on 8/5/23 when Resident #376 was found punching Resident #76 in their room and indicated they had reviewed the cameras to confirm what staff entered the room. When asked how long Resident #376 was in Resident #76's room, the Administrator revealed they did not know. The Administrator was asked why Resident #376's movements and behavior prior to the physical aggression were not included as part of the investigation but did not provide an explanation. When asked if the camera footage was available for review, the Administrator responded it was no longer available. When queried why the incident/investigation documentation for 6/27/23 and 8/5/23 did not include the schedule/names of other staff working and why no other staff were interviewed, the Administrator indicated only staff directly involved were interviewed. When asked about the inconsistencies in the investigation conclusion for 6/27/23 and lack of staff acknowledgement of accuracy of statement in comparison to interview, the Administrator did not provide a direct response but stated that Resident #76 was not harmed during the 6/27/23 or the 8/5/23 incident. The Administrator was asked if having a PEG tube pulled out by someone else unexpectedly or being attacke [TRUNCATED]

This Citation pertains to Intake Numbers: MI00124709, MI00131782, MI00132014 Based on observation, interview, and record review the facility was placed in Immediate Jeopardy due to the facility's systemic failure to account for narcotics and controlled substances on a daily basis and resolve discrepancies from [DATE] through [DATE], resulting in the diversion of at least 75 Norco tablets. There was likelihood for serious adverse outcomes, including harm and untreated pain, when residents did not receive necessary pain medications due to drug diversion. Immediate Jeopardy: In addition, the following occurred: Resident #103 did not receive 16 prescribed Narcotic pain medication Norco doses on the following dates and times: [DATE] 2200 (10:00 PM); [DATE] 0600 (6:00 AM), 1400 (2:00 PM), 2200; [DATE] 0600 and 1400; [DATE] 0600 1400; [DATE] 2200; [DATE] 0600 1400 2200; [DATE] 0600 1400 2200 and [DATE] 0600. On [DATE]-[DATE], nurses submitted requests for the Pharmacy to send additional blister packs of Norco for Resident #103, because the resident didn't have any. The Pharmacy would not send additional Norco pain medication for Resident #103, because they confirmed it had already been sent to the facility. On [DATE] the facility found empty Narcotic blister packs, including one for Resident #103's Norco, on the Unit Manager T's desk. There were several Narcotic Log (proof of use sheets) for the some of the empty Norco blister packs, with no nursing signatures to indicate the medication had been removed appropriately and administered to Resident #103. The Unit Manager T refused a drug test and quit on [DATE]. During a tour of the facility on [DATE] at 11:00 AM to 11:55 AM, while reviewing the Narcotics logs and counting the narcotics in each medication cart with a nurse and Interim DON, it was identified that 4 of 7 nurses were signing in advance that they had completed their end-of-shift Narcotics count. They had not counted the narcotics with another nurse. Nurses are supposed to count with another nurse and sign together confirming accuracy of the count. On [DATE] at 11:55 AM, , the 2nd Floor Medication Room door was found wide open and unattended; On [DATE] from 11:00 AM to 11:55 AM, during a tour of the medication carts with the Interim Director of Nursing and Corporate Nurse L it was identified that Narcotic count logs for 3 Medication Carts were inaccurate: 8 narcotics: 3 Gabapentin, 1 Methadone, 3 Ativan, 1 Xanax and 1 Norco were not signed out and accounted for on the Narcotics logs Controlled Substances Proof of Use, documents. Each document showed there were more narcotics present in the cart than there actually were. The nurses assigned to each medication cart was interviewed and admitted they had removed the narcotic medications and had not signed them out on the Narcotics Logs. On [DATE] at 3:00 PM, during an interview with the Interim Director of Nursing, she said multiple blister packs and Controlled Substances Proof of Use documents were found on top of Unit Manager Nurse T's desktop. She said there were not corresponding Controlled Substances Proof of Use, documents for all of the blister packs; some of which were empty. For some of the Narcotic medication Blister packs, the medication contained in the blister pack did not match the count on the corresponding Controlled Substances Proof of Use, documents. The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified on [DATE] of the Immediate Jeopardy that began on [DATE]. The IJ Abatement (Removal) Plan was approved on [DATE] with a Removal Date of [DATE]. Findings Include: Both Resident #103 and Resident #140 had missing narcotic pain medication/Norco. They did not receive the prescribed doses of pain medication as ordered by the physician. The facility was unable to locate or account for the missing narcotic medication for either resident. Resident #103: A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #103 indicated the resident was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses: History of a stroke, left sided weakness, arthritis, polyneuropathy, COPD, contracture left hand, heart disease, history of pressure ulcers unhealed and glaucoma. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] and the resident needed assistance ,d+[DATE] person with all care. A review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) for September and [DATE] for Resident #103 identified the resident was to receive the following pain medication: [DATE] MAR/TAR: Norco Tablet 7XXX,d+[DATE] mg (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours for Pain, Start Date [DATE]: Administration times- 0600 (6:00 AM), 1400 (2:00 PM), 2200 (10:00 PM). Resident #103 did not receive the prescribed doses of pain medication on [DATE] at 2200; [DATE] at 0600, 1400 and 2200; [DATE] at 0600, 1400 and 2200; [DATE] at 0600 and 1400; [DATE] at 2200 and [DATE] at 2200. A review of the progress notes for Resident #103 identified the following: [DATE] at 10:19 PM, a nurses note by Nurse Z, Norco Tablet 7XXX,d+[DATE] mg, Give 1 tablet by mouth every 8 hours for Pain; Med unavailable, contacted pharmacy ,d+[DATE], med ordered. [DATE] at 5:28 AM, a nurses note by Nurse Z, Norco Tablet 7XXX,d+[DATE] mg, Give 1 tablet by mouth every 8 hours for Pain; Med unavailable. [DATE] at 1:16 PM, a nurses note by Nurse GGG, Pharmacy aware. [DATE] at 11:35 PM, a nurses note by Nurse HHH, Unavailable. [DATE] at 5:03 AM, a nurses note by Nurse HHH, Unavailable. [DATE] at 4:43 PM, a nurses note by Nurse III, Resident waiting on pharmacy. [DATE] at 5:17 AM, a nurses note by Nurse JJJ, Medication not available. [DATE] at 2:43 PM, a nurses note by Nurse III, Waiting on pharmacy to dropship. There was no additional documentation in the medical record to address that Resident #103 had not been receiving his prescribed pain medication or what actions had been enacted to correct it. An interview with a Nurse Z on [DATE] at 1:05 PM, related to Resident #140's missing Norco revealed, I had ordered Norco for him on Thursday and the pharmacy said it would come up, usually at night. On Saturday, I went to give him his medication and there were only 2 or 3 pills left ([DATE]). I said, 'No way. I just ordered these.' I called pharmacy. They said we can't send any. We just sent you those. I contacted the Unit Manager T and told her. She said she would look into it. She said she called the pharmacy and they wouldn't send anything. She said to give Tylenol or give something else. She was supposed to investigate. She said she would but never did. She would come to the carts and clean them out. She would take the narcotics to her office. All in one night she signed out extra narcotics. Sometimes she didn't document the time that she took them. On [DATE] at 3:00 PM, the Administrator was interviewed related to a Facility Reported Incident (FRI) for missing narcotics for Resident #103 as submitted to the State Agency on [DATE]. She said the Interim Director of Nursing (DON) audited narcotics and identified Resident #103 had missing blister packs of Norco and the proof of use sheets were missing for delivery dates [DATE] and [DATE]. The Administrator said she and Interim DON went to the office of Unit Manager LPN T on [DATE]. She said a thirty-pack proof of use sheet was there for Resident #103's Norco. Another proof of use sheet and empty 15 count blister pack of Norco were found; the blister pack was empty. The Proof of use sheets did not have any signatures for removal of the Norco. Unit Manager T was called to come in for questioning about the blister packs on her desk and proof of use sheets. The Interim DON said there were many narcotic blister packs intended for destruction that were empty with no signature pages on Unit Manager T's desktop; the narcotics were for many different residents. The Administrator said Nurse T had said there was a signature page for the missing Norco for Resident #103; she could not produce it for the missing narcotics. During the interview, on [DATE] at 3:00 PM, the Administrator said the facility notified the police. She said Unit Manager Nurse T was asked to go for a drug test on [DATE], but the nurse did not go and did not return to work at the facility. The Administrator said she was terminated. She said the missing narcotics were not located and the pharmacy provided additional narcotic medication for the resident. A review of the [DATE] MAR/TAR revealed Resident #103 was to receive: Norco Tablet 7XXX,d+[DATE] mg (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours for Pain, Start Date [DATE]: Administration times- 0600 (6:00 AM), 1400 (2:00 PM), 2200 (10:00 PM). Resident #103 did not receive the prescribed doses of pain medication on [DATE] at 1400; [DATE] at 2200; [DATE] at 0600, 1400, 2200; [DATE] at 0600, 1400 and 2200; [DATE] at 0600. On [DATE] at 3:05 PM, the Administrator and Interim Director of Nursing were asked if they were aware that Resident #103 had not been receiving the prescribed doses of Norco from [DATE] to [DATE]. The nurses had not reported to them that the Norco for Resident #103 was missing from [DATE]-[DATE]. Further review of the MAR for [DATE] and review of the Controlled Substances Proof of Use, document for the ordered Norco for Resident #103 and the Medication Blister Pack Containing the Norco for Resident #103, indicated the Narcotic Count for the Norco on [DATE] for the 2200 (10:00 PM) count was wrong. It said there was one Norco pill remaining in the cassette and the prior entry said there were three pills remaining. The nurse was to take and administer one pill three times a day. The narcotic count should have been two, then one then zero. There was no nursing documentation to account for the inaccurate count. There was no explanation documented. Resident #103 did not receive the required doses on [DATE], [DATE], [DATE] or at 6:00 AM on [DATE]. Nursing progress notes from [DATE] at 9:36 PM to [DATE] at 5:25 AM revealed, medication on order; awaiting on delivery from pharmacy; on order will continue regimen upon arrival; medication on order and will be delivered with next delivery per pharmacy ([DATE]). There was no documentation that the narcotic count for the Norco was inaccurate. The nurses did not document that they contacted the pharmacy until [DATE] at 5:25 AM. The resident had been out of his pain medication for 4 days. Resident #103 was transferred to the hospital on [DATE] at approximately 4:49 PM for a change of condition and pressure ulcers. Resident #103 returned to the facility on [DATE] at approximately 11:06 PM. On [DATE] at 10:00 AM, the facilities pharmacy was contacted about the missing Norco for Resident #103. The pharmacist in charge X said that on [DATE] the pharmacy sent 43 tabs of Norco to the facility for Resident #103. They were not aware the resident needed more Norco until they received a new order and sent 9 tabs on [DATE] at 2:00 PM. The pharmacist said the [DATE] missing Norco was not reported until the nurses requested the medication and the provider sent a new order to the pharmacy. A review of the Care Plans for Resident #103 provided: (Resident #103) is at risk for pain, right foot, knee, general related to his diagnosis of: osteoarthritis, neuropathy, Gout, contracture left hand, GERD, BPH (enlarged prostate), anxiety & depression. He is at risk for pain related impaired mobility. Resident states acceptable level of pain is ,d+[DATE] on verbal pain scale (,d+[DATE]), Date initiated [DATE] and Revised [DATE] with Interventions: Administer medications as ordered Date initiated [DATE]; Observe and report any signs and symptoms of non-verbal pain .Mood/behavior (changes, more irritable, restless, aggressive . Report abnormal findings to physician, Date initiated [DATE]; Administer analgesia per physician orders. Observe for effectiveness, date initiated [DATE]. (Resident #103) has attention seeking behaviors . When resident's needs are not immediately addressed, he will yell at staff. Resident will often make statements that care has not been provided when it has. He often chooses to notify outside resources with concerns or discomfort versus staff, Date initiated [DATE], Revision [DATE] with Interventions: Rule out pain as a causative factor for behaviors, Date initiated [DATE]. The facility confirmed that Resident #103 had not consistently received his pain medications as they were missing and not available to be given. The facility was not able to locate the medications. Resident #103 did not receive necessary care and services. A nurses note dated [DATE] at 5:35 PM by Nurse EEE revealed, Resident stated he has pain in his hip all the time and on his bottom from his wound . [DATE] at 4:02 PM, a nurses note for Resident #103 by Nurse EEE provided, Resident was educated on how to report pain or any early onset signs/symptoms of pain . request to speak to the nurse, verbalize that you are in pain . There was no mention that the resident was ordered routine doses of Norco to be given three times a day or that the resident had not been consistently receiving his routine pain medication. Resident #140: During a tour of the facility on [DATE] at 1:45 PM, Resident #140 was heard calling out. She was observed lying in bed and asking for a drink of water. A staff member was observed entering the room to assist the resident. On [DATE] at 12:30 PM, Resident #140 was observed lying in bed. She was asked how she was doing and she readily responded to questions. The resident was asked if she had any pain and she stated, Yes, sometimes. Nurse Manager R was interviewed on [DATE] at 12:35 PM, she was asked if Resident #140 received pain medication and she said she currently had Morphine, but previously had Norco. The nurse said the resident's family felt the Norco caused the resident to be too sleepy and wanted her to have the Norco again., Nurse R said she spoke with the Nurse from Hospice and the Nurse Practitioner about their concerns. Nurse R said Resident #140 was also prescribed Haldol (an antipsychotic medication) because she had been screaming out; this was when she did not have her Norco pain medication. During the interview with Nurse R she was asked about the 30 count of missing Norco for Resident #140 and stated, I think somebody tried to order more. The nurse said, 'I don't have any.' The Nurse Practitioner said she had already sent a prescription in. The nurses on the unit had looked for the Norco blister pack. The pharmacy said they had already sent them. This was around [DATE]th; they asked why they were getting call backs on the orders. Nurse R said several weeks before this Nurse T had tried to take other resident's narcotics out of Nurse Rs medication cart. Nurse R said she told her she couldn't do that and stated, I was uncomfortable. She tried it 3 times after that. She was aggressive and physically trying to fight me for the pills. A record review of the Face sheet and MDS assessment for Resident #140 indicated Resident #140 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, pain, neuropathy, history of a stroke, left side hemiplegia, history of seizures, heart disease, Diabetes, COPD, anxiety depression and migraine. The resident was receiving Hospice services. The MDS assessment dated [DATE] indicated Resident #140 had severe cognitive loss with a BIMS score of ,d+[DATE] and needed extensive assistance with all care. A review of a Facility Reported Incident (FRI) dated [DATE] indicated on [DATE], Nurse R reported to the Interim DON that Resident #140 had a missing blister pack of 30 Hydrocodone-Acet ,d+[DATE] mg tabs (Norco). The facility contacted the pharmacy and they sent an Inventory sheet that indicated a 30 count blister pack of Norco ,d+[DATE] mg tabs was delivered to the facility on [DATE]. The facility Administrator and Corporate Nurse L viewed surveillance cameras for [DATE] and Nurse LLL was observed signing for the narcotics. On [DATE] the Narcotic blister pack count was wrong at the end of the shift count. Nurse MMM changed the count in purple ink and did not notify anyone that the count was wrong. The facility found a copy of the Controlled Substances Proof of Use, document for the Norco 30 blister pack for Resident #140. During the facilities investigation, they interviewed Nurse NNN on [DATE] and she said the resident did not receive her ordered dose of Norco on [DATE] at 2200 or on [DATE] at 0600 because there wasn't any in the medication cart. She said she gave the resident Tylenol instead at 5:30 AM. Nurse NNN said she contacted the pharmacy and they said they had sent 45 Norco previously and there should still be a 30 pack of Norco in the medication cart. Nurse NNN said she was unable to locate the Norco and Notified the Unit Manager Nurse R. The facility sent Nurse LLL for a drug screen and she was negative. They did not requests drug screens for any other nurses who had access to the 30 missing Norco. The facility was unable to locate the missing 30 count of Norco for Resident #140. An interview with the Administrator and Corporate Nurse L on [DATE] at 3:30 PM, related to the missing narcotics for Resident #140, the Administrator said that after the investigation, it was determined that the narcotics could not be located. A review of Resident #140's MAR/TAR's for [DATE] revealed pain assessments on a scale of 0 (no pain) to 10 (highest amount of pain). The resident had pain ratings between 2 and 10. On [DATE] when the Norco was missing, the order was discontinued and a new order for an antipsychotic Haldol was ordered to be given every 4 hours as needed. It was documented as given 7 times from [DATE] to [DATE]. This medication would not relieve the resident's pain and is sedating. Morphine was also ordered to be given every three hours as needed on [DATE]. The medication was given infrequently; not even daily. On [DATE] the Norco was reordered for Resident #140 to be given three times a day routinely. She had not received routine pain medication since [DATE], when her prescribed Norco disappeared. A review of the progress notes between [DATE] and [DATE] revealed Resident #140 had multiple instances of pain. On [DATE] at 4:45 PM, Nurse Y documented, Patient moaning at this time . stated my 'my life is falling apart.' Patient states 'Yes,' when asked if she has pain . continues to decline PO (by mouth) intake .' A review of the Care Plan for Resident #140 titled, (Resident #140) is at risk for pain related to depression, Migraine ., Date created [DATE] with Interventions: Administer medications as ordered . Date created [DATE]; Anticipate resident's need for pain relief . and respond immediately to any complaint of pain, Date created [DATE]; Observe and report any signs/symptoms of non-verbal pain . Mood/behavior . more irritable, restless, aggressive . Sad, crying, worried, scared . Date created [DATE]. The facilities pharmacist in charge was contacted on [DATE] at 10:00 AM, and questioned about the missing Norco for Resident #140 on [DATE] and [DATE]. The pharmacist said 45 tablets were sent to the facility for Resident #140 on [DATE] and 45 tabs were again sent on [DATE]. Reviewed with the pharmacist that provider order was written in the electronic medical record (emr) for Resident #140 on [DATE] at 3:19 PM and the Norco order was discontinued in the emr. The pharmacist said the pharmacy did not receive a copy of the discontinued order and sent more Norco on [DATE]. The MAR/TAR for [DATE] did not show the medication was given to Resident #140. The provider then ordered morphine liquid. On [DATE] at 3:39 PM, the facility provided paper copies of the narcotic blister packs and Controlled Substances Proof of Use sheets that were found scattered on top of Nurse T's desk. There were 112 empty narcotic blister packs. There were 52 Controlled Substances Proof of Use sheets. The Proof of use sheets did not all correspond to the narcotic blister packs. There was no clear indication the medications had been properly disposed of. Some of the documents had Nurse T's signature on them for removing the remaining amounts of medication, but they did not have a witnessed Registered Nurse/DON or designee. The narcotic medication was unaccounted for. A review of the facility policies revealed the following: Abuse Prohibition Policy, Date revised [DATE] and Effective [DATE], Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property . It is the responsibility of all staff to provide a safe environment for the guests/residents . Misappropriation of guest/resident property means that deliberate misplacement, exploitation, or wrongful, temporary or permanent use of guests/resident's belongings or money without the guests/resident's consent . Medication Administration, dated revised [DATE] and effective [DATE], Guest/resident medications are administered in an accurate, safe, timely, and sanitary manner . Medications are prepared, administered and recorded only by licensed nursing . medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications . Medications are administered in accordance with written orders of the attending physician . Note the physical appearance and packaging of the medication. Report any discrepancy to the pharmacy . Administer medications within 60 minutes of the scheduled time . Make sure the medication cart is locked at all times when it is not in use or not within your constant vision . Record the dose, route, and time on the Medication/Treatment Administration Record . Controlled Substances, Revised [DATE] and Effective [DATE], It shall be the policy to store and/or destroy all discontinued or expired controlled substances in accordance with legal and regulatory requirements . When a controlled substance is delivered from the pharmacy, the nurse will . complete the section of the Controlled Substances Proof of Use sheet. This includes the following: Amount received, Date received, Nurse signature. Put the medication in the mediation cart controlled substance lock box and file the Controlled Substance Proof of Use form in the appropriate binder . All controlled substances will be stored in the medication cart . If the controlled substance requires refrigeration, the following will be implemented to ensure that the location is double locked. The medication room door will be locked at all times when not monitored by a nurse. The refrigerator will have a lock on the door and/or The controlled substance will be stored in a container with a safety seal or secured lock box in the refrigerator . When a controlled substance is discontinued, expired or the order is changed, the nurse will alert the Director of Nursing (DON) or designee regarding the changed order. Alerting the DON or designee will prompt the individual to ensure that the controlled substance is obtained for destruction . The licensed nurse verifies the quantity of medication remaining, inserts quantity onto the proof of use sheet and the DON/designee signs witness to the quantity of medication being accepted . If it is discovered that the reconciliation has not been completed during shift change, the nurse manager will verify that the count in the cart is accurate with the nurse who is assigned to the cart . Any discrepancies will be reported to the Director of Nursing. If the Director of Nursing is not available the Administrator will be informed of the error . The Director of Nursing and/or Administrator will initiate an investigation . The Director of Nursing/designee and another licensed nurse must destroy all discontinued and/or expired controlled substances . A Registered Nurse must always be present when controlled substances are destroyed . Controlled substances cannot be stored in any area other than mediation cart, drop boxes or medication refrigerator in the Medication Room . the facility will keep a destruction record . A review of the Diversion Plan of Correction/Abatement Plan on [DATE] at 1:32 PM, with the Administrator and Interim DON, and Corporate Clinical Nurse L, revealed the following: On [DATE], the Unit Managers completed a pain audit that was conducted on 126 out of 126 residents for pain. On [DATE] at approximately 5:00 pm, the DON and the Regional Nurse Consultant audited the 5 medication rooms with narcotic boxes and 5 Medications carts with narcotic boxes and all the narcotics were accounted for. On [DATE] at approximately 5:30 pm, the DON and the Regional Nurse Consultant made rounds on the Medication rooms. On [DATE] at approximately 5:45 pm, the DON and the Regional Nurse Consultant reviewed the controlled substance inventory sheets. On [DATE] at approximately 6:00 pm, the DON and Regional Nurse Constant completed a narcotic audit. On [DATE] The facility reviewed their policies on Abuse Prohibition, Pain Management, Medication Administration, Controlled Substances and how and when to access medications from the Pyxis. On [DATE] at 5:15 PM, Re-education was started for the facilities 26 licensed nurses began by the DON. The agency staff that were present in the facility were educated as well. The Licensed Nurses and agency staff that have not been educated or were new to the facility would be educated at the start of their next shift. The DON or designee identified the need to randomly audit the narcotics on the medication carts on all units and shifts of the residents who have controlled substance orders to ensure all narcotics are accounted for 5 times a week for 4 weeks and monthly 2 months, any concerns will be addressed immediately with the licensed nurse and reported to the DON and NHA. Findings will be reported to the QAPI committee for review and further recommendations. The DON or designee will make rounds on the Medication rooms on all units and shifts randomly to ensure the doors were kept closed and locked, 5 times a week for 4 weeks and monthly 2 months, any concerns will be addressed immediately with the licensed nurse and reported to the DON and NHA. Findings will be reported to the QAPI committee for review and further recommendations. The DON or designee will randomly review the controlled substance inventory sheets on all units and shifts of the residents who have controlled substance orders to validate there is no evidence where nurses had documented in advance, 5 times a week for 4 weeks and monthly 2 months, any concerns will be addressed immediately with the licensed nurse and reported to the DON and NHA. Any discrepancies will be investigated by the DON and NHA and will be reported to the local police and state in accordance with the regulations. Findings will be reported to the QAPI committee for review and further recommendations. The DON or designee will randomly review the EMAR for controlled substance orders and validate the medications are available in the facility, 5 times a week for 4 weeks and monthly 2 months, any concerns will be addressed immediately with the licensed nurse and reported to the DON and NHA. Findings will be reported to the QAPI committee for review and further recommendations. The DON or designee will randomly interview 20% of residents on controlled substances to validate they are receiving their pain medication as prescribed by the ordering physician, 5 times a week for 4 weeks and monthly 2 months, any concerns will be addressed immediately with the licensed nurse and reported to the DON and NHA. Findings will be reported to the QAPI committee for review and further recommendations. The DON or designee will randomly make rounds and observe 20% of the residents on all units and shifts for signs of pain that is not controlled with their current pain medication regime, 5 times a week for 4 weeks and monthly 2 months, any concerns will be addressed immediately with the licensed nurse and reported to the DON and NHA. Findings will be reported to the QAPI committee for review and further recommendations. An Ad Hoc QAPI meeting was held on [DATE] with the DON, NHA, Regional Nurse Consultant and Medical Director to review the abatement plan. The Plan was reviewed and no further recommendations were made. The Administrator and Director of Nursing will be responsible for sustained compliance. On [DATE] at 4:00 PM, surveyors confirmed the facility had enacted their Plan of Correction for Narcotics Diversion.

This Citation pertains to Intake Number MI00132105 Based on observation, interview and record review, the facility failed to timely and accurately assess and respond to a change in condition for one resident (Resident #149) of three residents reviewed, resulting in a lack of assessment, interventions, and monitoring for change in condition, deterioration in health status, hospitalization with intensive care treatments, and subsequent further physical decline for Resident #149. Findings include: Resident #149: On 11/01/22 at 10:55 AM Resident #149 was observed lying in bed, scooted to the left, head pressing onto the bed rail. Right heal protection boot was off the resident's foot and on the floor. Tube feeding pump was beeping. Foley catheter tubing was observed draining milky urine and was touching the floor. Catheter collecting bag did not have a privacy cover on, catheter was not secured. Resident #149 had his mouth open, and his teeth stubs were observed. Mouth was dry with no visible infection noted around or inside the mouth. During conversation with nurse in care, LPN CCC, she said that Resident #149 came back from the hospital with tube feeding, Foley catheter and on hospice. Resident was non-verbal and had the tendency to scoots to one side of the bed. On 11/02/22 at 09:23 AM second observation was made of Resident #149. He was in his room, lying in bed. Tube feeding was infusing. Foley catheter tube was draining milky colored urine and was observed directly on the floor. Catheter collecting bag was observed hanging on the bed frame. Bag was not covered with privacy cover. During further observation catheter was not secured (to the resident's leg). Nurse in care, LPN CCC was asked to come in the room and confirm observations. According to admission face sheet, Resident #149 was an [AGE] year-old male, originally admitted to the facility on [DATE], with diagnoses that included: Chronic Combined Systolic and Diastolic (Congestive) Heart Failure (CHF), Hypertension (elevated blood pressure), Diabetes Mellitus Type 2, Chronic Kidney disease, Atrial fibrillation, Chronic Obstructive Pulmonary Disease (COPD), History of Cerebral Infarction (Stroke) without residual deficits, Venous Insufficiency (chronic peripheral), Dementia, Bipolar disorder, Anxiety disorder, Muscle weakness, and Benign Prostatic Hyperplasia (enlargement of prostate). According to Minimum Data Set (MDS) dated [DATE], Resident #149 was not scored on the Cognition Assessment, indicating Severe Cognition Impairment. According to the MDS, Resident #149 required two staff assistance with transfers, bed mobility and toileting. During interview with Registered Dietitian (RD) DDD he stated that he worked in a facility for about ten months and was familiar with Resident #149. When asked if he remember any changes in resident's food intake or weights, RD DDD said yes. He remembered nursing staff reporting to him that Resident #149 was not eating well and pocketing (not swallowing) his food. When asked when that information was relayed to him, he responded that he does not remember exactly the day; it was sometime before Resident #149 was hospitalized in October. When asked about Resident #149's weight loss he stated that he noticed a significant weight loss in October and re-weighted resident several times on that day to be sure. RD DDD also asked nursing staff multiple times to re-weight resident on a Hoyer lift. However, he did not receive any data on weight before resident's hospitalization . Review of Resident #149's electronic medical records revealed the following documentation: Weight summary- 08/02/22 - 204.6 Lb (sitting) 09/08/22 - 199.2 Lb (mechanical lift) (5.4 Lb weight loss in one month) 10/07/22 - 166.6 Lb (sitting) There was a 32.6 Lb weight loss In one month. Provider note dated 08/22/22: Patient denies any issues with intake of food or fluids or elimination of bowel or bladder. Patient is eating and drinking to maintain his/her nutritional and hydration status. Patient was recently seen by behavioral health services with new recommendations. On examination, patient is alert, calm, and cooperative. In no acute distress. Physician note dated 9/29/22 had the following: Patient is being seen today for his chronic illnesses. During the examination today patient denies confusion, slurred speech, difficulty understanding speech, paralysis or numbness of the face, arm, or leg, blurred or blackened vision, double vision, sudden severe headache, vomiting, dizziness, change in consciousness, lose your balance, or loss of coordination . General: Appears comfortable, alert, no anxiety noted, no acute distress. Provider note dated 10/03/22: Chief compliant- follow-up emesis. The patient has been followed up due to emesis on 10/02/2022. Patient was presented in room sitting on wheelchair. As per patient, he had vomiting one time yesterday. He had his breakfast today, but no vomiting noted. The vomiting was only for one time. He denied abdominal pain, diarrhea, and nausea. He also declined to have any chest pain, dizziness, change in consciousness, lose the balance or coordination. Under assessments and plans there was a recommendation: Vomiting, unspecified: Patient had one time vomiting on 10/02/2022. No any further incident. Monitor the patient to further emesis. Notify the provider for any changes. Monitor patient for electrolyte imbalance and hydrate the patient. From 10/03/22 to 10/07/22 there were no nursing assessment notes regarding Resident #149 hydration or nutritional status. On 10/07/22 there was a nursing progress note at 03:20 AM: CENA reported to this writer resident having difficulty swallowing. Message sent to provider with update on difficulty swallowing. Awaiting return response. On 10/07/22 at 04:54 PM Resident #149 did not receive his antihypertensive medication (Cozaar Tablet 50 MG, Give 1 tablet by mouth two times a day) with nursing note indicating no swallowing. Provider's order was noted in Resident #149's electronic medical record: Please check VS (Vital Signs) q8h- every 8 hours for BP (Blood pressure) monitoring -Start Date- 09/09/2022 at 10:00 PM, D/C (discontinue) Date-10/24/2022 at 04:10 PM. Review of the treatment administration record (TAR) for Resident#149 for October 2022 revealed the following data: 10/05/22 06:00 AM - BP 150/89 HR 67 10/05/22 02:00 PM - BP 150/89 HR 67 (exact same reading) 10/05/22 10:00 PM - BP 147/83 HR 76 10/06/22 06:00 AM - BP 147/83 HR 76 10/06/22 02:00 PM - BP 147/83 HR 76 (3 times same exact reading) 10/07/22 06:00 AM - BP 196/82 HR 65 10/07/22 02:00 PM - BP 196/82 HR 65 10/07/22 10:00 PM - BP 196/82 HR 65 10/08/22 06:00 AM - BP 196/82 HR 65 10/08/22 02:00 PM - BP 196/82 HR 65 10/08/22 10:00 PM - BP 196/82 HR 65 10/09/22 06:00 AM - no data 10/09/22 02:00 PM - no data 10/09/22 10:00 PM - BP 196/82 HR 65 10/10/22 06:00 AM - BP 196/82 HR 65 10/10/22 02:00 PM - BP 196/82 HR 65 10/10/22 10:00 PM - BP 196/82 HR 65 10/11/22 06:00 AM - BP 196/82 HR 65 10/11/22 02:00 PM - BP 196/82 HR 65 (Total of 12 times exact same Blood pressure and Heart rate with 2 recordings missing-not assessed). Upon further review of the Vital Signs record there were no in real time assessments of Resident #149's Heart Rate or Blood Pressure recorded from 10/07/22 at 04:11 AM till the time of his hospitalization on [DATE] at 05:30 PM. There was a provider note dated 10/10/22 The patient has been followed up due to anorexia, malnutrition due to not eating or taking meds from last over 24 hours. As per nursing staff, patient did not eat today morning or drink any fluid as well as did not take his medications. Discussed with the dietitian regarding patient's food intake. The speech therapist will follow up with the patient and evaluate the patient for any swallowing difficulties. Under physical exam part in the note provider used the same Vital Signs that has been automatically populated since 10/07/22 at 6:00 AM: Blood Pressure: 196 / 82 mmHg Temperature: 97 F Heart Rate: 65 bpm. Nursing note dated 10/10/22 at 02:41 PM revealed Resident refused medication, not swallowing, DON and management aware. Review of Resident #149's medication administration record indicated that he did not receive most of his medications on 10/10/22 and none of his medications or supplements on 10/11/22 due to inability/difficulty swallowing. During interview with speech therapist NNN on 11/03/22 at 03:23 PM she stated that she arrived at the facility on 10/11/22 approximately at 5 PM. She gathered her supplies and went to evaluate Resident #149. Upon entering the room, she observed resident resting on his back. She addressed resident by name and did not receive any response back. She came closer to the bed and spoke louder. No response. After touching resident's hand, raising the head of the bed, and not getting any response back, she attempted sternal rub. Resident did not react. Speech therapist went to find a nurse in care and relayed her findings to her. Nurse did try to arouse Resident #149 herself and after no response said she will get him transferred. The nurse responsible for the care of Resident #149 on 10/11/22 was contacted for interview on 11/2/22 and 11/3/22 and did not return the calls. Electronic medical record review for Resident #149 revealed the following assessment for change in condition signed by nurse in care on 10/11/22 at 05:30 PM: Functional decline (worsening function and/or mobility). At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 109/76, taken on 10/11/2022 at 05:30 PM Position: Lying l/arm. - Pulse: P 98, taken on 10/11/2022 at 5:30 PM. Pulse Type: Regular - RR: R 18.0, taken on 10/7/2022 at 04:11 AM (4 days prior to the hospitalization date) - Temp: T 101 F, taken on 10/11/2022 at 5:30 PM, Route: Forehead (non-contact) - Weight: W 166.6 lb, taken on 10/7/2022 at 12:32 PM, Scale: Sitting - Pulse Oximetry: O2 98 %, taken on 10/11/2022 at 5:30 PM, Method: Room Air - Blood Glucose: BS 114.0, taken on 6/10/2020 at 7:19 PM (2 years and 4 months prior hospitalization date). Nursing note dated 10/11/22 at 6:21 PM had the following: Resident #149 was sent to hospital. Has not been eating or taking meds today and unresponsive. Guardian, provider, and supervisor notified. During interview on 11/01/22 at 01:04 PM with paramedic DDD, who transported Resident #149 to the hospital, he shared that his team arrived at facility around 5:30 pm on 10/11/22. EMS (Emergency medical services) team was responding to facility's call for unresponsive resident. EMS team went the 2nd floor to assess the resident. Resident #149 was breathing, but not responded to sternal rub, only blinked his eyes. Resident was hyperventilating, taking shallow breaths. EMS team noted resident had barrel chest and asked nurse in care if he had a diagnosis of COPD or any other significant or chronic conditions. Nurse said that resident only had diagnoses of dementia, psychiatric disorder, and depression. She was not aware if Resident #149 had a history of diabetes or heart disease. When asked by EMS team how long resident was in this condition, nurse in care stated that he was in this condition since she began her shift in the morning. EMS team took resident's Vital signs. Paramedic remembered Resident #149's Blood Sugar was in high 300's and Blood Pressure low. In an ambulance on the way to the hospital EMS team read discharge paperwork to prepare for hand off report and realized that Resident #149 had multiple comorbidities and diagnoses of chronic diseases, including COPD, Diabetes Mellitus type 2, and Chronic kidney disease. Paramedic remembered resident being cold to touch, wearing brief, and a T-shirt, no catheter was noted. EMS team was surprised that facility's nursing staff waited so long to call them considering poor condition of Resident #149, and that nurse in care did not know full history of the resident in care. Resident #149 was hospitalized from 10/11/22 till 10/24/22. Hospital records revealed: Physician's admission note dated 10/11/22 at 06:28 PM had the following- Patient to emergency room via EMS with altered mental status. Nursing home reported that the patient (Resident #149) awoke altered. But they (facility) also stated that over the last week he has been having trouble feeding himself when he normally does not, but no one called EMS until 5 PM in the afternoon. On arrival patient is obtunded, not speaking. Nurse called over to the facility for the patient's past medical history which was reported. Patient admitted to ICU (Intensive Care Unit). Vital signs on admission were: BP-80/49 (low) HR- 113 (high) Respiratory rate-25 (high) Mean Arterial Pressure (MAP)-59 (Critical) Blood Glucose level- 350 mg/dL (high) Under Admission Diagnoses: 1. Dehydration 2. Cerebral Infarct (Stroke) 3. Altered mental status 4. Lactic Acidosis 5. Sepsis 6. Acute Hypernatremia (Critically elevated Sodium blood levels, on admission 177 mmol/L with normal range 135-145 mmol/L) 7. Acute Kidney Injury 8. Non-ST elevated MI (heart attack). 9. DVT (deep vein thrombosis) of right lower limb-acute During the hospitalization Resident #149 was diagnosed with dysphagia (difficulty swallowing) and had a surgical procedure (EGD-esophagogastroduodenoscopy) with PEG (feeding) tube placement. On 11/12/22 resident #149 underwent bedside flexible cystoscopy with complex Foley catheter placement. Cardiology consult note revealed: Due to altered mental status of the patient history could not be obtained. Nurse was contacted from his (Resident #149's) facility. She reported that resident has advanced dementia at baseline, needs assistance with activities of daily living. The patient has not been eating or drinking well for about a week. He stopped talking to people for last 2 days. He was grinding his teeth and mentation had worsened from his baseline. Later in the day he was found to be unresponsive in bed. Critical Care consultation note dated 10/12/22 at 08:18 AM revealed: Altered mental status likely secondary to hypernatremia (elevated blood Sodium) and CVA (cerebrovascular accident-stroke) and likely contributed by Sepsis, dehydration, and dementia at baseline. Sodium on presentation was 177, currently trended down to 173. Acute kidney injury likely contributed by Sepsis, and likely secondary to dehydration. Sepsis with elevated WBC's (white blood cells) at 13, with left shift, elevated anion gap, lactic acid 3.5 (sepsis assessment). Patient was hypotensive on presentation to ED (emergency department). Patient received Vancomycin and Zosyn (antibiotics) in ED. Currently on Vancomycin, Cefepime and Flagyl. Lactic Acidosis likely secondary to Sepsis, contributed to AKI (acute kidney injury). Patient prognosis is very poor. He presents with significant comorbidities and acute issues. Resident #149 returned to facility on 10/24/22. There was a re-admission nursing note dated 10/24/22 at 4:08 PM: Resident (#149) returned from (Hospital name). Resident returned with hospice care ordered. Hospice nurse present and did skin assessment with nurse. One skin issue noted-a pressure sore to coccyx. Patient has some general swelling and dry skin through body. PEG tube and Foley present and intact. V/S stable. Resident orientated to room. Call light in reach bed in lowest position. No concerns or pain noted at this time. Facility's Significant Change Policy was requested and reviewed. Policy effective and revised on 6/24/21 indicated the following purpose: Facilities have an ongoing responsibility to assess the resident's status and intervene to assist the resident to meet his or her highest practicable level of physical, mental, and psychosocial well-being. If interdisciplinary team members identify a Significant Change, either improvement or decline in a resident's condition, an assessment of that change must be completed to reflect the resident's current status and update the plan of care. Change in condition and assessment standards of nursing practice guidelines indicate: In a long-term care setting, any change from baseline in a resident's status must be identified and addressed. A resident is more likely to return to baseline status and avoid complications when a condition is recognized early so that it can be treated. By identifying such risk factors as chronic diseases, previous hospitalization s, and notable conditions in the resident's medical history, the nurse can anticipate some acute changes in status. The Care Plan should address the resident's risk factors, allow for rapid identification of a change in status, and define baseline assessment findings. According to CDC guidelines Sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death. A person with sepsis might have one or more of the following signs or symptoms: High heart rate Fever, shivering, or feeling very cold Confusion or disorientation Shortness of breath Extreme pain or discomfort Clammy or sweaty skin. Anyone can get an infection, and almost any infection, including COVID-19, can lead to sepsis. In a typical year: -At least 1.7 million adults in America develop sepsis. -At least 350,000 adults who develop sepsis die during their hospitalization or are discharged to hospice. -1 in 3 people who dies in a hospital had sepsis during that hospitalization -Sepsis, or the infection causing sepsis, starts before a patient goes to the hospital in nearly 87% of cases.

This Citation Pertains to Intake Number MI00126659. Based on interview and record review, the facility failed to operationalize policies and procedures to ensure comprehensive care and accurate documentation of pressure ulcers (wounds caused by pressure) including implementation of interventions, ongoing monitoring, and completion of treatments as ordered by the Healthcare Provider for one resident (Resident #125) of five residents reviewed resulting in Resident #125 developing two unstageable (full thickness tissue loss with unknown depth) and two Stage II (open wound with partial thickness tissue loss) pressure ulcers, unnecessary pain, and a decline in overall health status. Findings include: Resident #125: Review of intake documentation dated received on 2/24/22 for Resident #125 revealed multiple concerns related to care at the facility including lack of environmental cleanliness, lack of Activity of Daily Living (ADL) care, and Resident #125 not receiving assistance to get out of bed. The intake further detailed that Resident #125 had pressure ulcers (wounds caused by pressure) including sores on feet, wound care dressing changes were not being completed, and the Resident was not being rotated (turned/repositioned) on a regular basis. Record review revealed Resident #125 no longer resided at the facility. The Resident was discharged to the hospital on 4/13/22 and did not return to the facility. Record review revealed Resident #125 originally admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with subsequent hemiplegia and hemiparesis (one sided paralysis), dysphagia (difficulty swallowing), gastrostomy (surgically created opening in the abdominal wall into the stomach for the introduction of food), epilepsy, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive to total assistance to complete all Activities of Daily Living (ADL's). The MDS further revealed the Resident had one facility-acquired unstageable pressure ulcer and one unstageable pressure ulcer that was present upon admission. Review of Resident #125's admission MDS assessment dated [DATE] included contradictory documentation. Per MDS question M0100A (Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device), Resident #125 did not have a stage 1 or greater pressure ulcer. However, the MDS further detailed Resident # 125 was admitted to the facility with one stage two and one unstageable pressure ulcer. A review of MDS question M0100A historical data revealed documentation that Resident #125 did not have a Stage I or greater pressure ulcer on 8/29/21, 10/1/21, and 11/24/21. Review of Resident #125's Clinical Census Data revealed the Resident was out of the facility on the following dates during their stay: - 10/1/21 to 10/7/22 - 11/24/21 to 11/29/21 - 3/22/22 to 4/7/22 Review of Resident #125's care plans revealed a care plan entitled, (Resident #125) has impaired skin integrity/pressure injury R/T (related to) unstageable wound to rt. (right) plantar . has impaired mobility, hemiparesis, enteral feeding, incontinence (Created: 8/24/21; Initiated and Revised: 4/8/22). The care plan included the interventions: - Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician (Created and Initiated: 8/24/21; Revised: 4/8/22) - Cue to reposition self as needed (Created and Initiated: 9/25/21; Revised: 4/8/22) - Follow facility policies/protocols for the prevention/treatment of impaired skin integrity (Created and Initiated: 9/25/21; Revised: 4/8/22) - Turn/reposition resident every __ (Blank) hours and PRN (as needed) (Created and Initiated: 9/25/21; Revised: 4/8/22) A second care plan entitled, (Resident #125) has actual impairment to skin integrity r/t DTI (Deep Tissue Injury) to right heel (Initiated: 3/2/22) was noted in the Resident's Electronic Medical Record (EMR). This care plan included the interventions: - Apply pressure reducing mattress to protect the skin while in bed (Initiated: 3/2/22) - Float heels as resident allows (Initiated: 3/2/22) - Observe for s/sx (signs/symptoms) of infection of area . (Initiated: 3/2/22) - Treatment to skin impairment per order (Initiated: 3/2/22) - Turn and Reposition frequently and PRN (Initiated: 3/2/22) A third care plan entitled, (Resident #125) has Actual impairment to skin integrity r/t DTI to left heel (Initiated and Revised: 4/8/22) was noted. This care plan did not include any additional interventions not included on care plans above. Review of wound care documentation in Resident #125's EMR revealed the following: - 8/23/21: Admission Nursing Comprehensive Evaluation . Site: Left Heel . Deep Tissue Injury, 1 cm (centimeter) x 2 cm . Purple and Brown to color. No drainage . Right heel: Deep Tissue Injury, 3 cm x 2 cm, wound bed is pink to color. Surrounding tissue is dry and flaky . Right heel . Deep Tissue (Injury), 1.2 cm x 0.3 cm, wound bed pink to color, surrounding tissue dry and flaky . Other: coccyx: intragluteal fold, coccyx sacrum (no size and/or description included) - 9/25/21: Reentry . Nursing Comprehensive Evaluation . Left heel: lateral side there is a wound appears to be soggy . Sacrum: skin breakdown . - 9/26/21: Total Body Skin Assessment . Number of new skin conditions: 1. Comments: Open area missed on skin assessment, old peg site (open not healed yet), New site still bleeding some. both cleaned with wound cleanser and covered with dry dressing. - 10/8/21: Reentry . Nursing Comprehensive Evaluation . L (Left) heel pressure ulcer . L lateral plantar side of foot has pressure sore visual ecchymosis (skin discoloration caused by bleeding underneath skin) . R heel has pressure ulcer visual ecchymosis . Sacrum . skin breakdown, no open wound . - 10/15/21: Total Body Skin Assessment . Number of new skin conditions: 1. Comments: open area to the left buttock . - 11/4/21: Skin & Wound Evaluation . Pressure . Stage 2 . Coccyx . Present on Admission . New . Length: 0.9 cm . Width: 0.7 cm . - 11/18/21: Skin & Wound Evaluation . Pressure . Stage 2 . Coccyx . Present on Admission . Note: Pressure ulcer previously documented as facility acquired. - 11/30/21: Admission Nursing Comprehensive Evaluation . Bilateral tibia area has scabs scattered over leg. Scabs are dry and crusted over no open wounds . - 12/9/21: Skin & Wound Evaluation . Pressure . Unstageable . Slough and/or eschar . Sole Right Foot . Present on Admission . Exact Date: 12/6/21 . Length: 8.7 cm . 1.5 cm . Eschar- 30 % of wound bed . New . Healable . - 12/9/21: Progress Note . Wound Care . consulted for the evaluation and treatment of right hallux wound . Note: Resident #125 was present in the facility on 12/6/21. - 12/16/21: Skin & Wound Evaluation . Pressure . Unstageable: Obscured full-thickness skin and tissue loss . Due to: Slough and/or Eschar . Right foot, 1st digit hallux (big toe joint) . Acquired: Present on Admission . How long has the wound been present: 1 week . Wound Measurements . Length: 2.4 cm (centimeters) . Width: 0.8 cm . Healable . (Signed: 12/20/21) - 12/21/21: Total Body Skin Assessment . Comments: No new wounds noted. Resident has tx in place for redness to coccyx and for RT foot . - 2/10/22: Skin & Wound Evaluation . Pressure . Unstageable . Slough and/or eschar . Sole Right Foot . Present on Admission . Exact Date: 12/6/21 . Measurements . Length: 5.5 cm Width: 1.8 cm . Exudate: light . Serosanguineous . Healable . Additional Care (Interventions): None . Note: Resident #125 was present in the facility on 12/6/21. - 2/17/22: Skin & Wound Evaluation . Pressure . Unstageable . Slough and/or eschar . Sole Left Foot . In-House Acquired (facility acquired) . New . Measurements . Length: 10.3 cm . Width . 3.7 cm . Wound Bed: Eschar - 90% of wound filled . Evidence of Infection . Redness/Inflammation . Pink or Red . - 3/1/22: Total Body Skin Assessment . Number of new skin conditions: 1 . - 3/3/22: Skin & Wound Evaluation . Pressure . Unstageable . Slough and/or eschar . Sole Left Foot . In- House Acquired . New . Length: 5.8 cm . Width: 2.0 cm . Eschar . Exudate . Light . Serosanguineous . Pain . Resident sensitive to touch and repositioning . - 4/12/22: Skin & Wound Evaluation . Pressure . Unstageable . Slough and/or eschar . Sole Left Foot . In-House Acquired (facility acquired) . New . Length: 4.3 cm . Width . 1.0 cm . Wound Bed: Slough- 50% of wound filled . Exudate . Light . Serosanguineous . Pain: Mild discomfort noted during tx (treatment)/dressing change . New admission skin assess completed. Area noted to have small amt (amount) . drainage, slough noted on wound closest to 5th digit, medihoney (wound treatment) applied, maxorb ag (wound dressing) to wound closest to heel, chamosyn (ointment) applied to periwound, covered with (dressing) . - 4/12/22: Skin & Wound Evaluation . Pressure . Unstageable . Slough and/or eschar . Sole Right Foot . Length: 7.2 cm Width: 1.7 cm . Eschar: 80% of wound . Exudate: light . Serosanguineous . Healable . Additional Care (Interventions): None . Mild discomfort noted during tx and dressing change . Resident seen for new admission skin assessment . Note: Resident #125 was not a new admission on 4/12/22 per Clinical Census documentation. Review of Resident #125's Healthcare provider orders revealed the Resident had treatments ordered for their left foot and coccyx in August 2021. There were no orders and/or treatments in place for the DTI pressure ulcer on the Resident's right heel. A detailed review of the Resident's wound care treatment orders revealed the following: - Apply z-guard to coccyx after every brief change every shift for wound care (Ordered: 08/26/21; Discontinued: 10/6/21). The Treatment was not completed on 8/29/21 day, 8/31/22 day, 9/22/21 day, 9/26/21 day - Cleanse left foot with normal saline dab dry apply betadine and cover . every 48 hours for wound care (Ordered: 8/26/21; Start Date: 8/28/21; Discontinued: 10/6/21). The Treatment was not completed on 8/30/21, 9/3/21, 9/9/21, 9/13/21, 9/17/21, 9/21/21, and 9/23/21. There was no treatment, including preventative treatment, in place for Resident #125's coccyx from 10/7/21 until 10/17/21. No wound care treatments were ordered for Resident #125's right or left lower extremities following their readmission to the facility on [DATE]. - Cleanse coccyx with normal saline pat dry apply chamosyn cream (barrier cream that protects from irritation) and border gauze every day shift for wound care (Start Date: 10/17/21; Discontinued: 2/24/22). The treatment was not completed on 10/27/21, 10/31/21, 12/3/21, 1/19/22, 1/30/22, and 2/24/22. - To Right great toe and deep tissue trauma area on sole of foot, Triple antibiotic ointment, betadine, ABD pad and kerlix every night shift (Start Date: 12/9/21; Discontinued: 12/10/21) - Cleanse right foot with normal saline and pat dry apply betadine to right great toe and sole of the right foot eschar area also apply Triple antibiotic ointment to these areas apply ABD pad and kerlix and secure with tape every night shift (Start Date: 12/10/21; Discontinued: 3/4/21). The treatment was not completed on 12/16/21, 1/18/22, 1/21/22, 1/26/22, 1/27/22, 1/30/22, 2/2/22, 2/26/22, and 3/1/22. - Cleanse left sole of foot and shin with wound cleaner pat dry apply chamosyn cover with (dressing) . every night shift for wound care (Start Date: 2/24/22; Discontinued: 3/4/22). The treatment was documented as not completed on 2/26/22 and 3/1/22. - Cleanse left sole of foot with betadine apply chamosyn cover with (dressing) every night shift for wound care (Start Date: 3/4/22; Discontinued: 3/11/22) - Cleanse left sole of foot with wound cleanser, Santyl (wound debriding agent) to slough, periwound, cover remaining sites with maxorb ag (wound dressing for moderate to heavy draining partial to full thickness wounds) (dressing) every night shift for wound care (Start Date: 3/11/22; Discontinued: 3/17/22) - Clean area rt. (right) plantar foot closest to 5th digit, with wound cleanser, pat dry, apply wound gel, cover with (dressing) . daily every night shift for wound care (Start Date: 3/11/22; Discontinued: 3/24/22) The treatment was not completed on 3/22/22 and 3/23/22. - Cleanse left sole of foot with wound cleanser, Santyl (wound debriding ointment) to slough, chamosyn to peri-wound, cover remaining sites with maxorb ag (wound dressing for moderate to heavy draining partial to full thickness wounds) (dressing) daily every night shift for wound care (Start Date: 3/17/22; Discontinued: 3/24/22). Treatment was not completed on 3/23/22 and 3/24/22. - Cleanse right foot with betadine, apply (dressing) daily every night shift for wound care (Start Date: 3/4/22; Discontinued: 3/11/22). - Clean left sole of foot with wound cleanser, apply medihoney to wound closest to 5th digit, maxorb ag to wound closest to heel, chamosyn to periwound, cover with (dressing) daily every day shift for wound care (Start Date: 4/13/22). There was no documentation of treatment completion. - Clean sole of rt. foot with betadine, apply hydrogel to wounds, and wrap (dressing) daily . for wound care (Start Date: 4/13/22). There was no documentation of treatment completion. - Clean buttocks with wound cleanser, pat dry, apply chamosyn daily and prn (as needed) brief changes, and leave open to air every day shift for wound care/prophylaxis (Start Date: 4/13/22) There was no documentation of treatment completion. No wound care orders and/or treatments for Resident #125's coccyx and/or bilateral lower extremities were completed in April 2022 on the Medication Administration Record (MAR) and/or Treatment Administration Record (TAR). An interview and review of Resident #125's EMR was conducted with Wound care Licensed Practical Nurse (LPN) K on 11/3/22 at 12:38 PM. When queried regarding Resident #125, LPN K revealed they did not work at the facility during Resident #125's admission. When queried if there was another staff member who worked at the facility during the Resident's admission who was familiar with the Resident, Wound Care LPN K revealed there was not, and they were able to review the EMR and answer questions. Wound Care LPN K was asked about Resident #125's pressure ulcers when they were admitted to the facility on [DATE]. Wound Care LPN K reviewed Resident #125's Nursing Admission Evaluation and stated, Left heel DTI (Deep Tissue Injury pressure ulcer), right heel two DTI's, and something on their coccyx. When asked about the progression of the pressure ulcers, LPN K revealed Resident #125's EMR and stated their right heel pressure ulcer was resolved (healed) on 9/23/21 and the stage two left buttocks pressure ulcer was resolved on 11/11/21. When asked why there was not an order and/or wound care treatment on the MAR/TAR for the pressure ulcer, LPN K was unable to provide an explanation. When asked if the left buttocks pressure ulcer was facility acquired, LPN K indicated the wound was present on admission. When asked why a left buttocks pressure ulcer was not included on the admission assessment, LPN K revealed they were not sure. Resident #125's progress note dated 10/15/22 indicating there was a new open wound to the Resident's buttocks was reviewed with LPN K at this time. When queried again regarding the left buttocks pressure ulcer, LPN K stated, It was facility acquired then. LPN K was then queried regarding Resident #125's stage two coccyx pressure ulcer being documented as present on admission on the 11/4/22 assessment when there was no other documentation pertaining to the pressure injury. LPN K reviewed the EMR and stated the pressure ulcer was resolved (healed) on 11/19/22. When asked how the pressure ulcer was present on admission when it was identified on 11/4/22, LPN K replied, It's not and confirmed the pressure ulcer was facility acquired. When queried regarding the unstageable pressure ulcer on Resident #125's first hallux digit and being documented as present on admission, LPN K reviewed the documentation and dates in the EMR and stated, It's not present on admit and revealed the pressure ulcer was also facility acquired and was resolved on 1/16/22. When asked about the unstageable pressure ulcer on Resident #125's left sole, LPN K revealed it developed in house. LPN K was then asked about the unstageable pressure ulcer on the Resident's right heel. LPN K reviewed the EMR documentation and stated, By the dates and documentation, it was facility acquired. When queried regarding treatments not being documented as completed on the TAR, LPN K did not provide an explanation. When queried why a specialty mattress and/or lower extremity positioning devices were not implemented for Resident #125 due to limited mobility and pressure ulcers, LPN K reiterated they did not work at the facility at that time. With further inquiry regarding the Resident's care plan and lack of personalized interventions, LPN K divulged they would have implemented additional interventions to assist in the prevention of the development and/or worsening of pressure ulcers. LPN K was then queried regarding the unclear, inconsistent, and incorrect documentation of Resident #125's pressure ulcers. LPN K confirmed but did not provide further explanation. On 11/3/22 at 2:25 PM, an interview was completed with the facility Administrator. When queried regarding Resident #125's developing multiple facility acquired pressure ulcers, lack of treatment and documentation, missing treatments, inaccurate/inconsistent documentation, and lack of implementation of interventions to prevent pressure ulcer development and/or worsening, the Administrator did not provide an explanation. Review of facility policy/procedure entitled, Skin Management (Reviewed 7/14/21) revealed, It is the policy that the facility should identify and implement interventions to prevent development of . pressure injuries . Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing . Practice Guidelines . 3. Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan. 4. Guests/residents admitted with any skin impairment will have: o Appropriate interventions implemented to promote healing, o A physician's order for treatment, and o Wound location, measurements and characteristics documented 5. The licensed nurse will initiate documentation in the electronic health record, which includes a description of the skin impairment as follows: o In Electronic Health Record (EHR) facilities, the licensed nurse will document on the skin and wound evaluation for pressure injury and vascular ulcers. o Document weekly until the area is resolved . 8. The licensed nurse will document preventative measures on the care plan . 9. The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record . 12. If a new area of skin impairment is identified, notify the guest/resident, responsible party, attending physician, DON/designee and treatment team, if applicable. 13. Guest's/resident's with pressure injury and lower extremity ulcers will be evaluated, measured and staged weekly (pressure injury and vascular ulcers only) in accordance with the practice guidelines until resolved .

This Citation Pertains to Intake Number MI 089. Based on observation, interview, and record review, the facility failed to prevent a fall backwards in a wheel chair resulting in a physical injury requiring hospitalization , brain surgery and subsequent admission to a hospice facility for end-of-life care for one resident (Resident #23) of one resident reviewed for falls. Findings include: Resident #23: According to the Admission Record, printed 8/25/2021, Resident #23 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included end stage [CONDITION(S)], a history of Covid-19, depression, anxiety, [CONDITION(S)], stroke, heart beat irregularity, high blood pressure, and heart disease. According to an incident and accident report, dated 7/30/2021 at 11:30 AM, Resident #23 had been transferred from her bed to her wheel chair using a mechanical lift with two staff members present, when the back of the wheel chair released and the entire chair flipped back wards with Resident #23 landing on her back, still in the chair, the entire chair had flipped backwards. The incident and accident report indicated that she had hit back of head although the witnesses reported that she had not struck her head immediately when she had fallen, but had flung her head back to look around once she landed on the floor, then striking her head in the back. The incident and accident report indicated she had been sent to the emergency roiagnom on [DATE], that her sister was at the facility and Resident #23 was her own responsible party. The Hospital Discharge Summary, printed on 8/25/2021, stated that Resident #23 had come to the hospital from a nursing home where she had fallen and hit the back of her head. She was initially okay with no loss of consciousness after several hours her sister reported that she had lost consciousness and was not responding with acute left lower leg and left arm weakness. Resident #23 had presented to the Hospital with a trauma. The Hospital emergency room performed a computerized tomagraphy (CAT scan) on 7/30/2021 and diagnosed a subdural hematoma, a blood clot under the layer of the brain covering called the dura mater. According to the hospital Discharge Summary, printed on 8/25/2021, the clot was on the right side of the middle of her head, and caused the brain to shift inside the skull to the left. This caused left sided weakness. According to the Surgical Report, Resident #23 underwent brain surgery on 7/31/2021 beginning at 9:48 AM to remove the blood clot from the right side of her brain. There were three holes drilled into her skull to raise the bone and access the area. The clot was removed and the area was irrigated, the indentation of the brain slowly returned to normal. Another CAT scan was performed and two additional hematomas were observed, one at the right front of the brain and a larger one that was increasing in size under the dura mater. The Hospital Discharge Summary, reported the date of discharge as 8/12/2021. Resident #23 had been treated at the hospital for a loss of consciousness and syncopal [[CONDITION(S)]] episodes and fall. Resident #23 was found to have a subdural hematoma on arrival and underwent craniotomy [brain surgery]. She underwent repeat imaging which then showed a right [MEDICATION(S)] hematoma extending with a right to left midline shift of the brain secondary to trauma. She then had a right frontal lobe ischemic [lack of blood supply] stroke. She failed a swallow evaluation and had a feeding tube placed. Resident #23 had a complicated hospital course she was seen by many consultants. After discussion with her family, she was referred to hospice (for end of life care) and was discharged to a hospice facility on 8/12/2021 with a very poor prognosis. The Post Fall Evaluation, dated 7/30/2021, stated, Place in chair when High back chair malfunction & High back chair when back pt [patient] weight went back flip chair back the Root Cause of this Fall: was described as Assistive/protective device-equipment malfunction. and the initial intervention to prevent future falls: was described as Check w/c [wheel chair] lock's & High back locks Before Transfer. On 8/25/2021 at 11:15 AM an interview was held with Licensed Practical Nurse (LPN) B. LPN B stated that Resident #23 was already in the chair on the floor when they came and got me. The wheel chair wasn't locked, or hooked. The girls told me she hit the floor in her wheel chair. Resident #23 said she felt ok, and wanted to go out with her sister. I did a neuro [neurological] exam, got vitals, there were no abnormalities, no bruising, no raised areas, no cuts at that time. Your ride never came to pick her up, so her sister brought food for her. I didn't even know she was still in the facility, another nurse assessed her and sent her out. When I called the hospital to check on her, the nurse there told me she had a hematoma (localized bleeding). Certified Nursing Assistant (CNA) C was interviewed on 8/25/2021 at 2:00 PM. CNA C stated that she had been assisting another CNA to put Resident #23 into her wheel chair, a high back type using a mechanical lift. She was in back of Resident #23, positioning her into the chair, she took the straps off of the lift sling and then when she moved away, the chair went back and she had her head up so that it didn't hit the floor, but when she laid there for a minute, she flung her head back to see where she was. That was when she hit her head. I went to get her nurse and took her vital signs. I think it was the travel bag on the back of her chair got stuck in the handles. It should not have fallen down like that. We got her back into her chair and she asked for a Tylenol. She still wanted to go downstairs to meet with her sister and did not want to go back to bed, so we took her down. While she was downstairs, she went unresponsive, she was out for a minute but came back. The other aide and I showed the Director of Nursing (DON) how it happened, they checked the chair, they ended up replacing the wheel chair, and did an education for us to not have anything on the handles of the back of all wheel chairs. The DON informed me that the maintenance man who serviced the wheel chair on that day no longer works at the facility. The Nursing Home Administrator provided his phone number. On 8/25/2021 a telephone message was left for maintenance man staff F requesting a call back to provide additional details. As of the day of the end of the survey, the maintenance man had not returned the phone call. On 8/25/2021 at 2:50 PM, the DON was asked about the wheel chair for Resident #23. The original wheel chair could not be located, a similar wheel chair was brought down to examine. The DON showed how she was told the accident occurred, the bag got stuck in the braking mechanism and did not allow the wheel chair to lock properly. The anti-tippers on the bottom of the chair were not locked in properly, there are little knobs that fit into holes of the tubing on the device that lock it into place in an extended position. The DON thought that in the case of Resident #23, neither device had worked properly, contributing to the fall. The in depth analysis stated that Maintenance inspected the resident's wheelchair, and discovered that the one handle did not lock completely because the resident's personal bag was hanging on the back, and caused the lock not to latch securely. Also, the resident had anti-tipper in place of which the one on the right side had become unhinged which did not prevent the chair from tipping backwards. The DON was interviewed on 8/25/2021 beginning at 1:20 PM. The DON recalled that she had been present on 7/30/2021 when she heard a call for a nurse to the dining room between 12:30 PM and 1:30 PM, she entered the dining room and saw Resident #23, who was unresponsive. I did a sternal rub and she opened her eyes. She was clammy and said my head hurts. She said that she had fallen and hit her head, I felt a nickel sized hematoma on the back of her head. We called an ambulance for her, at first she refused to go, but we insisted she go and get checked out. I went upstairs to investigate and the CNAs did a return demonstration of what had happened. On 8/26/2021 at 10:30 AM, CNA G was interviewed. She stated that me an another aide, she was a two person assist, we locked the wheel of the chair, as soon as we put her into the chair and took the sling off of the lift, her chair fell , the whole chair went backwards. She did not hit her head on the floor at first, when she noticed she was on the floor, she laid her head back. It was before lunch, she was going to Applebee's with her family. We had got her cleaned up to go, she did not want to lay back down, we offered, but she wanted to go to Applebee's. Afterward, the DON and NHA came up to go over the story so we showed them what had happened. Resident #23 had things on the chair that are supposed to stop it from going back, it still fell . The chair was broken, they put a part on there, now I check before we use it. We called the nurse to check her and then we took her downstairs she was still going to get food. After I finished my lunch, she said she wasn't feeling well. A Neurological Assessment sheet for Resident #23 was attached to the incident report. The directions called for an assessment to be performed every 15 minutes for the first hour, the assessment for 7/30/21 at 11:30 AM and 11:45 AM were completed. The assessments for 12 PM and 12:15 PM, said LOA [leave of absence] and were blank. Then the assessment was to happen every 30 minutes for two hours, on 7/30/21 at 12:45 PM, the entry was LOA to the emergency room for evaluation. When the DON was questioned about the Neurological Assessment being blank at 12:00 PM and 12:15 PM, she stated that LPN B had been unaware that Resident #23 was still in the building, as she was on the third floor and Resident #23 had been brought downstairs by the CNA to go for lunch with her sister, although as it turned out, she did not go to Applebee's because the public transportation never came to get her and her sister brought food in for her. The Fall Management policy, revision dated 10/2019, directed that The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. The policy for Routine Guest/Resident Care, dated 10/2019, stated that Staff members should observe the following safety precautions with all guests/residents including Equipment with wheels (beds, wheelchairs and other equipment) should be in locked position when not moving.

This Citation pertains to Intake Numbers MI 012, MI 146, MI 308, and MI 330. Based on interview and record review the facility failed to report a fall and complete a post fall assessment, failed to ensure that appropriate assistance and devices were used during care which led to a fall with fracture for two (Resident #1 and Resident #2) of four residents reviewed for falls, resulting in a fall which was not reported, a missed post-fall nursing assessment, and a fall with fracture and associated pain. Findings include: Resident #2: Review of Resident #2's 12/16/2020 fall investigation indicated Certified Nurse Aide I had taken a soiled brief off the resident, left the resident on her right side, turned away and showed the nurse on the other side of the curtain the brief, and during the time CNA I turned away from the resident (estimated to be approximately less than a minute) the resident was unable to hold herself up and fell off the bed, and sustained a [CONDITION(S)]. During an interview on 3/16/2021 at 1:03 PM, the Director of Nursing confirmed Resident #2 was a one-person extensive assist for bed mobility at the time of the 12/16/2020 fall. When asked if the DON found anything wrong with what Certified Nurse Aide I did during the 12/16/2020 fall event the DON reported that turning away from the resident (was wrong). Review of Resident #2's care plan at the time of the 12/16/2020 fall, stated BED MOBILITY: (Resident #2) requires extensive/dependent assistance x 1 to reposition and turn in bed. Bilateral assist bars to bed for repositioning/mobility, Date Initiated: 10/24/2020 .Created on: 10/18/2016 .Revision on: 10/24/2020. Review of Resident #2's Incident and Accident Investigation Form, dated 12/16/2020 at 5 AM, stated, Resident rolled out of bed during incontinence care. and Resident was left briefly during incontinence care which resulted in the resident rolling off the bed resulting in a hip fracture. Staff interviews from the facility investigation stated the following: Registered Nurse J stated, I was passing meds (medications) to the resident in bed 1 (Resident #2's roommate). The curtain was pulled between the beds. The CNA (Certified Nurse Aide I) was on the other side providing care to (Resident #2). The CNA came round the curtain to show me something. Then I heard a loud noise. Ran over to the other side and observed (Resident #2) on the floor next to her bed. CNA I had stated, I was changing (Resident #2) and wanted to show the nurse what was in the brief. I was turned away from the bed less than a min (minute) showing the nurse on the other side of the curtain when I heard a loud noise then observed (Resident #2) on the floor next to her bed. Review of Resident #2's Incident and Accident Report form, dated 12/16/2020 stated, Resident was lying on (R) (right) side, she was holding self in position then fell . Physical Assessment noted with pain, redness to right leg during range of motion .Resident awaiting x-ray's to (L) leg. Review of Resident #2's post-fall evaluation, dated 12/16/2020, stated, Resident was on her right side after she changed per CNA (CNA I), Resident was turned on her Right side, she was trying to hold on to the bedside table, table rolled/was pushed away resident fell ., and Describe initial intervention to prevent future falls: assist bars on bed. The post fall intervention noted by the nurse was to have assist bars on bed, which had been an intervention and noted to have been put on the bed per the care plan back on 10/24/2020. It was unclear if there were assist bars on the bed at the time of the fall based on the documentation available, and the facility could not provide documentation that assist bars were affixed to the bed at the time of the fall. During an interview on 3/17/2021 at 12:45 PM, The DON and NHA were asked if there was any documentation to indicate that there were assist bars on the bed at the time of the fall as it was not noted in the post fall investigation in the provided documentation. They reported they had done a recent room sweep of all rooms looking at assist bars some days prior, but no documentation was available or provided. If Certified Nurse Aide I had not turned away, CNA I would have been present and could have ensured Resident #2 used an assist bar (rather than grabbing a rolling bed side table) and likely would not have fallen out of bed and sustained a fracture. Review of the investigation's progress notes, dated 12/16/2020 at 4:32 PM, .Resident complains of pain. Upon report of radiology noting a fracture. Resident was sent to hospital for evaluation and treatment. and at 2:46 PM Guest (Resident #2) results from x-ray resulted intertrochanteric fracture. Review of Resident #2's radiology results, dated 12/16/2020, stated, There is an intertrochanteric fracture (hip fracture) (left side). Review of Resident #2's face sheet, dated 12/29/2020, included diagnoses of [CONDITION(S)] (impairment of lower extremities), muscle wasting and atrophy (waste away), weakness, and spinal stenosis (spinal column narrows and compresses the spinal cord). Certified Nurse Aide I was called on 3/17/2021 at 10:00 AM, but was unable to be reached. Resident #1: Review of Resident #1's fall documentation of 11/4/2020 at approximately 7 AM, indicated the resident had a fall in his room, but according to facility documentation of the three Certified Nurse Aides (F, G, and K) who responded, none of them reported the fall to a nurse. Resident #1's 5-Day Investigation results, dated 11/4/2020, included the following interviews/interview summary: Certified Nurse Aide (CNA) K stated, .she walked by the resident's room and seen (Resident #1) sitting on the floor by the dresser and bed talking . Upon further questioning and reenactment, CNA K states she saw (Resident #1) on the floor, trying to get up as she was passing by and from the hallway she yelled for help. CNA F stated, she was at the nurse's station and she heard CNA K yelling for help . states when she entered the room, Resident #1 was halfway in the bed with one knee on the ground .states she helped to put Resident #1's feet in the bed, and then they (CNA's K and F) turned him over in the bed .states they then repositioned Resident #1 in the bed. CNA G stated, .that in the morning of 11/4/20 the CNA that was leaving (CNA K) was saying hey hey by the resident's (Resident #1) room. I went down there and observed (Resident #1) with half his body in the bed and half out of the bed and his lower half was out of the bed. During an interview on 3/17/2021 at 9:14 AM, the Director of Nursing (DON) confirmed Resident #1's 11/4/2020 incident was a fall. The Nursing Home Administrator (NHA) confirmed no nurse was notified and therefore no post-fall assessment was completed. The DON confirmed that CNA's K and G put Resident #1 back into bed, for the first fall on 11/4/2020 at approximately 7 AM, before a nurse assessed the resident and did not notify any nurse. During an interview on 3/17/21 at 12:45 PM, the DON reported Physical Therapist L observed Resident #1 grimacing during therapy around 10:30 to 11 AM, a nurse was notified, Resident #1 was assessed, and an x-ray was ordered. The resident could have had the [CONDITION(S)] since 7 AM on 11/4//2020 (after the first fall that was not reported), but, since no post-fall assessment was completed after the fall, this remains unknown. Resident #1 could have had increased pain due to fracture until this was later discovered by staff at 10:30 AM. Review of Resident #1's Incident and Accident Investigation Form, dated 11/4/2020 (no time stated, but for the approximate 7 AM fall), stated, Resident (#1) had hip x-ray on 11/4 which showed an acute fx (fracture) and Based on the interviews resident had a unwitnessed fall on the morning of 11/4. Educated staff on definition of fall, and all falls must be reported to the nurse or management. Review of Resident #1's progress note, dated 11/4/2020 at 9:41 PM, stated Resident had stat x-ray of pelvis and skull done at 6:45 PM , results faxed over at 8:27 PM showed fx (fracture) of left hip .order give to transfer to hospital . Review of the fall policy, revised 10/2019, stated, When a fall occurs, the licensed nurse will evaluate the guest/resident for injury, Do not move the individual until he/she has been examined by a nurse., The first responder will summon a nurse after ensuring the guest/resident is safe .

Based on interview and record review, the facility failed to prevent the development of an unstageable pressure ulcer (tissue damage covered by slough or eschar/dead tissue) for one resident (Resident #309) of four residents reviewed for pressure ulcers, resulting in a facility-acquired left heel unstageable pressure ulcer, the likelihood for pain, infection and a compromise of overall health. Findings include: On 8/27/20, a record review of Resident #309's electronic medical record revealed an original admission on 2/18/2015 with a readmission 10/16/2017 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment, dated 7/9/2020, revealed Resident #309 required extensive assistance with a two person physical assist for bed mobility. A review of Braden Scale for Predicting Pressure Sore Risk Effective Date: 07/10/2020 . revealed . Score: 14 . Moderate Risk 13-14 . A review of Resident #309's care plan revealed Focus (the resident) is at risk for skin breakdown/pressure ulcers r/t (related to) impaired mobility (hx (history) of [MEDICAL CONDITION]). He had [DIAGNOSES REDACTED]. Goal (the resident) will have minimized risk in an effort to reduce likelihood of pressure ulcer development through next review date. Date Initiated: 10/16/2017 . Interventions . Encourage (the resident) to allow his heels to be Floated while in bed. Date Initiated: 03/09/2016 . Revision on: 09/18/2017 . Ensure (the resident) wears heel boots while bed. Date Initiated: 08/05/2020 Created on: 08/05/2020 . A review of the ADL care plan revealed Focus (the resident) has an ADL Self Care Performance Deficit and requires assistance with ADL's and mobility r/t Fatigue/weakness, impaired Mobility r/t his hx [MEDICAL CONDITION]. Goal (the resident) will maintain current level of function in Bed Mobility . (the resident) requires total staff assist with mobility Date Initiate: 11/11/2014 . Bed Mobility: (the resident) requires extensive 2 person assistance to reposition and turn in bed. Date Initiated: 10/24/2014 . Resident #309 did not have a care plan for refusing care. A review of the progress notes from July, 7th to August 25th revealed no documentation that Resident #309 refused ADL care. A review of skin assessments revealed on 8/4/2020 . number of new skin conditions: 1 comments: 3 cm (centimeters) x (by) 3 cm area on right heel. Area appears to be new skin underneath of calloused area that has fallen off . The three previous weekly skin assessments revealed . skin condition: Normal . Number of new skin conditions: 0 . A review of progress notes revealed the following: . Chief Complaint . heel ulcer . seen today for new patient. He is alert . He was found to have a left heel ulcer. Documented by nursing staff as a potential pressure ulcer. Wound care team will assess today . 1 cm x 1 cm heel ulcer . document e-signed by (Physician Assistant O) on [DATE] . . chief complaint Foot wound . [AGE] year old male who developed a right heel wound. Has been managed well with local wound care. Slowly improving . General . answers questions well. Moving his extremities. Extremities well perfused. He has a 1-1/2 x 1 cm wound over the posterior aspect of the heel. Minimal slough. Excellent bleeding tissue following gentle debridement. Please refer to photograph for accurate dimensions and sizing of the wound. Depth 2 mm (millimeters) . Decubitus ulcer, heel, right, unstageable . document e-signed by (Physician AA) on [DATE] . On 8/27/20, at 2:25 PM, a phone interview with Physician AA regarding Resident #309's new pressure ulcer was conducted. Physician AA was asked if the new wound was a pressure ulcer and Physician AA stated, the location is suspicious to be a decubitus. Physician AA further offered that Resident #309 may have been admitted with it and Physician AA was alerted of the last readmission for Resident #309 was 10/16/2017 and Physician AA stated, I must have gotten report on the wrong patient then. On 8/27/20, at 3:00 PM, a review of the Resident Rights packet provided by the facility revealed . Planning and Implementing Care . iv. the right to receive the services and/or items included in the plan of care .

This citation pertains to Intakes MI 023, MI 449, MI 598, and MI 775 Based on observation, interview and record review, the facility is placed in Immediate Jeopardy due to its failure to properly follow and maintain accepted standards of infection control practice during a COVID-19 outbreak at the facility including, but not limited to, 1) the failure to ensure that certain residents were cohorted after developing signs and symptoms of respiratory illness, testing negative for Flu A and Flu B, and testing negative for Pneumonia, 2) the failure to isolate and segregate residents who exhibited signs and symptoms of respiratory illness, 3) the failure to immediately isolate and segregate residents who tested positive for the COVID-19 virus, 4) the failure to segregate staff caring for COVID-19 positive and/or symptomatic residents from staff caring for asymptomatic residents, 5) the failure to utilize its isolation wing for COVID-19 residents to its fullest extent, and 6) the failure to operationalize policies and procedures related to COVID-19. These deficient practices resulted in fourty three (43) facility residents with reported positive COVID-19 test results (Resident #'s 205, 204, 203, 201, 206, 235, 229, 210, 220, 233, 239, 236, 209, 237, 200, 218, 211, 212, 213, 214, 215, 216, 217, 219, 221, 222, 223, 224, 225, 227, 228, 231, 232, 234, 238, 242, 243, 247, 249, 202, 250, 252, and 245), sixteen (16) staff members with reported positive COVID-19 test results, nineteen (19) resident deaths (Resident #'s 204, 203, 207, 201, 206, 205, 235, 229, 210, 220, 230, 233, 239, 236, 209, 240, 237, 200 and 218), and six (6) residents who were symptomatic days-to-week prior to testing and who tested negative (#230, 240, 208, 241, 244, and 246) with the likelihood for further cross contamination of other residents residing in the facility (census of 93) thereby putting all facility residents at risk for infection, hospitalization and/or death. Immediate Jeopardy: This Immediate Jeopardy began on [DATE], when five of the facility's residents developed the onset of COVID-19 symptoms and were not isolated or tested for COVID-19 timely. On [DATE], The World Health Organization (WHO) declared the novel coronavirus (COVID-19) outbreak a global pandemic. According to the Genesee County Health Department's (GCHD) COVID-19 Dashboard on their website (gchd.us/coronavirus), The first two cases of COVID-19 in Genesee County were reported on [DATE]. 101 total cases of COVID-19 had been reported in Region 3 (Oscoda, Alcona, Ogemaw, Iosco, Gladwin, Arenac, Midland, Bay, Huron, Saginaw, Tuscola, Sanilac, Genesee, and Lapeer counties) between [DATE] and [DATE]. Thirteen cases were reported in neighboring Oakland County during that time. According to michigan.gov/coronavirus, the total reported COVID-19 cases in Michigan between [DATE] and [DATE], had reached 1,845. As of [DATE], there a total of 2058 confirmed cases in Region 3, and a total of 31,029 confirmed cases in the State of Michigan. The Immediate Jeopardy was identified on [DATE] at 1:13 p.m. The Administrator was notified on [DATE] at 03:34 p.m. of the Immediate Jeopardy that began on [DATE], due to the facility's failure to properly follow and maintain accepted standards of infection control practice during a COVID-19 outbreak at the facility. The Immediate Jeopardy was removed on [DATE]. Findings Include: On [DATE]th, 2020 the Centers for Medicare and Medicaid Service and the Centers for Disease Control and Prevention released guidance for Long Term Care facilities related to prevention and management of COVID-19 to protect their residents and staff from being affected by the deadly virus. Since that release the CDC has made changes to their recommendations for management of COVID-19 as more has been learned and as the pandemic evolved. During a phone interview with Nurse C on [DATE] at 12:13 PM she stated she was the nurse assigned to work on the COVID-19 unit. She stated at the time of interview that there were two residents on the COVID-19 unit, Resident #206 and #213. She said she heard a rumor that more residents would be coming to the unit. During a phone interview with Infection Control Nurse B on [DATE] at 2:18 p.m., she said as of that moment facility had a total of 2 residents that had tested positive for the COVID-19 virus, and one resident who also had tested positive for [MEDICAL CONDITION] and had deceased , and one symptomatic resident that had results pending. She explained that they facility had two employees that tested positive for COVID-19 and seven staff that had test results pending at that time. During a follow up interview on [DATE] at 1:10 PM, Nurse C explained that when she started her shift there was two residents (#206 and #234) on the COVID-19 unit she was working. She explained that within the past half hour she had received four (#'s 229, 202, 231, 233) residents from upstairs that were moved to the COVID-19 unit. When asked if she said those residents had just moved today, Nurse C said Yes, they just came down before taking this call. Record review revealed that Resident's #229, # 231 and #223's test results were reported positive on [DATE]. According to interview with Nurse C the facility waited two days after receiving positive test results to move them. During a phone interview on [DATE] at 10:18 AM, Confidential Staff Member V said they were afraid to speak out for fear of retaliation. Staff member was concerned that mandatory staff meetings were still held and go against social distancing precautions. Staff member was concerned that the NHA was not heading all the infection control nurses recommendations to prevent and control COVID-19 in their facility and gave the example of checking staff temperatures. Staff member stated the infection control nurse wanted to check all staff temperatures at the beginning of every shift and the NHA only wanted to get a baseline until after the outbreak started. Staff member felt the NHA and DON were not managing the outbreak based on the recommendations from the infection control nurse and CDC guidelines in order to save money. During a phone interview on [DATE] at 10:24 AM, Confidential Staff Member X stated that they were fearful of being fired by the cut throat management for speaking out. Staff member felt the facility should have starting preventative monitoring of COVID-19 symptoms sooner than the did based on the infection control nurses recommendation. The staff member said the certified nursing assistants (CNA's) are working all over the building and spreading [MEDICAL CONDITION] floor to floor. The staff member said the facility is waiting days after symptoms appear and test results come back to move residents to the isolation unit. During an interview on [DATE] at 5:09 PM, the NHA stated that she could not recall when the COVID-19 unit opened and did not know how many beds were on the COVID-19 unit. After a couple minutes of silence the NHA responded that the unit had 20 beds with 15 beds occupied at the time of interview. The NHA said they move the residents to the COVID-19 unit after they received positive results. When asked why the facility was not utilizing their COVID-19 unit for residents suspected of COVID-19 or not moving some of the residents that tested positive to the COVID-19 unit, the NHA stated that the unit was opened for the purpose of admitting residents from the hospital to those rooms. Electronic health record documentation (including medication and treatment administration records, census reports, physician order's, and lab requisitions), provided by the facility revealed: All sampled residents had an order that read, Respiratory Screen Q (Every) shift every shift for Respiratory Screening Document Yes or No if Cough, SOB (shortness of breath), or sore throat are present, that started on [DATE] or ,[DATE], unless otherwise noted. Resident #235's [DATE] Medication Administration Record [REDACTED]. Resident #235's March and [DATE] MAR's were not marked with yes or no from ,[DATE]-,[DATE], it was marked with a check. According to the chart code on the MAR, a check mark means administered. Resident #235's [DATE] MAR indicated [REDACTED]. Resident #235 also had a physician's orders [REDACTED]. The facility infection control line listing recorded Resident #235's respiratory symptom onset date as [DATE], three days after his first documented symptom of respiratory illness. Resident #235 was hospitalized on [DATE] and tested for COVID-19 on [DATE], his results were negative. His symptoms persisted after the negative results and he was re-hospitalized and [DATE] and re-tested for COVID-19, the results were reported positive on [DATE]. Resident #235 expired on [DATE]. Resident #213, a [MEDICAL TREATMENT] resident with wandering habits, had an order that read, Respiratory Screen Q (Every) shift every shift for Respiratory Screening Document Yes or No if Cough, SOB (shortness of breath), or sore throat are present, from [DATE]-[DATE] (the order was changed upon readmission [DATE] to respiratory screen three times a day Document Yes or No if Cough, SOB, or Fever are present.). According to March and [DATE] Medication Administration Record's (MAR's), Resident #213 had respiratory symptoms documented y on ,[DATE]-,[DATE], ,[DATE], ,[DATE]-,[DATE] and ,[DATE]-,[DATE]. Resident #213's March and [DATE] Mars documented a fever of 99.5 on ,[DATE], 100.1 on ,[DATE], 100 on ,[DATE], 99.6 on ,[DATE], and 99.1 on ,[DATE] on [DATE] and a fever of 99.4 on [DATE]. Resident #213 started an antibiotic for pneumonia on [DATE]. The facility infection control line listing recorded Resident #213's symptom onset date as [DATE], five days after his first documented symptom of respiratory illness. Resident #213 was hospitalized ,[DATE]-[DATE] and tested for COVID-19 at the hospital. His COVID-19 test results were reported positive on [DATE]. Resident #213 was placed on the COVID-19 unit when he readmitted from the hospital on [DATE]. Resident #213 was re-hospitalized ,[DATE]-[DATE]. Resident #213 had a physician's orders [REDACTED]. Resident #213 was roommates with Resident #210 and #219, who also tested positive for COVID-19 on ,[DATE] and ,[DATE]. Resident #203's March and [DATE] MAR's, revealed he had respiratory symptoms documented y on ,[DATE]-,[DATE], ,[DATE], and ,[DATE]-,[DATE]. Resident #203's March and [DATE] MAR's documented a fever of 99.3 on ,[DATE], and 99.2 on ,[DATE] and ,[DATE]. The facility infection control line listing recorded Resident #203's symptom onset date as [DATE], four days after his first documented symptom of respiratory illness. Resident #203 was tested for COVID-19 through the lab vendor of the facility on [DATE], 10 days after his first documented respiratory symptom. His test results were reported positive on [DATE]. Resident #213 was never placed on the COVID-19 unit at the facility. Resident #213 did not have a physician's orders [REDACTED]. Resident #203 expired on [DATE]. Resident #203 was roommates with Resident #200, who tested positive for COVID-19 on ,[DATE]. Resident #200's [DATE] MAR, revealed he had respiratory symptoms documented y on ,[DATE], ,[DATE], and ,[DATE]-,[DATE]. Resident #200's [DATE] MAR indicated [REDACTED]. The facility infection control line listing recorded Resident #200's symptom onset date as [DATE], two days after his first documented symptom of respiratory illness. Resident #200 was tested for COVID-19 at the hospital after he was transferred there on [DATE], 6 days after his first documented respiratory symptom. His test results were reported positive on [DATE]. Resident #200 was never placed on the COVID-19 unit at the facility. Resident #200 did not have a physician's orders [REDACTED]. Resident #200 expired at the hospital on [DATE]. Resident #200 was roommates with Resident #203, who tested positive for COVID-19 on ,[DATE]. Resident #219's, March and [DATE] MAR's revealed he had respiratory symptoms documented y on ,[DATE]-,[DATE], ,[DATE]-,[DATE], ,[DATE]-,[DATE] and ,[DATE]-,[DATE]. Resident #219's March and [DATE] MAR's documented a fever of 102.7 on ,[DATE], and 99.0 on ,[DATE] and ,[DATE]. The facility infection control line listing recorded Resident #219's symptom onset date as [DATE], nine days after his first documented symptom of respiratory illness. Resident #219 was hospitalized on [DATE] and tested for COVID-19 at the hospital. His COVID-19 test results were reported positive on [DATE]. Resident #219 was placed on the COVID-19 unit when he readmitted from the hospital on [DATE]. Resident #219 had a physician's orders [REDACTED]. Resident #219 was roommates with Resident #213 and #210, who also tested positive for COVID-19 on ,[DATE] and ,[DATE]. Resident #201's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE]-,[DATE]. Resident #201's March and [DATE] MAR's documented she had a fever on ,[DATE], ,[DATE]-,[DATE] and ,[DATE]-,[DATE]. She was prescribed Tylenol (fever reducer) around the clock for pain. The facility infection control line listing recorded Resident #201's respiratory symptom onset date as [DATE], eight days after her first documented symptom of respiratory illness. Resident #201 was tested for COVID-19 on [DATE], her results were reported positive on [DATE]. Resident #201 was admitted to hospice on [DATE] and expired on [DATE]. She was never moved to the COVID-19 unit and did not have an order for [REDACTED].>Resident #204's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE], ,[DATE]-,[DATE] and documented she had a fever of 100.2 on ,[DATE], and ,[DATE]-,[DATE]. The facility infection control line listing recorded Resident #204's symptom onset date as [DATE], four days after her first documented symptom of respiratory illness. Resident #204 was tested for COVID-19 on ,[DATE], she was sent to the hospital and expired on ,[DATE]. Her COVID-19 test results were reported positive on ,[DATE]. Resident #204 did not have a physician's orders [REDACTED]. Resident's #239 and #252 later moved to the same room Resident #204 resided in prior to her expiring and later tested positive. Resident #208's March and [DATE] MAR's revealed he had respiratory symptoms documented y on ,[DATE]-,[DATE], and ,[DATE]-,[DATE]. The facility infection control line listing recorded Resident #219's symptom onset date as [DATE], twelve days after his first documented symptom of respiratory illness. Resident #208 was tested for COVID-19 on ,[DATE], his test results were reported negative on ,[DATE]. Resident #208 did not have a physician's orders [REDACTED]. roommates with Resident #216 Resident #206, a resident with wandering habits, had respiratory symptoms documented y on ,[DATE]-,[DATE] and ,[DATE]-,[DATE] and a fever of 100.7 on ,[DATE] (fever continued ,[DATE]) on her [DATE] MAR. Resident #206's [DATE] MAR indicated [REDACTED]. According to the chart code on the MAR, a check mark means administered. The facility infection control line listing recorded Resident #206's symptom onset date as [DATE], fifteen days after her first documented symptom of respiratory illness. Resident #206 was tested for COVID-19 on ,[DATE]. Her test results were reported positive on ,[DATE]. Resident #206 was placed on the COVID-19 unit when on ,[DATE] prior to her test results coming back, due to her habit of wandering (according to interview with Nurse C). Resident #206 did not have a physician's orders [REDACTED]. She expired on [DATE]. Resident #220's March and [DATE] MAR's revealed he had respiratory symptoms documented y on ,[DATE]-,[DATE] and ,[DATE]-,[DATE], ,[DATE] and ,[DATE] and the presence of a fever on ,[DATE], ,[DATE] and ,[DATE]-,[DATE]. The facility infection control line listing recorded Resident #220's symptom onset date as [DATE], fifteen days after his first documented symptom of respiratory illness. Resident #220 was tested for COVID-19 on ,[DATE]. His test results were reported positive on ,[DATE]. He was moved to the COVID-19 unit on ,[DATE]. Resident #206 did not have a physician's orders [REDACTED]. He expired on [DATE]. Resident #220 was roommates with Resident #232. Resident #229's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE], ,[DATE]-,[DATE], ,[DATE]- ,[DATE] and ,[DATE]-,[DATE], and the presence of a fever of 99.2 on ,[DATE] and ,[DATE]. The facility infection control line listing recorded Resident #220's symptom onset date as [DATE], fifteen days after her first documented symptom of respiratory illness. Resident #229 was tested for COVID-19 on ,[DATE]. Her test results were reported positive on ,[DATE]. She was moved to the COVID-19 unit on ,[DATE]. Resident #229 had an order for [REDACTED]. Resident #233's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE]-,[DATE], ,[DATE]-,[DATE] and ,[DATE]-,[DATE], and the presence of a fever of 101.9 on ,[DATE], 100.1 on ,[DATE], and 101.6 on ,[DATE]. Oxygen was ordered for Resident #233 on ,[DATE]. On ,[DATE] it was documented that her oxygen saturation was 86%. The facility infection control line listing recorded Resident #233's symptom onset date as [DATE], fifteen days after her first documented symptom of respiratory illness. Resident #233 was tested for COVID-19 on ,[DATE]. Her test results were reported positive on ,[DATE]. She was moved to the COVID-19 unit on ,[DATE]. She had an order for [REDACTED]. She expired on [DATE]. Resident #233 was roommates with Resident #222. Resident #234's [DATE] MAR indicated [REDACTED]. According to the chart code on the MAR, a check mark means administered. [DATE] MAR indicated [REDACTED]. The facility infection control line listing recorded Resident #234's symptom onset date as [DATE]. Resident #234 was sent to the hospital and tested for COVID-19 on ,[DATE]. Her test results were reported positive on ,[DATE]. She was moved to the COVID-19 unit on ,[DATE]. She did not have an order for [REDACTED].#234 had a cough, was moaning in response to care and was on oxygen. Progress note dated [DATE] at 12:38 said Resident was lethargic and groaning. Her breathing was described as shallow with an oxygen saturation of 85% on 5 litters of oxygen via nasal cannula. Her heart rate was also noted as elevated at 119. According to the note, she was transferred to the hospital. Resident #202's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE]-,[DATE], ,[DATE], ,[DATE]-,[DATE], ,[DATE], and ,[DATE]-,[DATE] and a fever of 99.0 on ,[DATE] and 99.1 on ,[DATE]. According to Resident #202's physician orders, aerosolized breathing treatments were ordered for shortness of breath on [DATE] and droplet precautions were ordered [DATE]. The facility infection control line listing recorded Resident #202's symptom onset date as [DATE], 16 days after her first respiratory symptoms. Resident #202 was tested for COVID-19 on ,[DATE], the results were positive. According to her census report, Resident #202 moved to the COVID-19 unit on [DATE]. Resident #221's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE]-,[DATE] and ,[DATE]-,[DATE] and a fever of 100.7 on [DATE] and 102.8 on ,[DATE]. According to Resident #221's physician orders, droplet precautions were ordered [DATE]. The facility infection control line listing recorded Resident #202's symptom onset date as [DATE], twenty days after her first documented respiratory symptoms. Resident #221 was tested for COVID-19 on ,[DATE], results were reported positive on ,[DATE]. According to her census report, resident #221 moved to the COVID-19 unit on ,[DATE]. Resident #221 was a roommate of Resident #225, who also tested positive for COVID-19 on [DATE]. Resident #205's March and [DATE] MAR's revealed he had respiratory symptoms documented y on ,[DATE]-,[DATE] and ,[DATE] to ,[DATE]. According to his orders, Resident #205 was administered scheduled Tylenol (fever reducer) every eight hours around the clock. He did not have an order for [REDACTED].#205's symptom onset date as [DATE], ten days after his first documented respiratory symptom. Resident #205 was tested for COVID-19 on ,[DATE], results were reported positive on ,[DATE]. According to his census report, resident #205 never moved to the COVID-19 unit. Resident #205 was roommates with Resident # 244 who showed symptoms of respiratory illness but tested negative for COVID-19 on [DATE], and Resident #207 who expired on [DATE] but was never tested for COVID-19. Resident #205 expired on [DATE]. Resident #246's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE], ,[DATE], ,[DATE], ,[DATE]-,[DATE], ,[DATE]-,[DATE], ,[DATE]-,[DATE], and ,[DATE]-,[DATE] and she had documented fevers of 99.1 on ,[DATE] and 99.1 on ,[DATE]. According to her orders, Resident #246 was administered [MEDICATION NAME] (pain medication containing Tylenol, a fever reducer) around the clock. She had an order for [REDACTED].#246's symptom onset date as [DATE], thirty-six days after her first documented respiratory symptom. Resident #246 was tested for COVID-19 on ,[DATE], results were reported negative that same day. According to her census report, resident #246 never moved to the COVID-19 unit. Resident #207's March and [DATE] MAR's revealed he had respiratory symptoms documented y on ,[DATE] and ,[DATE]-,[DATE]. He did not have an order for [REDACTED]. The line listing did not include Resident #207 and he was not tested for COVID-19 on ,[DATE], isolated or moved to the COVID-19 unit. Resident #207 expired on [DATE]. Resident #207 was roommates with Resident # 244 who showed symptoms of respiratory illness but tested negative for COVID-19 on [DATE], and Resident #205 who tested positive for COVID-19 ON [DATE] and expired on [DATE] Resident #225's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE]-,[DATE], and ,[DATE]-,[DATE] and she had documented fevers of 99.1 on ,[DATE], 99.0 on ,[DATE], 99.1 on ,[DATE], and 100 on ,[DATE]. According to her orders, Resident #225 was prescribed on antibiotic for pneumonia on [DATE]. She had an order for [REDACTED].#246's symptom onset date as [DATE], 17 days after her first documented respiratory symptom. Resident #225 was tested for COVID-19 on ,[DATE], results were reported positive on ,[DATE] and she was transferred to the COVID-19 unit on ,[DATE]. Resident #225's had a progress note written on ,[DATE] at 05:21 that said, this morning at 0500 observed resident visibly sitting on the side of the bed, shaking, appearance of chills. Vs ,[DATE], ,[DATE] oral, HR 74, R 22, obtained order for COVID-19 testing . Resident #225 was roommates with Resident #221, who also tested positive for COVID-19 on [DATE]. Resident #210's March and [DATE] Medication Administration Record's (MAR) revealed he had respiratory symptoms documented y on ,[DATE]-,[DATE] and ,[DATE]-,[DATE] and documented a fever of 99.1 on [DATE]. The facility infection control line listing recorded Resident #210's respiratory symptom onset date as [DATE], twenty-three days after his first documented symptom of respiratory illness. Resident #210 was hospitalized on ,[DATE]-[DATE] and tested for COVID-19 on [DATE], his results were reported positive on [DATE]. He discharged from the hospital and returned to the facilities COVID-19 unit on [DATE] with an order for [REDACTED].#210's SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form dated [DATE] was marked no, for isolation precautions and no comment was made related to significant communicable disease. Resident #222's [DATE] Medication Administration Record [REDACTED]. Resident #222's [DATE] MAR's was not marked with yes or no ,[DATE]-,[DATE], it was marked with a check. According to the chart code on the MAR, a check mark means administered. Resident #222 had a fever of 99.1 documented on [DATE]. The facility infection control line listing recorded Resident #222's respiratory symptom onset date as [DATE], twenty-three days after her first documented symptom of respiratory illness. Resident #222 was hospitalized on ,[DATE]-[DATE] and tested for COVID-19 on [DATE], her results were reported positive on [DATE]. She discharged from the hospital and returned to the facilities COVID-19 unit on [DATE]. She had an order that read, readmitted on droplet precautions that was ordered [DATE]. Resident #222 had a progress note dated [DATE] at 11:47 that said, resident in respiratory distress 89% room air. 3L (liters) of oxygen applied and spo2 (oxygen level) was 93% .new orders to send to (hospital) . Resident #222 was roommates with Resident #233 who tested positive for COVID-19 on [DATE]. Resident #230's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE] -,[DATE], ,[DATE]-[DATE] and she had documented fevers of 99.5 on ,[DATE] and 100.5 on ,[DATE]. According to her orders, Resident #220 was prescribed an antibiotic for pneumonia on [DATE]. She did not have an order for [REDACTED].#246's symptom onset date as [DATE], 24 days after her first documented respiratory symptom. Resident #230 was tested for COVID-19 on ,[DATE], results were reported negative on ,[DATE]. Resident #230 was never transferred to the COVID-19. She expired on [DATE]. Resident #236's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE]-,[DATE] and ,[DATE]-,[DATE] and ,[DATE]-,[DATE] and she had documented fevers of 99.5 on ,[DATE] and 99.2 on ,[DATE] and ,[DATE]. She had an order for [REDACTED]. The facility infection control line listing recorded Resident #236's symptom onset date as [DATE], 25 days after her first documented respiratory symptom. Resident #236 was tested for COVID-19 on ,[DATE], results were reported positive on ,[DATE]. Resident #236 was transferred to the COVID-19 on [DATE]. She expired on [DATE]. Resident #236 was roommates with Resident #223 who tested positive for COVID-19 on [DATE]. Resident #212's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE]-,[DATE], ,[DATE]-,[DATE] and she had a documented fever of 100.1 on ,[DATE]. She had an order for [REDACTED].#212's symptom onset date as [DATE], 24 days after her first documented respiratory symptom. Resident #212 was tested for COVID-19 on ,[DATE], results were reported positive on ,[DATE]. Resident #236 was transferred to the COVID-19 on [DATE]. Resident #223's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE] -,[DATE], and ,[DATE]-,[DATE]-,[DATE], ,[DATE] and ,[DATE]-,[DATE] and she had a documented fever of 99.9 on ,[DATE]. She did not have an order for [REDACTED].#223's symptom onset date as [DATE], 24 days after her first documented respiratory symptom. Resident #223 was tested for COVID-19 on ,[DATE], results were reported positive on ,[DATE]. Resident #230 was transferred to the COVID-19 unit on ,[DATE]. Resident #223 was roommates with Resident #236 who tested positive on [DATE] and expired on [DATE]. Resident #232's [DATE] Medication Administration Record [REDACTED]. Resident #232's [DATE] MAR's was not marked with yes or no after ,[DATE], it was marked with a check. According to the chart code on the MAR, a check mark means administered. He had an order for [REDACTED].#232 was tested for COVID-19 on ,[DATE], results were reported positive on ,[DATE]. Resident #232 was transferred to the COVID-19 on [DATE]. Resident #232 was roommates with Resident #220 who tested positive for COVID-19 on [DATE] and expired on [DATE]. Resident #237's March and [DATE] MAR's revealed she had respiratory symptoms documented y on ,[DATE], ,[DATE], ,[DATE]-22, ,[DATE] and ,[DATE] and she had a documented fever of 101.8 on ,[DATE], 100.9 and 99.4 on ,[DATE], 99.9 and 101.8 on ,[DATE], 102.5 on ,[DATE]. Review of her orders revealed she was prescribed scheduled Tylenol daily. She had an order for [REDACTED].#237 was tested for COVID-19 on ,[DATE], results were reported positive on ,[DATE]. She was transferred to the hospital on [DATE] where she was tested again for COVID-19 and again tested positive. Resident #237 was not transferred to the COVID-19 unit. Resident #224's March and [DATE] Medication Administration Record's (MAR) revealed he had respiratory symptoms documented y on ,[DATE], ,[DATE]-,[DATE] and ,[DATE] and he had documented fevers on ,[DATE] and ,[DATE]. He had an order Readmitted on [DATE] with droplet precautio

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place to prevent the development of one Unstageable pressure ulcer on the lateral right foot, from lack of repositioning and one Stage 2 Pressure Ulcer on the hip/buttocks from a urinary catheter tubing for 1 Resident (#164) of 3 residents reviewed for pressure ulcers, resulting in prolonged healing, potential for infection and decreased quality of life. Findings Include: Resident #164 On 10/15/19 at 11:44 AM, during the initial tour, Resident #164 was observed lying in bed. The resident said he was admitted to the facility for IV (intravenous) antibiotics because of a wound infection stating, I had 1 small wound on the left leg/back of calf, I had an external device on to help with the contraction, and then I got a sore on my butt and they got infected. I went to (a different nursing home) then I got 2 sores on the sacrum. I went home for IV antibiotics and a wound vac (a device using negative pressure to aid in wound healing); then my femur broke. It popped. I went back to the hospital; then I went home. I was at home for 2 weeks and they couldn't bring me a nurse, no one to change my bandages. I called the caseworker. I kept calling, they kept saying some insurance thing that wouldn't do a wound vac. I stayed by myself. I was laying on chuks (incontinence pads). I was losing blood every day for 2 weeks. I cracked the door open, laid down in bed and called 911 and passed out. Now I'm here with a wound vac. A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #164 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. ). The MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 cognitively intact. The resident needed extensive 2-person assistance with bed mobility and transfers and extensive 1-person assistance with toileting. The resident did not walk. A review of the progress notes revealed a Wound Care Progress Note, written by Nurse Practitioner L dated 10/14/19 identifying 4 wounds: right ischium, left ischium, coccyx and left hip. The resident was receiving treatment with the wound vac to the left ischium and coccyx and wound ointment with a foam dressing to the left hip and right ischium. A review of the Care Plan At risk for impaired skin pressure injury related to [MEDICAL CONDITION], limited mobility, treatment to both ischium's, coccyx and left hip, date initiated 9/19/19 revision 9/30/19 with Interventions: Follow facility policies/protocols for the prevention/treatment of [REDACTED]. On 10/16/19 at 2:09 PM, wound care for Resident #164 was observed provided by Nurse J and assistance by Certified Nursing Assistant K. There was a large amount of yellow odorous drainage on the bed and pads when the resident was rolled over. The resident said no one had checked the wound vac dressing to make sure it was sealed and not leaking. An area was observed on the lower right hip/buttock; there was opened skin along an indented area shaped like the urinary catheter tubing. It was bright red, moist and blood tinged along the indentation where the tubing lay against the resident's skin. Nurse J said, That is new. It looks like it is from the catheter tubing. Resident #164 had a decreased ability to sense discomfort due to [MEDICAL CONDITION]. The nurse informed the resident that he had a new wound and would need a new treatment. During the wound care observation while observing the large amount of yellow drainage, when the staff turned the resident to the left, Certified Nursing Assistant (CNA) K said Nurse (M) had to replace the wound vac device, the night before, as it fell off the counter and broke after a CNA bumped it when weighing the resident with the lift. Resident #164 confirmed the incident happened and the dressing started to come off. Nurse J said the clear dressing was re-enforced. CNA K said she had not yet provided care to the resident on day shift, as he preferred to be last (It was now after 2:00 PM). The resident had not been assessed for drainage or leakage on the day shift; the CNA stated, It would help if other shifts cleaned him up too. The CNA said she was the only one. After Nurse J and CNA K repositioned the resident to the left side, his right lateral foot, outer area, was dark purple, round, and larger than a quarter in size. Nurse J said, I don't know what that is, and asked the resident, You've been laying a lot on your side? The resident had no protective device on his right foot and had not been assisted with repositioning. On 10/16/19 at 4:23 PM, Nurse J said Resident #164 was to receive new dressings to the right outer foot (skin prep and bulky dressing) and right hip urinary catheter tubing pressure wound (foam dressing). A review of the physician orders revealed the resident had new orders for the following: Right buttock wound- cleanse with wound cleanser, skin prep to surrounding tissue, cover with 4 x 4 foam dressing every day shift every 3 days, order date 10/16/19 and Right lateral foot- deep tissue injury- cleanse with wound cleanser, Apply skin prep, cover with ABD pad and wrap with Kerlix daily every day shift, order date 10/16/19. A review of the progress notes, physician orders and care plan did not reveal any additional interventions for prevention of pressure ulcers, related to repositioning or offloading pressure. An interview with the Administrator on 10/17/19 at 11:30 AM, about Resident #164's new wounds revealed, I heard about that. A review of the facility policy titled, Skin Management, dated revised 8/2016 provided It is the policy of the facility that a resident does not develop pressure injury unless clinically unavoidable . Appropriate preventative measures will be implemented on residents identified at risk . and the interventions are documented on the care plan . The interdisciplinary team considers whether the resident exhibits conditions or is receiving treatments that may place the resident at higher risk of developing pressure injury or complicate their treatment. Such conditions may include . Impaired/decreased mobility and decreased functional ability . consult with therapy as needed .

This citation pertains to MI 299. Based on observation, interview and record review, the facility failed to assess and monitor the residents' skin and response to treatment for 2 residents (#'s 2 and 3) of 2 residents reviewed for skin rashes, resulting in Resident #'s 2 and 3 itching and scratching continuously, resulting in a red, inflamed and scabbed rash on their arms, chest, abdomen, legs and buttocks that was not improving and further resulted in the residents' discomfort and feelings of frustration. Findings Include: On 4/3/19 at 9:15 AM, Residents #'s 2 and 3 were observed in their shared room. Resident #2 was lying in bed, awake, watching TV and Resident #3 was sitting in a wheelchair awake. Both residents were scratching. Resident #2 was scratching her left thigh and Resident #3 was scratching her chest/abdomen area. The residents were asked if they were experiencing itching and both replied, Yes. When asked if they had a rash, both replied, Yes. When asked how long they had been suffering with the rashes, Resident #2 said that she had hers, A long time, longer than Resident #3. Resident #2 was observed to have red, raised, scabbed and inflamed areas on her arms, abdomen, chest, and thighs. The thighs had about 50-100 scabbed areas and the resident said it bothered her the worst. Resident #2 said she had just been to a doctor for treatment for [REDACTED]. It's awful. Resident #3 was observed to have red, scabbed areas on her chest, abdomen, arms and legs. Both residents said they had itching in their axilla (arm pits) and groins also. On 4/3/19 at 9:35 AM, Nurses F and G were interviewed about the rashes that Residents #'s 2 and 3 had. Nurse G stated, (Resident #2) just went to a specialist for [MEDICAL CONDITION] arthritis they changed her cream and she's on [MEDICATION NAME] (an oral [MEDICATION NAME] medication to treat itching). (Resident #3) has a rash on the inner thigh. Resident #2: A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #2 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS (Brief Interview for Mental Status) Score of 15/15 and received assistance with dressing, bathing and toileting. A review of Resident #2's medications indicated the resident had received a variety of treatments for a rash over a 2-year period and in (YEAR) and (MONTH) (YEAR) received treatment for [REDACTED]. A review of Resident #2's Care Plan Potential for skin tears .has persistent itching, undated with Interventions: Identify potential causative factors and eliminate/resolve when possible, Measure area weekly and document characteristics in the record. Notify physician of abnormal findings . undated. There were no specific interventions related to the rash. A review of the Skin and Wound-Total Body Skin Assessments, for Resident #2 from 9/13/18-3/27/19, indicated there was no mention of a body rash or description of the [MEDICAL CONDITION]. A review of the progress notes for Resident #2 from (MONTH) 2019-February 21, 2019 revealed there was no mention of a rash. A progress note dated 3/4/19 and written by Nurse I provided, Resident was assessed by treatment nurse. Resident's skin is clean, dry and intact at this time. She continues to have a rash (Physician H) is aware and orders are in place. There was no description of the rash, location or the resident's response to the treatment. A review of the physician notes for Resident #2 (MONTH) (YEAR)-March 2019 indicated Physician H mentioned rash, but not the location, description or how the resident was responding to the treatment. Resident #3: A review of the Face Sheet and MDS assessment for Resident #3 revealed the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the resident had moderate cognitive decline with a BIMS score of 7/15 and needed assistance with transfers, dressing, toileting and bathing. A review of the physician orders [REDACTED]. A review of Resident #3's Care Plans revealed an At risk for skin breakdown/pressure ulcers . care plan that did not mention a rash and a Care Plan titled, Potential for excoriation/redness of the abdominal skin fold and under bilateral breasts at times . undated with Interventions: Do skin checks with showers, treatment as ordered . undated. There was no mention of the scabbed rash found on the resident's arms, chest, abdomen (above the skin fold), legs or thighs. A review of the physician progress notes [REDACTED]. There was no documented plan for treatment. 1/10/19- The physician note references a red yeast rash under the breast with no mention of a rash on other areas of the body. 1/31/19- .complaining of rash of her chest, upper arms, left shoulder area .states that she has been a little bit more itchy regarding chest area .has a little bit [MEDICAL CONDITION].formation . The physician ordered medication. There was no documented description of the rash to indicate it was observed/assessed. 3/13/19- .no wounds on skin. No signs of disruption, irritation. She is not itching today. The note did not indicate if all areas of skin had been assessed. 3/23/19- .fungal rash appropriately applied to the growing area . The physician did not indicate where the growing area was or what it looked like. A review of the Skin and Wound-Total Body Assessments, for Resident #3 from (MONTH) 2, (YEAR)-April 1, 2019 revealed there was no mention of the resident having a rash or identifying itching or scratching. A review of the progress notes for Resident #3 indicated a Total Body Skin Assessment, dated 4/1/19 written by Nurse G- Skin Condition: Normal and on 4/2/19 Nurse I documented Treatment in room to assess resident for possible skin impairment. Upon assessment it was noted that resident continues to have a slight redness to groin. She has a treatment in order at this time. Skin assessments to continue per policy. There was no mention if the rest of the resident's skin was assessed for [MEDICAL CONDITION] or if a cause was being investigated. On 4/3/19 at 12:57 PM, Wound Care Nurse I was interviewed about the itching, scratching and rashes for Resident's # 2 and 3. Nurse I said she was not aware that the resident's had rashes on their extremities, abdomen and chest and stated, (Resident #3) When I looked at her last, she had redness in her groin, and Resident #2 I've seen her many times. I saw her for a rash. They called the doctor. She was treated for [REDACTED]. Nurse I said she would reassess both residents. An interview with Infection Control Nurse A, on 4/3/19 at 1:19 PM, revealed the Nurse was new to her role-starting in (MONTH) 2019. Infection Surveillance for (MONTH) 2019-April 2019 was reviewed with the Nurse and no residents were identified with a rash, including Residents #'s 2 and 3. At 2:30 PM a call was placed to Physician H with no response. On 4/3/19 at 2:45 PM, during an Interview with the Administrator, the lack of documented assessment related to the itching, scratching, location and description of the rashes was discussed, as well as the residents' concerns of a lack of quality of life due to their discomfort. The Administrator said she was not aware of the resident's rashes or discomfort. At 3:10 PM on 4/3/19, Nurse I said she had re-assessed both Residents 2 and 3 but did not describe their rashes or document her findings. A Skin Policy was requested from the facility on 4/3/19 at 12:57 PM and was not received prior to exit.

This citation pertains to MI 409. Based on interview and record review, the facility failed to prevent a fall with a major injury by leaving one resident (#1) who was care planned for one-to-one supervision and who fell while she was left unattended, which two staff members attempted to cover-up by lying about the incident, out of one resident reviewed for falls, resulting in a left leg fracture from a fall which caused pain, and necessitated hospitalization and major surgery. Findings include: According to the Admission Record, dated 3/15/2019, Resident #1 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 2/21/2019, indicated that Resident #1 had a Brief Interview for Mental Status score of three which indicated that Resident #1 was severely cognitively impaired. The undated care plan for Resident #1 indicated that she was to have one-to-one supervision for safety because she wandered into other residents' rooms and invaded their privacy. During an interview with the Nursing Home Administrator (NHA) on 4/3/2019 at 12:00 PM, the facility had no policy or procedure that defined one-to-one supervision but Resident #1 was not to be left unattended at any time. The NHA said that if a staff member needed to leave a resident on one-to-one supervision, they would have to wait for another staff member to replace them so Resident #1 would not be left unattended at any time. A nursing progress note, dated 3/15/2019 at 4:19 AM, reported that Resident #1 was observed by the nurse lying on the floor on her back in front of her bed in her room. At that time, a small abrasion was noted on Resident #1's right elbow. Range of motion had been performed by the nurse with no other injuries noted at the time. A progress note recorded on 3/15/2019 at 7:44 AM that Resident #1 had began crying out and complaining of left hip pain. The nurse on duty noted that Resident #1's left leg was shorter than her right leg while she was laying flat on her back and any movement to the left leg or hip resulted in Resident #1 crying out. The progress notes revealed that Resident #1 was subsequently sent to the emergency room . According to the hospital's Documentation Clarification Form, Resident #1 had been admitted to the hospital on [DATE] and had surgery to repair a left 3 part traumatic extra-articular intertrochanteric [MEDICAL CONDITION]. During an interview with Licensed Practical Nurse (LPN) B, who was the Unit Manager, on 4/3/2019 at 12:55 PM, she stated that she had begun the fall investigation. LPN B stated that she had reviewed the Incident and Accident Report for the fall on 3/15/2019 at 3:00 AM witnessed by Certified Nursing Assistant (CNA) C. LPN B said that she had spoken with CNA C who told her that Resident #1 was in the bathroom when the incident occurred. CNA C said that they were getting her off of the toilet when Resident #1 lost her balance and fell back hard onto the toilet. LPN B said she called CNA D who also told her that the incident had happened in the bathroom. LPN B said she had next called LPN E who was on duty and who had completed the Incident and Accident Report who also said Resident #1 had fallen in the bathroom. LPN B said she had then turned her notes and the investigation over to the NHA because she found it hard to believe that a fractured leg could happen as a result of falling back onto a toilet. LPN B said that she had later watched a video recording from the facility camera in the hallway and said the video showed CNA's C and D running from the day room into Resident #1's room. LPN B said she could tell that they had heard something that had made them run. In a few moments the camera showed CNA D come back out of the room and return with LPN E to go in to Resident #1's room. During an interview with the NHA on 4/3/2019 at 12:00 PM, she stated that she had initially interviewed LPN E on Friday 3/15/2019. The NHA stated that initially LPN E had confused this incident with a recent incident with Resident #1 who had fallen in the bathroom but had stated with certainty that on the occasion of 3/15/2019 when Resident #1 had suffered a fracture, she had been found on the floor by her bed. The NHA said she had also interviewed CNA's C and D who had told her on Friday 3/15/2019 that the incident had happened in the bathroom as they were trying to get Resident #1 off of the toilet in the bathroom. The NHA said that on Monday 3/18/2019, CNA D admitted to the truth and changed her story. CNA D then said that CNA C had come out of Resident #1's room, leaving the resident unattended, and had come to the day room to talk. CNA D said she heard a loud thump and she and CNA C ran in to Resident #1's room where they had observed her to be on the floor near the foot of her bed. The NHA said that CNA C had eventually changed her story as well and reported that she had left Resident #1's room where she had been assigned the one-to-one duty because she was getting sleepy and went into the day room, leaving Resident #1 unattended. CNA C had said that she heard a loud noise and she and CNA D went running into Resident #1's room where they saw her lying on the floor at the foot of her bed. The undated facility 5 day Investigation Results confirmed the details of the interview with the NHA. The facility Fall Management policy, dated as revised 8/2016, stated that The facility will identify hazards and resident risk factors and implement interventions to minimize falls. Resident #1 had an undated care plan in place to provide her one-to-one supervision for her safety. CNA C did not follow the care plan as she had been assigned to provide one-to-one care for Resident #1 on 3/15/2019. When Resident #1 was left unattended, she fell and fractured her femur resulting in pain, hospitalization , and surgery.

This Citation pertains to Intake# MI 724 Based on interview and record review, the facility failed to ensure Critical Laboratory (Lab) values were reported to the physician and appropriate assessment and interventions were provided for 1 (#13) of 13 residents reviewed, resulting in Resident #13 having unreported critically low sodium (aids in supporting blood pressure, nerve and muscle function and fluid balance), hemoglobin (a protein in the red blood cell that carries oxygen to organs and tissues), hematocrit (indicates red blood cell volume) and platelet (aids in blood clotting) levels, which can result in weakness, shortness of breath, confusion and bleeding. Resident #13 was found lying on the floor beside the bed unconscious and bleeding and was transferred to the hospital. Findings Include: Critical Values. LabCorp-2019 defines critical values (or panic values) as laboratory test results that exceed established limit(s) (high or low) as defined by the laboratory for certain analytes as listed in the Critical (Panic) Limits. Critical results are considered life-threatening and require immediate notification of the physician . A record review of the Face Sheet and Minimum Data Set (MDS) assessment revealed Resident #13 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment, dated 1/9/19, indicated the resident was cognitively intact and needed extensive 2-person assistance with bed mobility, transfers and toileting and 1-person assistance with walking, dressing, hygiene and bathing. A review of the Progress Notes, dated 1/15/19 at 7:54 AM and written by Nurse G, indicated Resident #13 was observed on the floor at approximately 4:45 AM, On the floor in her room face down with left arm under her, looking out of place. Turned her over and noted bleeding from nose and mouth, non-responsive with staff, 911 called .They arrived approximately 5:00 AM. Resident was transferred from the floor to bariatric stretcher with 4 EMT personnel. Left the facility at 5:35 AM (to the hospital emergency room ). A review of the Incident and Accident report, dated 1/15/19 at 4:45 AM, revealed, Resident rolled out of bed .observed face down between bed and window area up against bed table .bleeding from nose and around mouth, left arm looks further displaced .incontinent at time of fall . A review of the Lab Results Reports, indicated Resident #13 had blood drawn on 1/14/19 at 11:35 AM. The Laboratory received the blood on 1/14/19 at 2:52 PM and reported the results to the facility on [DATE] at 6:07 PM. The results indicated the resident had several critically low values: Sodium-126 (critically low) Normal range-136-145, Hemoglobin 6.5 (critically low) Normal range 12.0-16.0, Hematocrit 19.6 (critically low) Normal range 36.0-46.0 and Platelets 54 (critically low) Normal range 130-400. The sodium, hemoglobin and hematocrit values were all critically lower than the last time they were checked by the facility on 1/7/19. A review of the Progress Notes revealed there was no documentation that the physician had been notified of the critically low values on 1/14/19 or 1/15/19 prior to Resident #13 being found on the floor non-responsive and bleeding. A review of the Weights and Vitals Summaries, indicated Resident #13 had not received a daily assessment of vital signs (blood pressure, pulse, respiratory rate or temperature). The blood pressure and pulse (heart rate) were missing documentation on 1/13/19, 1/10/19/ 1/8/19, 1/6/19 and 1/5/19. The respiratory rate was not assessed on 1/14/19, 1/13/19, 1/10/19, 18/19, 1/6/19 or 1/5/19. The temperature was not assessed on 1/10/19, 1/8/19, 1/6/19 and 1/5/19. None of the vital signs was assessed after the abnormal lab values were received from the laboratory on 1/14/19 at 6:07 PM. The resident's last documented nursing assessment was 1/14/19 at 8:52 AM. The assessment indicated the resident received oxygen, but the nurse did not obtain a current respiratory rate; the last documented respiratory rate was 1/12/19 at 11:15 PM. A review of the Physician's Progress Notes indicated the last note was dated 1/14/19 at 9:45 AM, prior to the critical values. A review of the Care Plans for Resident #13 indicated the following: Potential for difficulty breathing and risk for respiratory complications related to being morbidly obese, sleep with [MEDICAL CONDITION] (continuous positive airway pressure machine) sleep apnea and [MEDICAL CONDITION] with oxygen dependence, dated 1/3/19 and revised 1/14/19, Interventions: Administer Medication and Treatments per physician orders. Monitor for ineffectiveness, side effects and adverse reactions report abnormal findings to the physician. Specify (No device was specified) dated 1/14/19 .Encourage Frequent position changes for optimal breathing-dated 1/14/19 .Observe for signs/symptoms of respiratory infection: elevated temp . increased difficulty breathing (dyspnea)-dated 1/14/19 .Obtain labs and diagnostics as ordered and report abnormal findings to the physician dated 1/14/19. Alteration in nutritional and/or hydration status .[MEDICAL CONDITION] . dated 1/3/19, Interventions: Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated, dated 1/3/19. At risk for discomfort or adverse side effects: receives diuretic therapy related to [MEDICAL CONDITION] and hypertension, dated 1/14/19, Interventions: Report pertinent lab results to MD (especially Hematocrit, Sodium and potassium), dated 1/14/19. At risk for complication related to [MEDICAL CONDITION], dated 1/14/19, Interventions: Obtain labs and diagnostics as ordered and report abnormal findings to the physician, dated 1/14/19. The Activities of Daily Living (ADL) care plan, dated 1/3/19, had not updated the interventions for assistance with care after the MDS dated [DATE] was completed. The care plan did not reflect the resident's need for 2-person assistance with bed mobility, transfers and toileting. At risk for signs/symptoms of liver complications .dated 1/14/19, Interventions: Obtain labs and diagnostics as ordered and report abnormal findings to the physician, dated 1/14/19. A review of the Nurse Aide documentation in Tasks, revealed the last time the facility documented care provided to the resident prior to the resident found on the floor was 1/14/19 at 9:27 PM, when the resident was repositioned and 4:40 AM on 1/15/19 immediately prior to the resident being found on the floor. The resident was supposed to be repositioned every 2 hours with 2 assist. A review of the physician orders [REDACTED]. days-order date 1/9/19 with start date 1/10/19. A review of the Weights, indicated the resident had 2 documented weights: 1/2/19 383.8 pounds and 1/8/19 369.6 pounds. The resident had not been weighed every other day as ordered on [DATE] to begin 1/10/19. There was no weight after 1/8/19. An interview with the Director of Nursing on 1/17/19 at 2:50 PM revealed, Critical results should be reported to the physician immediately. The Director of Nursing was queried about the lack of documentation of assessment including vital signs, repositioning and toileting for Resident #13 and stated, Let me look into that. The Director of Nursing did not provide any additional information regarding the resident's incident prior to exit on 1/17/19 at 5:00 PM. During an interview on 1/17/19 at 3:50 PM Nurse N was queried on how often a resident receiving skilled nursing services should have their vital signs taken and stated, I take them per shift and the skilled note is done daily. When asked what the nurse would do if she received a report of critical lab values, she said, Report it to the physician immediately. On 1/17/19 at 3:58 PM, Nurse G who found the resident on the floor, was left a message via phone with no return response. A review of the facility policies revealed the following: Skilled Care Documentation, dated 11/2017 provided, Daily documentation in the chart of the resident's care and status is required as condition of participation under the Medicare program .Describe the following information in the narrative note .any change in condition .Heart/lung sounds, rate and quality of apical pulse, vital signs .Pulmonary related, vital signs . and Change in status, identifying and communicating, long-term care, dated (MONTH) 18, (YEAR), You should assess changes from the resident's normal status at admission , at preset intervals based on the resident's condition and regulatory requirement and whenever there's a change in the resident's status .A change in status can happen rapidly in minutes or slowly over hours or days .you can perform an assessment and initiate a treatment plan in the facility. It's useful to do a focused, thorough assessment of the resident's condition to identify a recurring fluctuation in symptoms .obtaining vital signs .Early recognition assessment and intervention assist you in providing necessary care which can decrease the need to transfer to an acute care facility or emergency department .as a nurse you're responsible for communicating a resident's change in status, including the assessment findings to the practitioner .

This citation pertains to intake number Based on observation, interview and record review, the facility failed to provide monitoring and supervision to prevent the elopement from the facility for one (#9) of five Residents reviewed for elopement risk, out of a total sample of 29 Residents. The facility was placed in Immediate Jeopardy (IJ) as a result of the facility's failure to prevent the elopement and ensure the safety of Resident #9 by not responding in a timely manner to audible alarms. Resident #9 eloped from the facility on Wednesday, (MONTH) 17, (YEAR) at 3:19 AM. Resident #9 was discovered approximately 40 minutes later at a McDonalds' restaurant, which was located one-half mile from the facility. The facility was unaware of the Resident's whereabouts resulting in the potential for serious harm, injury and/or death. Findings include: Resident #9 eloped from the facility on 10/17/18 at approximately 3:19 AM and ambulated an estimated half mile up a four lane, highly traveled highway, utilized by rapid moving emergency vehicles; to the gas station and purchased a cigar and lighter and then proceeded to McDonalds's. The Resident's Wanderguard was intact and functioning adequately when he exited the building. The alarms alerting facility staff sounded as Resident #9 exited the building and the staff did not respond to the alarm until approximately 10 minutes after sounding. Resident #9 previously eloped from the facility on 4/17/18 and the facility was aware of his exit seeking behaviors. During the initial tour on 10/16/18 at approximately 11:30 AM, Resident #9 was observed laying in his bed, there was an isolation kit draped over his door. It was reported by CNA (Certified Nursing Assistant) RR Resident #9 [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) within his leg wound. The resident had a private room due to his isolation precautions. It can be noted the Resident's room during initial tour was located on the 2nd floor locked unit. A review was completed of Resident #9's medical records on 10/16/18 at approximately 4:00 PM, it revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent cognitive assessment deemed the resident was cognitively intact. Upon arrival at the facility on 10/17/18 at approximately 7:45 AM, CNA S was observed sitting outside of a room on the 1st providing one to one supervision of a resident. During initial tour the day prior there were no Resident's down this hallway who were receiving one to one supervision. CNA S reported Resident #9 eloped from the facility and went to McDonalds the night prior. At approximately 8:00 AM on 10/17/18, Nurse R entered Resident #9's room to complete her morning assessment. Resident #9 stated, I went to McDonalds to get a coffee, I walked there, it's only a half a mile, I wanted to get my ID (identification) out of my old apartment near Kettering University. It was a little after 4 AM, it's a 24-hour McDonalds. I just walked out the side door, it was no one at the door. I packed my clothes and put them in a white plastic bag and put them in front of the scrub store last night. Nurse R stated, the front lobby door is locked at 8 PM and everyone uses the north side door to enter. The lab lady came in and entered the code. It was the perfect storm, the security guard was on his phone, with his head down, sitting in his vehicle. It can be noted Resident #9 was moved from the 2nd floor locked unit to the 1st floor prior to his elopement. The resident's new room was near the north side door that he exited out of. On 10/17/18 at 8:20 AM, an interview was conducted with the DON (Director of Nursing) regarding Resident #9's elopement from the facility. The DON stated, He packed his stuff and left. She reported the nurse contacted her at 3:50 AM and reported Resident #9 was not in his room and was not in the facility as they had already completed an interior and exterior sweep. The DON explained the resident was moved to a private room yesterday. The DON instructed the nurse to contact law enforcement and told them to double check all the rooms as he likes to sit in inconspicuous spaces. The nurse called the DON back at 4:01 AM reporting Resident #9 was located in the parking lot of McDonald's. The resident went to the gas station and purchased a cigar and lighter as reported by the gas station attendant. The Resident did not say why he left, he is alert and oriented x 3 and did not sign out of the building or alert the nurse that he was leaving, as he is his own person. Resident #9 was out of building from 3:19 AM to 4:01 AM. The resident is equipped with a Wanderguard that did sound the alarm when he left out the building at 3:19 AM. Staff did not respond to the alarm until 3:30 AM (when the nurse responded to it). The nurse assigned to the care of the Resident was providing care to another resident. The DON reported he had his bags packed and was waiting until the CNA's were not looking. She reported Resident #9 has eloped once before from the facility. On 10/17/18 at 10:33 AM, an interview was conducted with CNA RR, he reported Resident #9 was still on the 2nd floor locked when he left work around 3 PM on 10/16/18. He reported the resident is mainly independent and before he left work he was not behaving oddly. He reported on 10/16/18 Resident #9 did not display any exit seeking behaviors and added that his room was next to an exit stairwell. CAN RR was queried as to facility protocol if they hear an alarm going off. He reported they are supposed to stop what they are doing and investigate why the alarm is sounding. At 10:41 AM on 10/17/18 an interview was conducted with Operations Manager KK from the Security Company the facility contracts with. The Security Company Operations Manager reported he was unaware that there was an elopement from the facility. He reported his guard provided him with a verbal report and reported everything was quiet. He reported if someone did walk out through the north entrance its possible he assumed they were staff as a code is required. He reported the security completes rounds 2-3 times on their shift. It was requested that Operations Manager KK have the Security Guard contact this writer at his earliest convenience. At 12:14 PM on 10/17/18, Social Worker C provided a list of current residents who are an elopement risk at the facility. After reviewing the list, it was found that it was last updated on 9/14/18. Social Worker C reported they have initiated new elopement assessments for all residents and the updated list is not yet completed. On 10/17/18 at 1:09 PM, an interview was conducted with Fire Marshall LL who reported during his facility tour with the Maintenance Director, he observed on the 2nd and 3rd floor stairwells the speaker for the Wanderguard alarms had tape over them. Fire Marshall LL queried the Maintenance Director about this. The Maintenance Director reported the facility staff thought the alarms were too loud, so they covered them with tape. Further review of Resident #9's medical records on 10/17/18 at approximately 1:15 PM revealed the following: - On Resident #9's MAR (Medication Administration Record) it stated the following order: Wanderguard to right lower leg every day and night shift for elopement. Check functioning and placement each shift. This order was added to the Resident's MAR indicated [REDACTED]. - Facility form entitled, Release of Responsibility for Leave of Absence, for Resident #9 was reviewed. It showed that the last time he signed out to the facility was 8/15/18 at 10:22 as he was taken to the bank and returned to the facility at 1:17 PM. - Resident #9's care plan stated the following: o Focus: I am at risk for elopement from the facility .I have left the facility without notifying my nurse and singing out LOA . initiated 4/20/18 and revised on 10/17/18. The following progress notes were reviewed and revealed the following: -4/17/18 at 9:24 PM - I went to residents room to give him his medications. He was not in his room. I asked other staff members if they had seen him. At the beginning of my shift he was in his room. Shortly after he was near dining room and front desk. Code Amber was called. Staff searched the facility. Several staff members went around the building and 3 staff members went to the Admiral Gas Station and then to a store down Ballenger road. They said they has seen him approx. (approximately) 1 hour ago. The DON was notified after search of the building was completed and the resident was not found. 911 was contacted and informed of the situation. Requested for wellness check. Residents address was given and information where the resident was seen by staff that were searching for resident. -4/17/18 at 11:51 PM - Resident returned to the building with CNA at 1:22 PM. Stated he went to the store to turn in some pop bottles for money. -4/20/18 at 12:04 PM - Wanderguard placed to right leg. -8/23/18 at 6:00 PM - Pt (patient) exited door across room [ROOM NUMBER] and was on the first floor when an aide came and brought him back . - 9/28/18 at 12:14 PM - Resident had room change to the first floor. Once on the 1st floor he frequently sat next to the front door and watched as staff placed alarm code in panel to disarm activation. Staff would redirect him to resident areas with activities/food and he would immediately return to the front doors. Frequently asking staff to take him to his bank. -9/28/18 at 4:18 PM - Resident was returned to secured unit R/T (related to) attempts at learning alarm system and statement of wanting to exit the facility. On 10/17/18 at 2:15 PM, this writer walked (and counted the footsteps) from Resident #9's room to the double doors leading to the kitchen service area and onto the entry/exit doors the resident eloped out of. It was approximately 5-7 steps from Resident #9's room door to the double doors leading to the kitchen service wing. It was an additional 20-23 steps from the double doors to the staff entry/exit door (north side entrance). There are two keypads near one another, one is for the Wanderguard and the other for the entry/exit door. On 10/17/18 at 3:43 PM, an interview was conducted with Social Worker SS who reported after Resident #9 eloped from the facility all the Social Workers completed a building sweep and redid all elopement assessment for the entire facility. She reported some residents were equipped with Wanderguard's and their elopement assessments had not been updated in over a year. It was reported the Social Worker's just learned there was an elopement assessment component within the Nursing Comprehensive Assessment. It was explained that it's possible the stand-alone elopement assessment and assessment within the nursing assessment could be different. Social Worker SS was queried if some resident's Wanderguards were removed today as there was no necessity for them, the Social Worker reported, Yes. On 10/17/19 at 4:15 PM, an interview was conducted with Social Worker H who additionally stated they (Social Services Department) were unaware there was a section of the Nursing Comprehensive Assessment that indicated elopement risk. She reported the Nursing staff does not communicate the scores from their assessment to the Social Services Department. She added that this morning they did a building wide sweep and there were some Residents that no longer required Wanderguards and were in turn removed. At 4:21 PM on 10/17/18, the DON was queried on if the double doors leading to the kitchen service wing were alarmed with the Wanderguard audible alarm system. The DON responded, No. At 8:52 AM on 10/18/18, an interview was conducted with Social Worker C regarding the reason for Resident #9's room change. She reported she did know the reason behind the resident's room being changed. She stated she was contacted by the DON and instructed to change his room. At 8:58 AM on 10/18/18, an interview was conducted with the DON regarding Resident #9 and his multiple room changes since April. The DON explained he was moved to the 2nd floor locked unit when he was stalking the alarms on the first floor. She reported the IDT (Interdisciplinary Team) met and concluded they were violating the resident's dignity by having him on a floor where he was not able to socialize with other residents given their advanced disease processes. The DON continued he had to be moved to a private room as he is still on precautions [MEDICAL CONDITION]. The DON was queried as to why he was moved just steps away from an exit door to the facility. It was explained that this was the only private room available without uprooting two other residents. It can be noted at the time of the room change Resident #9 was still on isolation precautions and was not allowed to leave his room. At this time, he was able to socialize with any other residents given his isolation precautions. On 10/18/18 at 11:17 AM the Immediate Jeopardy (IJ) was presented to the facility, as it was identified on 10/17/18. The facility was instructed to complete an abatement plan to remove the immediacy. On 10/18/18 at 12:40 PM, an interview was conducted with CNA N regarding the elopement with Resident #9. The CNA reported she worked the 11pm-7am (beginning on 10/16/18 and ending on 10/17/18) that night and was assigned to the care of this resident. She reported she arrived at work at 11 PM on the 16th and she completed rounds upon her arrival. CNA N stated during her initial rounds Resident #9 was observed in his room. She reported she checked on him at 12 AM and she took lunch from 2:10 AM-2:45 AM and then returned to the floor. When she returned to the floor at 2:45 AM she completed a bed check and peeped her head in Resident #9's room and saw the Resident's feet moving. She reported once she completed her bed check she saw the Phlebotomist as she was leaving the facility. She reported Nurse M was now at the nurse's station and once she donned her PPE (Personal Protective Equipment) CNA N walked into Resident #9's room around 3:15 AM and saw the resident was not in his room. The CNA alerted Nurse M, and proceeded to check the resident's bathroom and the remainder of the 1st floor. CNA N was queried if she heard the alarm going off and she reported she never heard an alarm going off. The CNA reported its possible she was in the back of the hallway providing care to another resident and when staff are in those rooms it is not much that can be heard. On 10/18/18 at 3:05 PM, the abatement plans the facility provided was accepted by the Survey Manager. The plan is as follows: Element 1: 1. Resident #9 was assessed for injury upon his return on 10-17-18 by the Nurse Manager and has had no ill effects from leaving the facility without signing LOA. Resident #9 was placed on 1:1 supervision which continues at this time. Care plan was reviewed and updated 10-17-18. Element 2: 2. All residents with Wanderguards had the function and placement of their wander guards rechecked by the Assistant Administrator on 10-17-18. All are in place and functional. 3. All residents were re-evaluated for elopement risk by the social workers on (MONTH) 17-18. Any new residents identified at risk were placed on Wanderguards per policy. Care plans were reviewed and updated as needed. 4. All of the Wanderguard equipped doors were checked for function by the Director of Maintenance on 10-17-18 @ 0900 and were functional. 5. Elopement books on all units and the reception desk were reviewed by the Assistant Administrator ON 10-17-18 and were accurate. Elopement books will be updated weekly by the social worker. Element 3: 6. Education on the elopement policy and procedure was immediately started on 10-17-18, and as of 2:25 pm 10-18-18, 145 of 182 employees have been educated on the elopement policy and procedure, with the remaining employees to be educated prior to returning to work. All new employees will be educated during the new orientation program. 7. Elopement drills continue to be completed every shift every quarter by the maintenance director. 8. An ad hoc QA meeting was held on 10-17-18 which included the DON, LNHA, Assistant Administrator and ADCS. The P[NAME] was reviewed and approved by the committee. ELEMENT 4: 9. Random elopement drills will be conducted for the next 4 weeks, then monthly. Drills will be completed by the maintenance department and results of drills will be forwarded to the QAPI committee for review and recommendation. Any identified issues will be addressed immediately. 10. Audits of new admission elopement assessments will be completed weekly x 1 month, then monthly x 3 by the DON/ designee with all results forwarded to QA committee. 11. Audits of the elopement books will be conducted weekly by the administrator/designee to ensure weekly updates are being conducted with all results forwarded to QA committee. Allegation of compliance 10-17-18 Administrator responsible for sustained compliance. On 10/18/18 at 3:20 PM, a review was completed of the facility security camera from 3:00 AM-3:20 AM, it revealed the following: The camera showed plenty of movement on hall and CNA N was in and out of many of the residents' rooms, CNA N was observed entering a resident room that was next to Resident #9's room. The camera stopped recording at 3:08 AM as there was no movement. At 3:19 AM, it captured Resident #9 walking out of his room with his coat and pajama pants on. He was carrying a large plastic bag and he walked through the double set of doors into the kitchen service area and then out of the north side exit doors. After reviewing the video, the DON and this writer tested the door alarm that Resident #9 exited out of and the loudness of it. As the DON set the alarm off this writer walked to residents' room where CNA N was located during the elopement. The alarm was able to be clearly heard. The DON clarified there would have been two separate alarms going off simultaneously that the staff would have been able to hear. At 4:19 PM on 10/18/18, an interview was conducted with CNA D. She reported she was the float CNA on the 11 PM- 7 AM shift that began on 10/16/18 into 10/17/18. She reported she was not assigned to Resident #9. The CNA reported she did hear the alarm go off, but she does not know what time this was, as she was in a resident room with Nurse M providing wound care. She reported as they were providing care to this resident they had a conversation as they thought they heard the alarm going off but were not certain about it. Neither CNA D or Nurse M stopped care to check on the sound they heard. Upon completion of wound care Nurse M left out to go check on the alarm and then it was announced on the PA (Public Address) system that there was an elopement. CNA D reported she assisted in the search for Resident #9 and left with another staff to conduct a search of the surrounding areas. She reported they went to the Citgo Gas Station and the attendant informed them that Resident #9 was there and had purchased a cigar and lighter. They left the gas station and drove around the McDonald's drive through and that is where they located the Resident. CNA D reported she was able to confiscate the lighter from the resident and educate him on why he could not have the lighter in the facility. She reported he was put on a 1:1. CNA D reported she questioned CNA N on if she had physically seen Resident #9 during her shift. CNA N stated that she saw the Resident's feet and that he was an black man. CNA D reported she educated CNA N that Resident #9 was a Caucasian male. She reported CNA N was sitting at the desk while other facility staff were actively searching for Resident #9. CNA D was queried if she thought CNA N would have heard the audible alarms, she reported if they heard it on the opposite side of the building she believes CNA N heard the alarms as well. On 10/18/18 at 6:00 PM, an interview was conducted with Nurse M regarding the elopement of Resident #9. The nurse reported she worked the 6 PM-6 AM shift beginning on 10/16/18 and ending on 10/17/18. The Nurse reported she saw Resident #9 multiple times throughout her shift, as he was constantly in the doorway requesting coffee. She reported that she saw the resident about a half hour before he eloped from the facility. Nurse M explained when the incident occurred she was on the opposite side of the floor completing wound care on another resident with CNA D. Nurse M was queried if she heard the alarms going off in the building and if she and CNA D had a conversation while providing care about hearing the alarms going off. Nurse M responded, No. Nurse M explained once she completed wound care she walked out of the room and could see the lab lady who was about 15 or so steps in front of her. She stated she then heard the alarm going off and initially assumed it was the laboratory employee that set the alarm off. Nurse M approached the doors and put in the code on the key panel that is right next to door and heard the alarm was still going off. She then realized it was the Wanderguard alarm sounding, Nurse 'M proceeded to enter the code for this. Nurse M clarified that are there two alarms (one for the entry/exit door and one for the Wanderguard), and there are two different distinct alarm sounds. Nurse M reported the facility instructs them to investigate the alarm if it is sounding. Nurse M reported they initiated an interior and exterior search and they were not able to locate Resident #9. She stated there is a Security Guard that is stationed right outside this entry/exit door and he denied seeing anyone exit the building. Nurse M reported that CNA N was by Resident #9's room when he eloped. Nurse M was questioned if staff are able to hear the alarms at the nurse station and in the resident rooms on that side where Resident #9's room was located? She responded, Yes, you can hear the alarms at the nurse's station and all the resident rooms on that side. Upon arrival at the facility on 10/22/18 at 8:15 AM, the facility was questioned if anyone had left the facility since the team left on 10/18/18. It was reported Resident #9 left AMA (against medical advice) on 10/19/18. On 10/22/18 at approximately 9:00 AM, a review was completed of the facility document entitled, Release of Responsibility for Discharge Against Medical Advice, dated 10/19/18 at 3:05 PM. The form stated that Resident #9 left the faciity on [DATE] against the advice of his Physician. On 10/22/18 at approximately 10:30 a review was completed of the facility's investigation file. Resident #9 was identified as missing at 3:47 AM. The following interviews were reviewed: Resident #9 -Resident states he left the facility with the plans to return after he went to his old apartment to look for his ID and drop off his bag of clothes to donate. Nurse M - I heard alarms at the back door at 0345 as I was checking (CNA N) told me (Resident #9) was not in his room. CNA D - I didn't see him on my shift. I was not assigned to me (he was not assigned to me). The nurse told me he was missing. I helped with the search. The nurse and I found him at McDonalds. CNA N - I went in his room to do a bed check and he wasn't there. I told (Nurse M) as she was going to the alarm. I helped search for him. No further information was available per the DON regarding Resident #9 and his elopement from the facility. On 10/22/18 at approximately 11:00 AM, a review was completed of the facility policy entitled, Elopement Policy, revised 5/2017, the policy revealed, .If an employee hears a door alarm, he or she should: a. Immediately go to the site of the alarm .

Based on observation, interview and record review, the facility failed to 1) prevent development of two pressure ulcers for 1 resident (Resident #39) and one pressure ulcer for 1 resident (Resident #47), 2) do complete nursing pressure ulcer/skin assessments and implement care planned interventions for a pressure ulcer for 1 resident (Resident #47) and 3) initiate treatment in a timely manner for 1 resident (Resident #39) of two residents reviewed for pressure ulcers, resulting in pressure ulcers, pain and discomfort, medical care with wound treatments. Findings Include: Resident #39: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment) dated 5/18, nurses and physician notes dated 5/18 through 10/18, revealed Resident #39 was [AGE] years old, re-admitted to the facility on [DATE], alert, non-ambulatory and required staff assistance with Activities of Daily Living (ADL's). The resident's [DIAGNOSES REDACTED]. Review of Resident #39's facility Nursing Assistant/CNA's plan of care/Kardex dated 5/6/18, stated Turn/reposition resident every 2 hours. Review of Resident #39's Skin care plan dated 5/1/18, stated Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of the facility Skin Management policy dated 8/16, stated The licensed nurse will document preventive measures on the care plan/kardex, the licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record. The licensed nurse will document findings of the skin assessment. The CNA's report any new skin impairment to the licensed nurse that is identified during daily care. Review of the residents Shower/Bathing documentation (the CNA ADL documentation) dated 9/20/18 through 10/15/18, revealed no documentation of any abnormalities at all on the residents' skin. Review of the resident's facility Skin & Wound-Total Body Skin Assessment's dated 9/12/18, 9/19/18, 9/26/18, 10/3/18 and 10/10/18, revealed no documentation of any skin irregularity, discoloration, pain, complaints of burning or pain or any skin abnormality at all. Review of the resident's facility Skin & Wound-Total Body Skin assessment dated [DATE] (done 2 days after the resident's skin assessment dated [DATE], which had nothing documented as skin irregularity), stated Left gluteal fold, Pressure (pressure ulcer), Length 2.6, Width 1.6. Wound bed covered in thick yellow adherent slough (non-viable tissue that requires debridement/removal), peri wound skin is light pink in color, scant amount of serosang drainage noted. Pain level hurts a little more. Right gluteal fold, Pressure (pressure ulcer), Length 2.2, Width 0.9. Wound be (bed) is covered with a thick yellow adherent slough, peri wound skin is light pink in color, scant amount of serosang drainage. Pain level hurts a little more. Observation was done on 10/16/18 at 7: 20 a.m., of Resident #39's Bilat (both sides) pressure ulcers. Resident #39 had one pressure ulcer on her left ischium area (per Wound assessment dated [DATE], 2.6 cm length and 1.6 cm width) and one pressure ulcer on her right ischium area (per Wound assessment dated [DATE], 2.2 cm length and 0.9 cm width). During an interview done on 10/18/18 at 10:25 a.m., the facility Wound Nurse RN J stated, she (Resident #39) has Bi-lateral pressure ulcers, I feel that the resident's assessments are incomplete, there is (there would be) some sort of discoloration of pressure ulcers prior to opening (prior to the skin opening, stage II pressure ulcer) and the nurses had been educated on skin and wound assessments in (MONTH) (9/18). During an interview done on 10/18/18 at 11:15 a.m., Resident #39's primary physician MD CC said the resident would have had signs of pressure ulcers, skin breakdown prior to them opening stating, before it opened it would have had redness, some skin breaking and softness. During a phone interview done on 10/18/18 at 12:00 p.m., the Nurse Practitioner (NP) DD was asked if staff had notified her of any changes in the resident's skin prior to 10/12/18, when it was documented she had two open pressure ulcers and she stated, no. During an interview done on 10/16/18 at 10:23 a.m., Resident #39 stated, On my bottom, it burns, it has a hole in it. I cried and complained for a while now, no one would listen to me. The Aide (CNA K), she would not let me lay down, she said you have to wait your turn to be put down. The wound nurse came in and said, You are not supposed to be sitting up for a long time. Now I have a hole in that area on my bottom, no one cared. During a phone interview done on 10/18/18 at 3:08 p.m., Nurse LPN V (documented on 10/10/18 that the residents skin had no abnormalities at all) stated, she (Resident #39) complained she was kept up in her chair. The nurse did not say he did anything about the residents' complaints nor followed through regarding her complaint. During an interview done on 10/17/18 at approximately 10:20 a.m., CNA K said Resident #39 did have to wait to be put to bed, there was not enough staff for all the lifts (mechanical lifts), it was on second shift. I had to put other residents to bed and she was a lift (requiring 2 staff members). The nurses do not help. I was busy, I did tell her she had to wait her turn to be put to bed. Patients/Residents at risk for the development of pressure ulcers should be repositioned if chair-bound every hour if they cannot perform pressure-relief exercises (shift weight and move without assistance). Guideline for Prevention and Management of Pressure Ulcers, Wound, Ostomy and Continence Nurses Society, W[NAME]N Clinical Practice Guideline Series, 2003 Review of the resident's physician orders [REDACTED]. Review of the physician order [REDACTED]. Review of the resident's facility treatment record dated 10/18, revealed treatment for [REDACTED]. During a phone interview done on 10/22/18 at 10:45 a.m., the facility Wound Nurse RN J was asked by this surveyor if she thought it was reasonable as a Wound Nurse, to delay the Santyl (debridement) ointment treatment until the NP came in to see the resident on 10/15/18; and asked why it was not started until 10/16/18. The Wound Nurse J stated, I refuse to answer that, and stated, I did order a dressing on the day I found the pressure ulcers and it can be used for debridement. Review of the resident's physician orders [REDACTED]. Review of the resident's physician orders [REDACTED]. Review of the dressing Exuderm [MEDICATION NAME] Wound Dressing Instructions for use handout dated 7/2016, stated [MEDICATION NAME] dressings may be used for the management of light to moderately exuding (drainage), partial and full thickness. Pressure ulcers, leg ulcers and diabetic ulcers. Surgical wounds, donor sites, dermatological excisions, second degree burns, and traumatic wounds. During an interview done on 10/22/18 at 11:35 a.m., the facility Staff Education Nurse RN E was asked by this surveyor if the Exuderm dressing was used as a debridement dressing for slough (as documented on the residents Wound assessment dated [DATE], which requires debridement) and she stated, no, it's for absorbing drainage, it is not for [MEDICATION NAME]. It's for superficial wounds, lacerations, the top most layers. Review of the facility Wound Nurse's J Training Hours documentation dated 3/1/18 through 10/18/18, revealed she had been educated by the facility on Wound Care, Identification and Assessment on 6/21/18. During an interview done on 10/22/18 at 8:50 a.m., the Director of Nursing said all documentation regarding the resident's pressure ulcer had been given to this surveyor from 10/16/18 through 10/22/18. Resident #47: A review, of Resident #47's medical record, revealed an admission, into the facility, on 3/17/15, with a readmission on 2/14/17, with [DIAGNOSES REDACTED]. A review, of the Minimum Data Set assessment, revealed the Resident had severely impaired cognition, needed extensive assistance with bed mobility, dressing and personal hygiene and total dependence of two-person physical assist with transfers and toilet use. A further review of Resident #47's medical record revealed the following: A progress note dated 9/11/18 at 19:26 (7:26 PM) that revealed, Total Body Skin Assessment . Skin condition: Normal; Number of new skin conditions: 0 (none). A progress note dated 9/12/18 at 13:51 (1:51 PM) that revealed, Wound/Skin Healing Note. (Resident #47 in room number) had a wound noted on 9/12/18. The wound is as follows: Right heel- Pressure: Length= 5.0 (centimeters, cm), Width= 7.0 (cm), Depth=--, -Stage Suspected Deep Tissue Injury, undermining/tunneling-None. Wound is a desiccated blister that is black/dark brown in color. Peri wound skin is normal for skin tone. No open areas or exudate noted . A Wound/Skin Healing Record dated 9/12/18 at 13:51 (1:51 PM), that revealed, Date of onset 9/12/2018. Site 49) Right heel; Type Pressure . Wound Bed Black/Brown (eschar) . Pain r/t (related to) Wound, 1. Is the resident experiencing pain related to the wound? Yes; 2. Non-verbal's demonstrated b. Grimacing, e. Guarding; Pain Location, right heel; Nature of Pain, unable to describe. communication deficit; Frequency, Episodic. A Wound Care Progress Note, dated 9/17/18, created by the Nurse Practitioner DD, revealed, Plan: Recommend: Treat right heel wound skin prep wipe and cover with dry bulky wrap 3 times a week and as needed. Arterial Doppler to rule out arterial insufficiency. Continue the current pressure downloading interventions, it is imperative he maintains a heel lift pressure offloading boot while he is in bed and while he is up in the chair. On 10/18/18 at 9:58 AM, an observation was made of Resident #47 sitting in a wheelchair in their room, positioned near the side of the Resident's bed. The Resident had a grip sock on the left foot and a white sock over a dressing to the right foot. The Resident was observed to be pushing with both feet to maneuver the wheelchair back and forth. On 10/18/18 at 11:43 AM, an observation was made of Resident #47, in the same position seated in a wheelchair near the side of the bed. Footwear remained the same. On 10/18/18 at 12:28 PM, a review of Resident #47's care plan for impairment to skin integrity related to suspected deep tissue injury of the right heel with interventions that included, Heel protector boot to the right heel at all times, with a date initiated on 9/12/18 created by Nurse J. On 10/17/18 at 2:43 PM, an observation was made, of Nurse JJ, changing the dressing to Resident #47's right heel wound. The wound was blackened in areas and encompassed the heel area. The dressing did not remove easily, to the back of the heel, until the Nurse loosened the old dressing with the wound cleanser. On 10/18/18 at 9:51 AM, an observation was made, of Resident #47, sitting in their wheelchair. No boot was noted to be on the right foot. The Resident had grip socks to both feet. The dressing to the right heel area appeared to be intact. The Resident had his tennis shoe in his hands and tried to untie the shoelace. The staff was observed to go into the Resident's room and was told, by the Wound Care Nurse J, that the Resident was to have a boot on his right foot and not the Resident's tennis shoe. On 10/18/18 at 3:22 PM, an interview with the Wound Care Nurse J, was conducted regarding Resident #47's right heel wound. The Nurse stated, It started as a deep tissue pressure injury, not changing at all. The Nurse Practitioner suggested a Doppler study. It started as a pressure (wound) but due to poor blood supply, has not changed at all, no improvement. When queried regarding interventions to prevent worsening of the wound and observations of the Resident not wearing the boot on the right foot when up in the wheelchair, the Nurse indicated the Resident was to wear an off-loading boot at all times, started on 9/12/18 and stated, He is supposed to wear it all the time. They (staff) are supposed to put it back on when he gets in his chair. There is an order not to wear shoes. The shoe could have been causing extra pressure. The shoes were off before it (wound) developed. When queried regarding the Resident untying his tennis shoe the Nurse stated, Honestly, I thought they (shoes) were hidden. The Wound Care Nurse was queried regarding the date of origination on 9/12/18 and stated, One of the nurses was doing some kind of care with him (when it was observed.) When queried why the wound was not observed the day before on the Total Body Skin Assessment, the Nurse stated, I can't explain why it was not on the skin assessment the day before. The day before, it (Skin Assessment) shows nothing. When queried if the wound was noticeable on 9/12/18 the Nurse replied, Oh yes. The measurement was 5.0 by 7.0, with a black cap from the time I assessed it (on 9/12/18). When queried if the wound had developed after the prior skin assessment, the Nurse stated, I don't know but not likely. When queried if the facility had a problem with Nurses doing a thorough assessment to identify pressure wounds, the Nurse had no answer.

Based on observation, interview and record review the facility failed to obtain physician orders for oxygen therapy for 2 (#'s 1 and 15) and an order for [REDACTED].#1) of 3 residents reviewed for specialty care and oxygen therapy from a total sample of 15, resulting in the potential for each resident to receive an inadequate amount of oxygen to meet their needs, leading to adverse effects including respiratory distress. Findings Include: Resident #15: On [DATE] at 5:52 PM, Resident #15 was observed lying in bed visiting with her husband. Oxygen was running at 5 liters (l) a minute via an oxygen concentrator (machine that creates oxygen) and a collar over the [MEDICAL CONDITION] (trach) tube. T Mist (humidification) was set for 28%. The resident started to point at [MEDICAL CONDITION] and then at the oxygen. She was not able to speak due to the effects of the stroke; her face became distorted and she appeared not to be breathing. Nurse T was at the nurse's desk and notified of the situation. She said she was on her way into the room. Per Nurse T, she suctioned mucous from the [MEDICAL CONDITION] and the issue resolved. When queried about the resident's oxygen therapy, Nurse T stated, She is supposed to have 8L/minute, but the oxygen concentrator only goes up to 5 Liters. On [DATE] at 7:00 PM, Unit Manager D and this surveyor entered Resident #15's room. The resident had changed rooms and was sleeping in bed. Oxygen therapy was being administered via a 10 liter oxygen concentrator. It was larger than the concentrator in the previous room. The oxygen dial was set at 8 liters a minute and T Mist was at 28%. The Unit Manager was queried about physician orders for oxygen and proceeded to the computer at the nurse's desk, looked at the resident's orders on the Electronic Medical Record (EMR) and stated, There is no order for oxygen. The nurse would have to call the doctor or go down and look to see what she is on. A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #15 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment was dated for [DATE] and unfinished except for the Mental status exam that indicated a severe cognitive deficit. A review of the physician orders for Resident #15, did not reveal an order for [REDACTED]. On [DATE] a physician's order was noted for the size of the oxygen concentrator- indicating a 5-liter oxygen concentrator could be used until a 10 liter concentrator was available. There was an order for [REDACTED]. A review of the Care Plans for Resident #15 revealed, .At Risk for Respiratory Distress . created on [DATE] and revised [DATE], Interventions: Give oxygen therapy as ordered by the physician. Dated [DATE]. The Nursing Comprehensive Evaluation dated [DATE] and signed by Nurse FF provided, Oxygen therapy liter/min and frequency: 8. There was no further explanation. There was one physician note dated [DATE] from Physician Q. It mentioned 28% T Mist, but not the amount of oxygen to be administered. Resident #1: A record review of the Face Sheet and MDS assessment for Resident #1, indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] from the hospital with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities and needed assistance with all care except for eating and walking. The resident returned from the hospital on [DATE] at 5:03 PM and died at the facility [DATE] at approximately 5:40 AM, after becoming unresponsive. On [DATE] at 8:40 AM, an interview with Confidential Person GG provided, He went to [MEDICAL TREATMENT] and they sent him to the hospital. He was there about a week and went back to the facility ([DATE]). The hospital called me and said he needed his [MEDICAL CONDITION] machine 24 hours a day. My friend went up (to the facility) a few hours after he was admitted and he did not have the [MEDICAL CONDITION] on. The nurse at the facility said they had no recollection of him having a [MEDICAL CONDITION]. They could not find the [MEDICAL CONDITION] that I brought up and set on the bed earlier in the day on [DATE]. They said they did not have any record that he was supposed to have a [MEDICAL CONDITION]. For at least 2 hours after returning from the hospital he did not have a [MEDICAL CONDITION] on. The hospital said the only way he could come back was if he had a [MEDICAL CONDITION]. The doctor said, From now on he has to be on a [MEDICAL CONDITION]. A review of the facility Admission Packet 'Notice', dated [DATE] revealed Equipment Needs (to be in room Prior to admission), [MEDICAL CONDITION]/[MEDICAL CONDITION], was checked. In the Notes, section it stated, [MEDICAL CONDITION], [MEDICAL TREATMENT]. During a review of the Care Plans for Resident #1 it was noted: .At risk for respiratory distress related to dependence on oxygen related to [MEDICAL CONDITION], created [DATE] and revised [DATE], Interventions: Observe for s/s of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, Shortness of breath at rest, Cyanosis (turning blue), Somnolence (sleepiness). Report issues to physician as indicated, initiated [DATE], revised [DATE], Give oxygen therapy as ordered by the physician, created [DATE] and revised [DATE] . At risk for cardiac issues . created [DATE] and revised [DATE], Interventions: Oxygen therapy as ordered (Specify), created [DATE], revised [DATE]. There was no mention of using a [MEDICAL CONDITION] machine. A review of the physician orders for Resident #1 revealed there was no order for the amount of oxygen therapy to be administered. There was no order for use of a [MEDICAL CONDITION] machine. A review of the resident's Medication Administration Records (MAR's) for (MONTH) (YEAR) did not indicate any documentation of oxygen or [MEDICAL CONDITION] administration. The Treatment Administration Records (TAR's) for (MONTH) (YEAR) revealed, O2 (oxygen) to maintain saturations >89% every shift related to Heart Failure, start date [DATE] and discontinued [DATE]. The last day of documentation was [DATE]. There was no additional entry for oxygen from [DATE] to [DATE]. There was no mention of [MEDICAL CONDITION] use. On [DATE] at 10:45 AM, during an interview with Nurse H she was queried about Resident #1's return from the hospital on [DATE] and stated, I came in at 6:00 PM. (Resident #1) was already there. It was pretty busy. We got a call from (the hospital) that he needed to wear a [MEDICAL CONDITION]. That was before my medication pass at 8:00 PM. I was told Respiratory had brought one in, but it wasn't on him. We weren't told he needed to wear it all the time. He had oxygen on. I think it was 3 or 4 liters/minute. The [MEDICAL CONDITION] and oxygen should have been in the admit orders; whoever did the admit packet. As soon as the hospital called, I placed the [MEDICAL CONDITION]. (The resident) was anxious before and after the [MEDICAL CONDITION] and kept trying to take it off. He would say he was tired and wanted to be left alone. He kept trying to sit up. Nurse H was queried if she obtained a physician's order for the [MEDICAL CONDITION] and stated, I was the only nurse on the first floor. I didn't think about it. About 5:00 AM the nurse aide came and got me and said 'He doesn't look right,' and we started CPR and the (Administrator) called 911. A review of the Weights and Vitals, Nursing Evaluation Data and progress notes for (MONTH) (YEAR) revealed vital signs-blood pressure, pulse, respiration and oxygen saturation were obtained on admission ([DATE]) at 5:06 PM. There were no vital signs or assessment documented between 5:06 PM and 5:00 AM. There was no documented respiratory assessment after the [MEDICAL CONDITION] was placed at approximately 8:00 PM. On [DATE] at 10:40 AM, an interview with the Admissions Director U revealed, We have a packet from the hospital we give them (nurses). We make a copy of everything we have including orders. The Admissions Director was queried if the hospital had indicated that Resident #1 was to wear a [MEDICAL CONDITION] and stated, We had checked that he was coming on [MEDICAL CONDITION]. During an interview with the Administrator, on [DATE] at 11:00 AM, she was queried if there were orders in the medical record for oxygen therapy for Resident's #1 and #15 and stated, I don't see an order for [REDACTED]. A review of the facility policy titled, Oxygen Administration, dated (YEAR) provided, A patient will need oxygen therapy when hypoxemia (low oxygen in the blood) occurs, or results from a respiratory or cardiac emergency or from an increase in metabolic function .The equipment needed depends on the type of delivery system ordered . Oxygen Source (example: cylinder, liquid tank, or concentrator) .Appropriate oxygen delivery system (example: nasal cannula, simple mask, [MEDICAL CONDITION] collar etc.) .Verify the practitioner's order for oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed. Orders should include the oxygen source to be used, method of delivery, flowrate of delivery, and oxygen saturation monitoring parameters .monitor the patient's response to oxygen therapy using pulse oximetry .

This citation pertains to intakes MI 605 and MI 618. Based on observation, interview, and record review the facility failed to supervise 3 Residents (#101, #102 and #103) to prevent falls resulting in Resident #101 to have two avoidable falls, Resident #102 to have 6 falls resulting in head injuries with laceration/sutures, and no assessments of neurological checks with 2 falls, and Resident #103 to have a fall with Fracture. Findings include: Review of the facility policy Fall Management, with a revision date of 8/2016, revealed 5. If a potential head injury is present, complete the Neurological Record 8. The IDT will review all resident falls within 24-72 hours at the morning stand -up meeting to evaluate/investigate the circumstances and probable cause for the fall. 9. The IDT will reviw and modify the plan of care to minimize repeat falls and update the resident care plan/kardex as needed. Resident #103 Electronic medical record review of Resident #103's face sheet, (MONTH) (YEAR) physician orders, quarterly minimum data set (MDS) assessment dated [DATE], care plans, revealed Resident #103 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. BIMS (Brief interview of Mental Status) assessment was a 3 out of 15 which indicated resident was severely cognitively impaired. Resident #103 had a fall resulting with fracture of right femur on 5/9/18. According to Resident #103's Minimum Data Set (MDS) assessment dated [DATE] required extensive assist to ambulate and required 2 person assist for transfer and mobility. Review of Resident #103's ADL (Activity of Daily Living) care plan revealed Resident #103 was Impaired cognition and impulsiveness. with interventions that included: Encourage resident to use call light for assistance as needed initiated 4/19/18 ; (Resident) required two person assist to repositon and turn in bed, toilet and bathing, initiated 4/19/18. Review of Resident #103's Risk for Falls care plan r/t (related to) impaired cognition, poor safety awareness and impulsivity. He has a DX (diagnosis) of [MEDICAL CONDITIONS](stroke). DM, Depression and anxiety that also put him at risk for falls. he receives medications that could increase his risk for falls. He attempts to self transfer and ambulate and is unaware of his limitation. Interventions included the following: Do not leave resident unattended in bathroom initiated 4/19/18; Encourage and assist resident to the bathroom after breakfast initiated 5/7/18, Intervention following fall on 5/9/18 included, Room change to area of high supervision Review of Resident #103's Incident and Accident Report dated 5/5/18 at 9:30 AM, revealed, resident had a self reported fall, Resident states he walked to his bathroom and slipped on something wet on the floor and slid on his left hip. Review of Resident #103's Incident and Accident Report dated 5/9/18 at 3:00 AM, revealed resident Pt stated was trying to go empty urinal, urinal fell and slip on urine and had a fall. c/o (complain of) pain of right hip. head to toe assessment. pain level 6 out of 10. Observed on floor in sitting position. Interventions included: room change to area of high supervision related to FX (fracture) right femur. Review of Resident #103's electronic medical records revealed prior to falls, Care Plan and Kardex with intervention of Encourage resident to use call light for assistance as needed. On 6/6/18 at 5:00 PM, during an interview, Attending Physician stated, Resident #103 had no incite, long history of [MEDICAL CONDITION] required close supervision such as one on one or one to two. Attending Physician Z reported that residents with a higher acuity were usually admitted to the first floor but Resident #103 was admitted to the third floor and did not feel he was supervised according to his acuity. On 6/6/18 at 5:45 PM, during an interview, Director of Nursing B and Administrator A DON B stated, Resident's BIMs did not reflect his cognition, he did use his call light at times, did not feel the incident was reportable as we knew how resident fell . Resident #101 Review of Resident #101's face sheet, (MONTH) (YEAR) physician orders, quarterly minimum data set (MDS) assessment dated [DATE] and care plans, revealed Resident #101 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the BIMS (Brief interview of Mental Status) assessment indicated Resident #101 was cognitively intact. According to Resident #101's Incident Report dated 4/30/18 at 7:50 AM, Resident was sitting on side of bed. Attempted to stand up and walk and fell . Interventions implemented included, encourage resident to not sit on side of bed unless she is transferring . Review of Resident #101's Care Plan revealed, (Resident) is at risk for falls r/t (related to)[MEDICAL CONDITION]([MEDICAL CONDITION], stroke) with left side impairment . intervention dated 2/19/18, 2 staff present at all times during transfers. CNA (Certified Nursing Assistant) Kardex revealed, If resident resists having 2 PA (2 person assist) with transfers, notify CN (Charge Nurse). On 6/6/18 at 10:10 AM, during an interview, CNA U stated, I left (resident #101) at the side of the bed, not knowing she was going to get up. I went to go get someone to help with a transfer, when I came back (Resident #101) was on the floor. CNA U stated, (Registered Nurse (RN) K) had stated, 'not to get her up at all until I had some one ready and there and ready to transfer so she would not attempt to get up again.' CNA U reported she had listened to Resident #101 about transfer status and did not looked at the kardex. On 6/6/18 at 10:00 AM, during an interview Registered Nurse (RN) K stated, Certified Nurse Aid (CNA) U reported the fall, had gotten resident dressed, left her sitting on the side of bed, left the room to get assistance to transfer, and resident got up unassisted and fell . RN K stated 'I told (CNA U) not to sit resident at edge of bed unless ready to transfer as resident thinks she can still do these things. Review of Resident #101's Incident Report dated 5/17/18 at 4:43 PM, (CNA P) was transferring pt to the BR (bathroom) next to nursing station and (CNA P) stated (Resident #101's) knees buckled and she fell . Review of Resident #101's At risk for falls care plan revealed the intervention of, 2 staff present at all times during transfers. This intervention was dated 2/19/18. On 6/5/18 at 2:20 PM, during an interview, Licensed Practical Nurse (LPN) S stated, (CNA P) should have looked at the Kardex, Resident #101 buckles and her weight could not keep her up. Had there been 2 (staff) could have prevented (Resident #101) from a fall. On 6/5/18 at 5:00 PM, Certified Nurse Aide (CNA) P reported she had been responsible for Resident #101 on 5/17/18. CNA P further reported that she transferred Resident #101 without assistance. Resident #101 informed me she could transfer with one staff. CNA P further stated that after the fall, Director of Nursing (DON) B, instructed me that Resident does lie about care, and to always follow the care plan/Kardex. CNA P stated that she received a disciplinary action for not following the care plan for appropriate transfer. On 6/7/18 at 5:30 PM, DON B stated Resident #101 was impulsive at times and other times could follow directions 100% of the time, and agreed staff did not follow the care plan for 2 staff assist for transfer on 5/17/18 and it was not a safe transfer. Resident #102 Review of Resident #102's face sheet, (MONTH) (YEAR) physician orders, quarterly minimum data set (MDS) assessment dated [DATE], and care plans revealed that Resident #102 was a [AGE] year old female admitted to the facility on [DATE], and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the BIMS (Brief interview of Mental Status) assessment indicated resident was severely cognitively impaired. According to Resident #102's Minimum Data Set (MDS) assessment dated [DATE] required total assist for Activities of daily living and was non ambulatory. Resident #102's last fall assessment was completed with the quarterly assessment on 4/13/18 with a fall on 2/19/18, a history of falls indicated and was at risk for further falls. There was no further documentation of risk assessments noted in the medical record following any of Resident #102's six falls. Review of Resident #102's care plan dated 1/18/18, Resident is at risk for falls r/t her need for extensive 2 person assist with transfers. She is wheelchair bound secondary to her history of cerebral infarction. She is alert with [MEDICAL CONDITION]. She is not always able to make her needs known but she is able to say 1 word answers. She also uses a communication board at times. She has poor safety awareness. She has limited ROM to her R (right) hand She is also at risk for falls r/t her psychoactive drug use. She has a [DIAGNOSES REDACTED]. Per interview with sister (name) has an extensive history of falls at her pervious LTC (long term care) facility with interventions that included the following: Provide (Resident) with activities that minimize the potential for falls while providing diversion and distraction date initiated 12/30/17; Put (Resident's) call light within reach and encourage him/her to use it for assistance as needed. date initiated 12/30/17; Ensure the resident is wearing appropriate foot wear, date initiated 12/30/18; wing mattress date initiated 2/7/18; resident had a history of [REDACTED]. Review of Resident #102's Behavior care plan dated 12/1/17 and revised 4/21/18, revealed Resident has a behavior problem ie (example) will yell out making a screeching sound and attention seeking, resident will yell out when she is soiled or she thinks it is taking to long for staff to change her r/t decompressive craniotomy of left skull and right sided hemi ([MEDICAL CONDITION]). Resident will push her call light button repeatedly after her needs have been met. She will also yell out, and is currently hitting her head. Resident will take off the helmet and throws it. She will take off her brief and throw on the floor along with her clothing. She will also take off the bedding from the bed. she also has a h/o of biting with interventions that included the following: Replaced resident's call light with a bell and all cords are moved so they are not within resident's reach due to safety reasons date initiated 3/12/18. Review of Resident #102's medical record, revealed that between 4/22/18 and 5/31/18, Resident #102 had fallen 6 times. Four of these falls resulted in head injuries with lacerations, and neurological assessments were not completed for two of them. Review of Resident #102's Incident Report dated 4/22/18 revealed Resident #102 was noted by housekeeper she called for assistance nurse responded patient laying on the floor next to bed, upon assessment noted patient had a bulge on the right hip . Review of Resident #102's Incident report dated 5/11/18 at 3:36 PM, revealed, Patient dropped stuffed animal on floor on the (Left) side of w.c. (wheelchair). She reached down to get it to pick up as she leaned down she fell forward and out of w/c onto ground . 3 cm (centimeters) laceration to mid forehead. Resident was sent to the ER for evaluation. Review of medical records and confirmed in an interview with Director of Nursing (DON) B on 6/7/18 at 5:15 PM, There were no neuro (neurological) checks available . for Incident Report dated 5/11/18. Review of Resident #102's Incident Report dated 5/14/18 at 12:53 PM, revealed, CNA doing 15 minute checks (resident) sleeping, check noted patron on floor, next of bed 1, Head on bed frame shoulder on bed frame laying over base of bedside table. Patient had abrasion post fall to mid forehead reopened same area. Review of medical records and and confirmed in an interview with DON B on 6/7/18 at 5:15 PM, There were no neuro (neurological) checks available. The incident report was unclear as to the location of how Resident #102 was located at the time of the fall. In an interview on 6/6/18 at 9:45 AM, Certified Nurse Aide (CNA) J reported Resident #102 was observed on 5/14/18 lying on the over bed table legs on the floor at the head of the bed and had an injury on her head. CNA J reported Resident #102 was always trying to get out of bed. Review of Resident #102's Incident Report dated 5/17/18 at 9:00 AM revealed, resident observed lying on floor on her backside- no bottom clothes on and lying in a puddle of water redness noted to (Right) shoulder and (Right) hip. In an interview on 6/5/18 at 2:10 PM, Unit Manager N reported she had responded to Resident #102's fall on 5/17/18. Resident #102's falls were discussed during IDT meetings every day and was unsure if resident's 15 minute checks had been initiated. Unit Manager N was unsure if the care plan or Kardex had been updated to include the 15 minute checks. In an interview on 6/5/18 at 3:15 PM, Registered Nurse (RN) M reported she had responded to Resident #102's falls on 5/14/18 and 5/17/18, neurological checks should have been done following fall on 5/14/18 as resident had reopened a head wound. RN M stated, following the fall on 5/17/18 15 minute checks were initiated but were not added to the care plan. RN M reviewed the care plan and Kardex and agreed there were no 15 minute checks on either documentation. Review of Resident #102's Incident Report dated 5/29/18 at 2:25 AM revealed, CNA heard (Resident #102) yelling just before entering (Resident 102's) room. (Resident #102) Observed on floor head at HOB (head of bed) head against back wall, blood observed on (Left) [MEDICAL CONDITION] 1.5 cm x 4 mm (millimeters). In an interview on 6/6/18 at 2:40 PM, Licensed Practical Nurse (LPN) F reported CNA BB heard a noise, reported the fall to LPN F, Resident #102 was found on the floor, head to east against back of wall, hit head against wall, called for assistance, stopped bleeding on right forehead. LPN F reported there was no wing mattress (as required by Resident #102's care plan) on the bed. Resident was moved closer to the nurses station and 15 minute checks were being done. Review of Resident #102's Incident Report dated 5/31/18 at 1:30 PM, Resident in day room in w/c (wheelchair) leaned to the left and threw herself to the floor, hit her right side of head on floor. On 6/5/18 at 3:40 PM, during an interview, Registered Nurse (RN) E stated she had responded to Resident's #102's fall on 5/31/18, was informed by one of the social workers about the fall. Staff were doing 15 minute checks and staff were unable to get to her in time to prevent the fall. On 6/6/8 at 11:30 AM, during an interview, CNA U reported being responsible for Resident #102 on 5/31/18, was in the dining room feeding other residents, Resident #102 was in the day room at the time of the fall. CNA U was unsure who was monitoring Resident #102 at the time of the fall on 5/31/18. On 6/5/18 at 12:15 PM, during an interview, Hospice RN C stated, The Hospice care plan included 'safety measures' and did not have every 15 minute checks as an intervention. Hospice RN C stated, There were no specific safety measures on the care plan for Resident (#102). On 6/6/18 at 9:15 AM, during and interview with Licensed Practical Nurse (LPN) CC and review of Resident #102's 15 minute checks were reviewed. There had been no documented 15 minute checks on the following dates: 5/20/18 4:30 5:45 PM and 4:00 AM-6:45 AM 5/27/18 3:15 PM - 6:45 PM and 7:00 PM - 5:45 AM 5/28/18 3:15 - 5:45 PM 5/29/18 3:00 PM - 5:45 PM 6/5/18 at 5:15 PM - 6/6/18 9:15 AM, no checks. 6/2/18 3:45 PM -5:45 PM no checks, no sheet for the night shift. 6/4/18 at 6:15 PM - 10:45 PM 6:15 AM There were no forms available prior to 5/20/18 for Resident #102. On 6/6/18 at 5:15 PM, during an interview, DON B stated, I had considered other interventions to prevent falls and ensure safety/supervision .I thought of a mattress on the floor but it is so undignified and thought moving her closer to the nurses station would be better. DON B stated, I had no idea 15 minute checks were not on the care plan or Kardex and responded, I have no idea .I did see a few holes in them (holes in documenting the 15 minute checks).

Based on observation, interview, and record review, the facility failed to prevent a fall with injury by not following care planned interventions for transfer status in one (#702) of two residents, out of a total sample size of two residents reviewed for falls, resulting in a fall with major injury. Findings include: On 2/12/2018, at 9:10 AM, Resident #702 was sitting in the room in the wheelchair with left leg elevated on a leg rest and an interview was conducted regarding Resident #702's fall on 11/16/2017. Resident #702 stated, I fell in the big bathroom. I was going to the bathroom. I grabbed the railing to stand and reached back to grab my wheelchair after I turned around the wheelchair was moved. Resident #702 also stated, My leg was going to give out and I fell and heard my leg snap. I can't stand on my leg and I think the aide that let me fall got fired. On 2/13/18, at 9:00 AM, a review of Resident #702's medical record revealed an admission on 11/1/16 with a readmission on 11/22/17 with the following diagnoses; [MEDICAL CONDITION], muscle wasting, intra-[MEDICATION NAME] fracture of left femur and obesity. The Minimum Data Set assessment ((MDS) dated [DATE] revealed intact cognition. A review of Resident #702's MDS dated [DATE] revealed the Resident required extensive assistance with two people for all transfers. On 2/13/18, at 1:30 PM, a review of Resident #702's Incident and Accident Report date 11/16/17 4:50 PM, revealed the following; CNA (certified nursing assistant) attempting to transfer resident 1 PA (person assist) to toilet in shower room. Resident slipped and fell to floor. Unable to do ROM (range of motion) to LT (left) hip due to pain . send to (the hospital) ER to R/O (rule out) fx (fracture) . On 2/13/18, at 1:50 PM, during an interview with the DON (Director of Nursing) in regards to Resident #702 being transferred with only 1 person when the care plan states Resident #702 is a 2 person assist, the DON revealed that staff did do the transfer incorrectly. On 2/13/18, at 1:45 PM, a review of Resident #702's fall care plan created on 05/21/2015 was reviewed to reveal the following; (the resident) is at risk for falls r/t (related to) impaired mobility, gait/balance problems . has a history of falls . created on 5/21/2015 . interventions . follow facility fall protocol . anticipate and meet needs . Resident #702's Activities of Daily Living (ADL's) care plan created on 05/21/2015 was reviewed to reveal the following; (the resident) has an ADL Self-care deficit and requires assistance with ADL's and mobility r/t fatigue/weakness, limited mobility, impaired balance . Interventions . requires extensive max assistance with transfers with 2 staff assistance . revision date 5/24/2017, 7/25/2017. Resident #702 remained a 2 PA assist with transfers prior to fall which occurred with only 1 PA. (the resident) requires a Hoyer lift (a mechanical lift to assist with transfers for people who can't stand) with 2 PA for transfers . revision date initiated 11/22/2017 . On 2/13/2018 at 2:30 PM, a request was made to the DON for a copy of Resident #702's Kardex (a reference tool for nursing and nursing aides to follow for personalized care of the residents). The DON was unable to provide a copy of the Kardex personalized for Resident #702 prior to the fall on 11/16/17 and was able to offer a copy of the Kardex after the fall which revealed, transfer: (the resident) requires Hoyer lift with 2 PA for transfers. On 2/14/2018, at 9:00 AM, a review of Resident #702's admission notes once returning back into the facility after the fall revealed the following; x-ray results from the hospital the left knee, 11/16/17 findings: there is a mildly displaced oblique fracture through distal femur . left hip two views findings: [MEDICAL CONDITION] shaft of the left femur . 11/18/17 Left femur ORIF (Open Reduction Internal Fixation, a surgical procedure) . 11/22/17 (hospital) discharge instructions Lt femur fracture repaired. Lt knee brace-ok to keep off in bed. NWB LLE (non-weight bearing lower left extremity). A nursing admission note on 11/22/17 by Nurse A revealed (the resident) arrived by EMS (ambulance) at approximately 4:20 PM. (the resident) has an immobilizer to the left leg. Dressings removed and surgical sites observed. OT (occupational therapy) did evaluation, (the resident) to transfer with Hoyer lift and 2 person assist. (the resident) is non-weight bearing, non-ambulatory at this time. On 2/14/18, at 11:00 AM, Resident #702 was sitting in the wheelchair in the room with left leg elevated on a leg rest. Resident #702 was further interviewed on how the fall has affected the quality of life and well-being of day to day living and Resident #702 stated, I can't stand on my leg because they told me I couldn't walk at all. Well the way I feel is she messed up my life because I can't walk ever again. I want to walk so bad but I can't. On 2/14/18, at 12:10 PM, a review of the facility policy Fall Management . revised 8/2016 revealed the following; The facility will identify hazards and resident risk factors and implement interventions to minimize falls . Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review.

Based on observation, interview and record review the facility failed to follow physician orders and provide effective interventions to prevent the worsening of pressure wounds for 2 (#'s 501 and 507) of 4 sampled residents with facility acquired pressure ulcers, from a total sample of 24, resulting in the worsening/deterioration and unhealed pressure ulcers, unnecessary pain, and the potential for complications related to impaired skin integrity. Findings include: Resident #501 On 8/21/17 at 1:30 p.m., Resident #501 was observed resting in a geri-chair in the dining room after eating lunch. The resident was alert and only able to respond to simple questions with short answers. On 8/22/17 at 9:05 a.m., resident #501 was observed sitting in the geri chair in the dining room while being fed by a Certified Nursing Assistant (CNA). Resident #501 consumed approximately 30 percent (% ) of the breakfast meal. On 8/22/17 at 11:00 a.m., record review revealed that resident #501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/11/17, indicated a severely impaired cognition. Resident #501 was identified as requiring extensive to total assistance with all activities of daily living (ADLs) and bed mobility with the assistance of two persons. On 8/22/17 at 3:15 p.m., interviews and record reviews were conducted with the Director of Nursing (DON) and the Treatment Nurse (Nurse A) regarding Resident #501's pressure ulcer (PU). The following was revealed: Resident #501's Wound/Skin Healing Record, dated 6/21/17, indicated a facility acquired stage two (II) pressure ulcer (PU) that measured 1.3 centimeters (cm) length X 1.0 cm width and 0.2 cm in depth to the right buttock, with scant serous exudates, granulation tissue, and surrounding tissue with hardness/induration. The documented onset date was 6/20/17. Resident #501's wound progress notes were reviewed. A late entry, for the day of 6/21/17 was written on 8/15/17 (55 days later). The note written on 8/15/17 revealed the following documentation: Wound is as follows: right gluteal fold. Pressure. Length 0.8 cm, width 1.0 cm and depth 0.2 cm, stage III. The wound measurements and the stage of the wound were different as indicated in the Wound/Skin Healing Record, dated 6/21/17. The previous documented onset date was 6/20/17 and not 6/21/17. Nurse A was queried regarding the discrepancies regarding the onset dates, stages of the PU, measurements, and the late documentation for the onset date of the facility acquired PU. Nurse A stated, I have to transfer the information from the wound log into the system (computer). Sometimes I am pulled to the floor to work. There was no follow-up weekly Wound/Skin Healing Record for 6/28/17 (as required per facility's policy). The next Wound/Skin Healing Record was dated for 7/5/17 (14 days later). The location was now described as right gluteal fold. The onset date was documented as 6/23/17 (not 6/20 and/or 6/21 as previously documented). The report indicated an increase in the width of the pressure ulcer. The new measurements were 1.3 cm in length, 2.0 cm in width (an increase) and 0.2 cm in depth. Maceration to the surrounding tissue was then present. It was not prior. The PU was documented as a stage II. Review of the Treatment Administration Record (TAR) for the month of July indicated a six day gap where the treatment was not performed. The missed scheduled days of the treatment were on July 5th and the 7th. Review of the EMR with the DON, Treatment Nurse, and the Administrator revealed no documentation of the PU being treated on the missed days indicated on the TAR nor anywhere else in the EMR. The current physician's order was [MEDICATION NAME] pad 4 x 4 (gauze pads and dressings to right buttock wound topically every Mon, Wed, Fri., cleanse with wound cleanser, apply [MEDICATION NAME]. The Wound/Skin Healing Record, dated 7/10/17, for the right gluteal fold PU revealed a decline. The PU measured at 1.5 cm X 2.0 cm and 0.3 cm in depth, and now described as a stage III from a stage II. The onset date was documented as 6/21/17. The TAR for the month of July revealed missed treatments days where the treatment were not completed for five to six days at a time. Treatments to Resident #501's wound were not done on July 5th and 7th. A documented treatment was rendered on 7/3 and the next documented treatment was not until 7/10 (six day gap in treatment). A documented treatment was on 7/26. The next documented treatment was not until 7/31 (five days later). Review of the EMR with the DON, Treatment Nurse, and the Administrator revealed no documentation of the PU being treated on the missed days indicated on the TAR. The Wound/Skin Healing Record, dated 7/17/17, for the right gluteal fold, onset date of 6/21/17, revealed the following measurements: 1.5 cm X 1.8 cm X 0.2 cm, stage III PU. The month of August revealed a missed treatment on the 2nd, resulting in the treatment not being rendered for a total of three days. Review of Resident #501's EMR did not reveal Wound/Skin Healing Records for the dates of 8/14/17 and 8/22/17, but instead, the Treatment Nurse (Nurse A) presented on a loose piece of paper written measurements for those dates on the area of the right ischium. The paper revealed the following documentation: 8/14/17, PU measurements 1.0 cm (increased) X 0.7 cm X 0.2 cm. 8/22/17 measurements of the wound measured 1.4 cm (increased) X 0.7 cm X 0.2 cm. On 8/23/17 at 11:35 a.m., a wound observation revealed a PU to Resident #501's right buttock. The wound base was pink and a small amount of serosanguinous drainage was noted on the old dressing. The area was cleansed with a wound cleanser and an [MEDICATION NAME] dressing was applied. Resident #507 On 8/22/17 at 8:40 a.m., record review revealed that Resident #507 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed that the resident was dependent for transfers, hygiene and toileting, had no pressure ulcers, and had moderate impaired cognition. A review of physician's orders revealed the following: [MEDICATION NAME] Pad to left hip wound every Monday, Wednesday and Friday initiated 6/9/17. On 8/22/17 at 10:05 a.m., a review of the skin care plan(s) revealed the following: Skin care plan created 2/23/17: Problem: (Resident #507) has actual impairment to skin integrity r/t (related to) redness blanchable to buttocks, immobility, needs assist with positioning. Decreased appetite and weight loss present. Goal: L (left) hip will decrease in size by 1 cm (centimeter) by 7/15/17 (initiated 6/8/17). Interventions (initiated 2/23/17): Apply foam pressure relieving/reducing mattress, pillows, to protect the skin while in bed. Treatment as ordered by the physician. Skin care plan created 3/9/17: Problem: (Resident #507) is at risk for skin breakdown/pressure ulcers or further breakdown r/t Decreased mobility, Incontinence .She is a Hospice patient. Goal: Risks will be minimized in an effort to reduce likelihood of pressure ulcer development through next review date. Interventions (all initiated 3/9/17): Resident's family prefer for resident to remain in bed as she is more comfortable in bed. Administer treatments as ordered and observe effectiveness. Pressure relieving mattress to bed, pressure reducing pad to wheelchair. Skin care plan (created 6/9/17 by Wound Care Nurse A): Problem: (Resident #507) is at risk for skin breakdown/pressure ulcers or further breakdown r/t Actual pressure ulcer L hip, Decreased mobility, Incontinence, On Hospice, Poor nutrition .She has a pressure offloading roho mattress since admission. Skeletal prominence present r/t poor oral intake. Goal: (Resident #507) Pressure ulcer will show signs of healing and remain free from infection . Interventions (initiated 6/9/17): Administer treatments as ordered and observe effectiveness. On 8/22/17 at 10:15 a.m., a record review of the left hip wound care notes revealed the following: 6/5/17-The wound was acquired at the facility on 6/2/17. Wound caused by pressure and is unstageable (wound stages are 1-4,the higher the stage the deeper the wound; Unstageable wounds have dead, nonviable tissue covering the wound bed preventing the clinician from staging the wound). Measurements: 3 cm (centimeters) x 4 cm 6/12/17-Measurements 3.5 cm x 4 cm 6/19/17-Measurements 3.5 cm x 3.8 cm 6/26/17-Measurements 3 cm x 3 cm 7/5/17-Measurements 5 cm x 3.7 cm 7/11/17-Measurements 4.3 cm x 3.7 cm 7/17/17-Measurements 4.2 cm x 4.0 cm 7/24/17-Measurements 4 cm x 4.2 cm 7/31/17-Measurements 4.2 cm x 4.2 cm 8/7/17-Measurements 4.7 cm x 4.5 cm 8/14/17-Measurements 5.5 cm x 4.5 cm On 8/23/17 at 11:50 a.m., an observation of the resident' s wound care to the left hip with Wound Care Nurse A revealed that the pressure ulcer had a round shape, no odor and had red skin around the wound. The wound bed was red and moist, with clear, thin watery drainage. There was about 1/3 of it covered in yellow slough tissue (dead tissue). Wound Care Nurse A cleansed the wound, while wiping it using gauze, Resident #507 grimaced. Wound Care Nurse A stated, We treated her with [MEDICATION NAME] to help with the pain. During the treatment, Resident #507 was observed to be lying on her right side on a blue, wing-tipped mattress (a mattress with a border on it). Wound Care Nurse A was queried about the choice of mattress utilized verses a specialty air mattress (a mattress that utilizes air flow to provide automatic pressure relief). Wound Care Nurse A stated, She is on a roho mattress, studies have shown they are more effective (in relieving pressure) than a specialty air mattress. During this time, the sheet was lifted to reveal the blue wing-tipped mattress. The Wound Care Nurse A was asked if they made roho mattresses that were wing-tipped. Wound Care Nurse A stated, Oh, I don't know, I think so .that is a roho mattress. She has had this mattress since the beginning. Hospice must have put this egg crate foam cover (it was present over the mattress underneath the sheets and was the length that would only cover the trunk of Resident #507's body) on her, I am going to have to check with them. Wound Care Nurse A was asked to provide documentation or proof that the mattress was a roho mattress but did not by the end of the survey. On 8/23/17 at 12:40 p.m., a record review of the progress notes for Resident #507 revealed that on 5/19/17 a winged-tipped mattress was applied to the bed. On 8/23/17 at 1:40 p.m., the Administrator and Director of Nursing (DON) were queried regarding the mattress choice for Resident #507 that had a facility acquired pressure ulcer that was unstageable. The Administrator stated, I don't know why they would not put a specialty air mattress on the bed, we have some in the building. The Administrator also stated, I don't think those (wing-tipped mattresses) are roho mattresses. The Administrator and DON were both asked to verify if the mattress on Resident #507 had roho mattress on her bed. Later on, at 2:00 p.m., the DON stated, I can tell you right now that that is not a roho mattress. On 8/23/17 at 2:20 p.m., a review of the treatment administration record (TAR) revealed the following: May 2017 Order to left hip: Exuderm LP 4 x 4 Pad every Monday and Thursday. Start date 5/29/17. Blank entry for 5/29/17 (no nurse initials indicating treatment was completed). June 2017 Order to left hip: Exuderm LP 4 x 4 Pad every Monday and Thursday. Start date 5/29/17. Exuderm signed out as completed on 6/1/17. New order to left hip: [MEDICATION NAME] Pad 6 x 6 every Monday, Wednesday and Friday. Start date 6/9/17. Treatment not signed out as being completed on 6/21/17 and 6/28/17. July 2017 [MEDICATION NAME] treatment not signed out as being completed on 7/3/17, 7/14/17 and 7/21/17. On 8/23/17 at 2:30 p.m., a record review of the Braden Scales (a tool used for predicting pressure sore development) for Resident #507 was completed and the following was revealed: 2/23/17 0 (admission) 3/2/17 15 3/9/17 15 3/16/17 15 3/23/17 14 Scores under 9 indicate a severe risk for pressure ulcer development. Scores 10-12 indicate a high risk. Scores 13-14 indicate a moderate risk. Scores 15-18 indicate a mild risk. On 8/23/17 at 3:15 p.m., a review of the nursing admission assessment dated [DATE] revealed there was no open areas on Resident #507's skin. On 8/23/17 at 3:45 p.m., a review of the facility policy titled, Skin Management revised 8/2016 revealed the following: #2. The Braden Scale will be completed upon admission, weekly for 4 weeks, quarterly and with a significant change of status by a licensed nurse to determine the risk of pressure injury development. #3. Appropriate preventative measures will be implemented on residents identified at risk (a score of 18 or less on the Braden Scale) and the interventions are documented on the care plan.

Based on interview and record review, the facility failed to provide a safe transfer with a mechanical lift, in accordance with the resident's assessment, for one (#506) of four sampled residents, all reviewed for falls, out of total of 24 sampled residents, resulting in the resident sustaining a fractured shoulder. Findings include: Clinical record review on 10/1/14 at 10:00 a.m., revealed that Resident #506 was originally admitted into the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent annual Minimum Data Set, dated dated [DATE], Resident #506 was cognitively intact, and was totally dependent upon staff for transfers. Review of a physician's orders [REDACTED]." Review of an undated "Resident Care Guide" for Resident #506 noted that the resident was a Hoyer lift for transfers. Review of an "Incident and Accident Report" for Resident #506, dated 6/5/14, noted the following: Describe the nature of the Accident/Incident: "Resident transfer from toilet to hospital stretcher. Resident was on sit-to-stand with staff assist (Sit-to-Stand Lifts are designed to lift patients who are partially dependent with some upper body strength, can stand but have difficulty walking, can sit up on the edge of a bed with or without assistance, and are able to bend hips, knees, and ankles). Resident legs weakened and she dropped down the stand. Staff assist resident off stand before she could fall on the floor." Type of injury: Fracture Left shoulder Review of a Nurse's note for Resident #506, dated 6/5/14, noted: "Resident lost her balance during transfer on sit-to-stand. Staff was present at the time and assisted resident onto hospital stretcher with assistance from paramedics...Resident was transferred to dialysis via ambulance. Paramedic came back to the facility and reported that the resident c/o (complained of) arm pain so she was taken to (local) hospital." Review of the hospital discharge summary for Resident #506, dated 6/5/14, noted that the resident had sustained a "fractured shoulder". During an interview on 10/2/14 at 10:00 a.m., Nurse manager "D" was queried regarding the 6/5/14 transfer for Resident #506 that resulted in the Resident sustaining a shoulder fracture. Nurse manager "D" stated that Resident #506 was being toileted before she went to dialysis. Nurse "D" stated that certified nurse assistant (CNA) "E" and a paramedic were transferring Resident #506 from the toilet onto a hospital stretcher with a sit-to-stand lift, when the Resident's legs gave out. When queried as to why Resident #506 had been transferred with a sit-to-stand lift, instead of the Hoyer lift as ordered on [DATE], Nurse "D" stated that she thought therapy had changed Resident #506 to a sit-to-stand, but was unable to provide any physician's orders [REDACTED]. On 10/2/14 at 10:15 a.m., the Director of Nursing (DON) was queried as to why Resident #506 had been transferred with a sit-to-stand lift instead of a Hoyer lift on 6/5/14. The DON stated that she thought the CNA had received a verbal order from therapy on that morning to change the transfer status of Resident #506 from a Hoyer lift to a sit-to-stand lift. The DON was unable to provide an order, care plan, or nurse's note to document this change. On 10/2/14 at 11:30 a.m., Physical Therapy Assistant (PTA) "C" was queried regarding Resident #506. PTA "C" stated that on the morning of 6/5/14 during therapy treatment, she had transferred Resident #506 from the bed to the wheelchair using a sit-to-stand lift, and that the Resident had no problems or knee buckling. PTA "C" stated that she gave CNA "E" a verbal "OK" in the hallway on 6/5/14 to use a sit-to-stand lift for Resident #506, instead of the Hoyer lift, but that there was no order written for the change in transfer status. ( )

THIS CITATION PERTAINS TO INTAKE #MI 508 Based on observation, interview, and record review, the facility failed to provide a safe transfer for 1 of 6 (Resident #101) sampled residents, from a total of 6 sampled residents, resulting in a fall which fractured her leg, caused her pain and suffering and led to her admission to the hospital for additional care. Resident #101 subsequently died two weeks after admission to the hospital. Findings include: According to the face sheet, dated [DATE], in the medical record, Resident #101 was a [AGE] year old female who was admitted to the facility for long term care due to the following Diagnoses: [REDACTED]. On [DATE] at 2:00 PM, a record review of Resident #101's minimum data set (MDS), dated [DATE], indicated that she was alert and oriented to person but was not able to communicate verbally. Resident #101 was able to indicate her needs through gestures such as pointing her fingers or nodding/shaking her head. She required extensive assistance with moving from one surface to another and was a two person transfer. On [DATE] at 2:00 PM, a record review of Resident #101's care plan for falls, dated [DATE], showed that Resident #101 was considered a fall risk. A written note on Resident #101's care plan for falls, dated [DATE], stated Resident #101 was a "2 person assist with a gait belt" (a device wrapped around a person's waist used to assist in ambulation and prevent falls). On [DATE] at 2:00 PM, a record review of Resident #101's accident and incident report, dated [DATE], revealed that Resident #101 had bare feet at the time of the fall, staff did not use a gait belt when transferring her, and the alarms on Resident #101's wheelchair were turned off because Resident #101 was being toileted. On [DATE] at 2:00 PM, a record review of the facility's documentation of the investigation into Resident #101's fall, dated [DATE], noted that Resident #101 was taken by wheelchair to her room to be toileted at 9:45 AM on [DATE] by certified nursing assistant (CNA) #4. CNA #4 moved Resident #101 into the bathroom in her wheelchair. Resident #101 stood up without assistance, grabbed a handbar on the wall and fell to her knees. Licensed Practical Nurse (LPN) #11 entered the room to care for another resident and observed Resident #101 on the floor in the bathroom. LPN #11 asked CNA #4 what happened and gave directions to not move Resident #101 until LPN #11 was able to assess Resident #101's condition. LPN #11 was called away to an emergency situation with another resident. When LPN #11 returned to the room, Resident #101 had been moved to her bed by CNA #4. LPN #11 assessed Resident #101's condition and noted Resident #101's right leg was swollen and Resident #101 was grimacing with pain. Resident #101 was asked if her leg hurt and, by pointing to her right leg and nodding her head, she communicated that she experienced pain in her right leg. The attending physician and family were notified of the fall and of Resident #101's condition. Resident #101 was sent to the hospital for evaluation and treatment. The hospital x-ray, dated [DATE], confirmed a right femur fracture. On [DATE] from 2:15 PM to 2:45 PM, resident care in the facility was observed. Residents were treated with kindness. Resident #105 was observed being transferred from wheelchair to bed by two (2) CNA's. No concerns or problems noted. On [DATE] at 11:30 AM, CNA #4 was interviewed. According to the statements made during the interview, CNA #4 denied that Resident #101 fell in the bathroom. CNA #4 said that, when he wheeled Resident #101 into her room, he removed her seatbelt and went to the doorway by the hall to look for someone to assist him in caring for Resident #101. When he looked back at Resident #101, she was on the floor. CNA #4 said he did not know what happened. CNA #4 denied that Resident #101 reached for the handbar in the bathroom, he denied that Resident #101 was in the bathroom. According to CNA #4, Resident #101 fell in her room next to the entrance to the bathroom door. When asked how far away CNA #4 was from Resident #101, he said he was two (2) to three (3) feet away from Resident #101 before she fell . According to CNA #4, LPN #11, the charge nurse, came into the room, saw Resident #101 on her knees and left the room without saying anything to CNA #4. CNA #4 then moved Resident #101 back into her wheelchair by himself and put Resident #101 into her bed. CNA #4 was asked if he was aware Resident #101 was a two (2) person transfer with gait belt and CNA #4 admitted that he was aware of this. CNA #4 was asked if he knew that he was not to move any resident after a fall until a nurse assessed the resident and CNA #4 said he was aware of this policy. CNA #4 said he made a mistake, panicked and moved Resident #101 without assistance to her bed. After Resident #101 was in bed, Registered Nurse (RN) #7, who was the unit manager, came into the room and assessed Resident #101. RN #7 left the room for several minutes then, when she returned, RN #7 suspended CNA #4. On [DATE] at 1:30 PM, an interview was conducted with RN #7. RN #7 was asked to recount the events that occurred when Resident #101 fell . According to RN #7, she was in her office when a CNA (could not identify the CNA) came running in and told her to come to Resident #101's room, "there's something wrong". RN #7 ran to the room. When she entered Resident #101's room, CNA #4 was observed at the foot of Resident #101's bed and Resident #101 was in bed and "moaning in pain and covered with bowel movement". RN #7 asked "what is going on?" She was told by CNA #4 that Resident #101 had a fall. RN #7 asked "Where?" CNA #4 replied "I was taking her to the bathroom". RN #7 asked "You and who?" CNA #4 said "Just me". RN #7 asked "Where did it happen?" CNA #4 said "In the bathroom". RN #7 asked "How did she end up in bed?" CNA #4 said "I lifted her up and put her back in bed". RN #7 observed that Resident #101 was covered with a sheet. When the sheet was removed for the assessment, Resident #101's right leg was observed. Resident #101's right leg was lying straight in the bed and her ankle and foot were rotated to the right. On [DATE] at 1:30 PM, during the interview with RN #7, she said that, when a resident experienced a fall, according to the post fall policy and procedure, staff was to page the phrase "Star Trek" overhead three times with a room number which alerts "appropriate team members" who go to the room to assist the resident. Unit manager noted that no one paged a "Star Trek" when Resident #101 fell . On [DATE] at 9:30 AM, LPN #11 was interviewed. When asked to describe CNA #4, she stated that CNA #4 "did his own thing". When asked to explain this statement, LPN #11 said CNA #4 "wasn't good at following orders, would not do what was requested, would need to be directed multiple times to complete an assignment such as vital signs and always had excuses why duties were not completed". LPN #11 felt CNA #4 needed more monitoring than other CNAs in the facility. LPN #11 gave the following information about Resident #101's fall. During medication pass, LPN #11 entered Resident #101's room to administer medication to her roommate. As LPN #11 exited the room, she noted that the bathroom door was ajar. LPN #11 opened the bathroom door, saw CNA #4 in the bathroom and Resident #101 was lying flat on the floor. LPN #11 asked what happened and CNA #4 said "she's OK, she just slipped out of her chair, she didn't fall". LPN #11 replied "No, she's on the floor, it's a fall". LPN #11 told CNA #4 "Stay there, don't move her". There was no response from CNA #4. LPN #11 went to get the blood pressure cuff and was approached by another CNA who stated another resident was experiencing chest pain and needed immediate assistance. LPN #11 said she knew Resident #101 was on the floor and would be safe until LPN #11 returned. LPN #11 went to check the status of the resident with chest pain. LPN #11 was approached by RN #7 who asked if LPN #11 knew Resident #101 was on the floor and needed an assessment. Both nurses went to assess Resident #101. LPN #11 was surprised to see Resident #101 in bed and asked CNA #4 "Why didn't you follow protocol?" CNA #4 shrugged his shoulders and replied "Because I didn't". LPN #11 noted the presence of two (2) other CNAs in the room. On [DATE] at 10:00 AM, CNA #12 was interviewed about the events that occurred when Resident #101 fell . According to CNA #12, she was returning from her morning break when CNA #4 called her into Resident #101's room. CNA #12 observed Resident #101 lying in bed and she smelled strongly of bowel movement. CNA #4 asked CNA #12 to look at Resident #101's leg. CNA #12 thought Resident #101's leg "looked bad". CNA #12 asked what happened and CNA #4 said resident had slipped out of a sit-to-stand (a machine used to transfer a resident from one surface to another) and fell . CNA #12 noted there was no sit to stand machine in the room and, when CNA #4 asked CNA #4 where the sit-to-stand machine was, CNA #4 said Resident #101 fell when he tried to toilet her. CNA #12 asked CNA #4 if he had told the nurse and CNA #4 said he did tell the nurse and the nurse said "OK". CNA #12 went to get RN #7, the unit manager, and inform her of the fall. When RN #7 entered the room, she questioned CNA #4 "What happened, why didn't you call Star trek" and other questions in an attempt to discover what had happened. CNA #4 kept saying "I don't know" in response to all questions. On [DATE] at 10:50 AM, Resident #14 (non-sampled resident), who was the roommate of Resident #101, was interviewed. Resident #14 said she observed CNA #4 take Resident #101 to the bathroom. Resident #14 observed LPN #11 and CNA #4 have a conversation in the bathroom but could not hear what was said. After LPN #11 left the room, Resident #14 saw CNA #4 move Resident #101 out of the bathroom in her wheelchair and put her to bed. She noted that Resident #101 was moaning in pain and CNA #4 told Resident #14 that Resident #101 "hurt her leg".