Every finding on record at Lahser Hills Care Centre

Based on observation, interview and record review, the facility failed to prevent pressure ulcer formation, document accurate skin assessments and implement interventions for one (R80) of three residents reviewed for pressure ulcers resulting in R80 acquiring a Stage 4 (full-thickness skin and tissue loss). Findings include: On 6/3/25 at 9:51 AM, R80 was observed lying in their bed. R80 was asked if they had any wounds or sores. R80 explained they had a couple wounds on their bottom. When asked if they had developed the wound at the facility or if they were present when they were admitted , R80 explained one developed at the facility. Review of the clinical record revealed R80 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: paraplegia, hypertension and stroke. According to the Minimum Data Set (MDS) assessment dated [DATE], R80 was cognitively intact. The MDS assessment also indicated in section M0300 that R80 had one facility acquired Stage 4 pressure ulcer. Review of R80's skin management care plan revealed an intervention initiated 1/17/25 that read, CNA's (Certified Nursing Assistants) will check my skin daily with care and report anything unusual they notice to the nurse. Review of R80's Total Body Skin assessment dated [DATE] documented 0 in the box for Enter the # (number) of New Wounds. Review of R80's March 2025 Treatment Administration Record (TAR) revealed an order with a start date of 3/19/25 that read, Lotrimin AF (anti-fungal) External Cream 1 % . Apply to bilateral gluteal topically two times a day for rash until 04/01/2025 23:59 (11:59 PM) cleanse bilateral gluteal fold apply cream x 2 weeks. The treatment was marked as completed two times a day from 3/19/25 until it was discontinued on 3/25/25. Review of R80's Wound Evaluation dated 3/25/24 read in part, .#3 - Pressure - Unstageable (Slough and/or eschar); Body Location: Location not set; New - Minutes old; acquired: In-House Acquired . Length 3.24 cm (centimeters; Width 1.69 cm; Deepest Point 1.5 cm .Goal of Care: Healable . Review of R80's Wound Evaluation dated 4/1/25 read in part, .#3 - Pressure - Stage 4; Body Location: Right Ischium (bony protuberance of the sit bone); Stable - 7 days old; Acquired: In-House Acquired .Length 1.33 cm; Width 0.76 cm; Deepest Point 1.6 cm .Goal of Care: Healable .Progress: Stable . Review of R80's Wound Evaluations dated 4/8/25, 4/15/25, 4/22/25, 4/29/25, 4/29/25, 5/6/25, 5/13/25, 5/20/25, 5/27/25 revealed wound #3 on the Right Ischium was documented as Stable or Improving, none documented stalled, deteriorating. On 6/4/25 R80 was out of the facility on outside appointments. Review of a Skin & Wound Evaluation dated 6/3/25 read in part, .Type: Pressure . Stage: Stage 4 .Location: Right Ischium .Length 0.8 cm .Width 0.7 cm .Depth 1.0 cm .Undermining 1.9 cm .Goal of Care: Healable .Progress: Stable . On 6/5/25 at 8:42 AM, R80 was observed sitting up in the bed eating breakfast. R80 was asked about observation of wound care. R80 explained their wounds had already been changed that morning and as it was painful was hesitant to have it done again. R80 was asked if they knew how they acquired the wound. R80 pointed to their motorized wheelchair, that had a reclining seat, and explained they used to be up in their chair all day and now tried to only be in the chair for two hours at a time and felt that contributed to the wound. On 6/5/25 at 10:40 AM, the Director of Nursing (DON) was interviewed and shown the picture of R80's Right Ischium wound on the Wound Evaluation dated 3/25/25. The DON was asked if a wound should ever be first identified as an Unstageable pressure ulcer. The DON acknowledged the concern. When asked about the Total Body Skin assessment dated [DATE] that documented no new wounds and the Lotrimin Cream documented as applied two times a day, the DON had no answer. The DON was asked if the wound in the picture could have developed that day. The DON acknowledged the wound would had not developed that day. On 6/5/25 at approximately 12:30 PM, the DON provided an undated, unsigned document that read in part, .On 3/25/25- patient developed stage 4 to right ischium. Seen by wound care on 3/25, documentation of skin breakdown and worsening are unavoidable. Recommend hospice and palliative services . This occurred despite consistent implementation of pressure injury prevention interventions related to limited mobility and paralysis secondary to paraplegia and CVA (stroke). Neuropathy causing diminished sensation, and patient's refusals of hospice or palliative care support . The DON was asked if the wound could be truly unavoidable since it was continuing to heal and had never deteriorated in the two months since it had been identified. The DON acknowledged the concern. Review of a facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol revised 10/2010 read in part, .the nurse shall assess and document/report the following: .b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .

Based on observation, interview, and record review, the facility failed to ensure weights were taken appropriately and verified as accurate per professional standards of nutritional practice for one Resident (R21) of two residents reviewed for nutritional status, with multiple facility residents affected who were weighed. Findings include: On 6/03/25 at 9:46 a.m., R21 was observed dressed, seated on the edge of their bed. R21 was thin in stature. Their breakfast tray was observed in front of them on a tray table, which included scrambled eggs, biscuits and gravy and two bowls of cereal, with juice, milk, and coffee. R21 showed this Surveyor their meal ticket. It was noted the word Oatmeal was scratched out with a black marker. R21 was observed feeding themselves breakfast. The ticket showed R21 was on a regular diet with thin liquids. On 6/03/25 at 9:48 a.m., R21 reported they wanted Oatmeal every day, and their dentures were loose, which they wanted addressed to help them chew food more easily. Review of R21's Electronic Medical Record (EMR) showed their weights until 2/04/24 were documented as follows (in the Vitals section): 1/08/25: 182.0 pounds (in standing). 1/15/25: 183.0 pounds (in sitting). 1/15/25: 183.8 pounds (in sitting). 1/20/25: 183.8 pounds (in sitting). 2/04/25: 144.4 pounds (in sitting). The weight record reflected a 39.4-pound weight change in a two-week period, from 1/20/25 to 2/04/25, which would be atypical. On 6/03/25 at approximately 9:50 a.m., R21 was asked about any significant weight loss during their stay. R21 responded they were not specifically aware of a significant weight loss but could not be certain. Review of R21's census revealed they were admitted to the facility on [DATE]. Review of R21's initial dietary assessment, dated 1/07/25, revealed they were on a regular diet with mechanical soft textures, and had upper and lower dentures. The assessment showed their hospital weight was 77.1 kg (169.97 pounds), nearly 170 pounds, and said they were consuming 75% to 100% of meals. The assessment further revealed R21 had no difficulty swallowing and had some difficulties chewing due to loose dentures and they had requested follow-up. The recommendations revealed: Diet as ordered, obtain weights per protocol, and honor food preferences as feasible. Review of R21's hospital weight records, from the hospital discharge record, printed 1/06/25, dated 12/31/24 to 1/01/25, revealed a weight of 66.9 kg (kilograms = 147.48 pounds), from their most recent admission. Review of R21's (hospital) After Visit Summary, dated 12/26/24 through 1/06/25, printed 1/06/25, revealed R21's height as 6 feet, 2 inches, and a weight of 147 pounds and 7.8 ounces (66.9 kg). Review of R21's Minimum Data Set (MDS) assessment, dated 1/12/25, revealed R21 was admitted to the facility on [DATE], with diagnoses including dementia and anxiety. The assessment revealed R21 required set up with eating, moderate assistance with transfers, and supervision with wheelchair mobility. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 10/15, which showed R21 had moderate cognitive impairment. The nutrition assessment revealed R21 was 72 tall and weighed 184 pounds upon admission. The MDS weight was noted as a significant difference from their hospital weight. Review of R21's Dietary Weight Change note, dated 2/11/25 at 3:27 p.m., revealed R21's current body weight was 144.4 pounds. The note described, .(R21's) weight loss may be r/t (related to) weighing errors and/or varying PO (by mouth) intake at/between meals .Goal is weight stability at this time. Reweight requested .Obtain weights per protocol . On 6/05/25 at 12:59 p.m., RD M was asked about R21's wide fluctuation in weight, and significant weight loss per the EMR weight documentation, which showed a considerable weight loss of nearly 40 pounds for R21, from 1/08/25 through 2/04/25. RD M explained the facility had scale discrepancies and inconsistencies across staff weighing the facility residents at that time. RD M reported the facility completed a Past Non-Compliance (PNC), and said the main deficiency was one of the scales was not calibrated properly. RD M explained the facility had since calibrated the scales and had a consistent person taking the residents' weights, to ensure the weights were taken the same way, by the same person, and with the same scale. RD M was asked what they did about R21's significant documented weight loss, per their notes and the weights in the EMR. RD M reported they notified R21's physician and family member when the significant weight loss (or change) was discovered, which was reflected in their notes, and worked to discover the cause. On 6/05/25 at approximately 1:10 p.m., RD M was asked to review R21's facility admission hospital records with this Surveyor. RD M reviewed the hospital discharge weight of 66.9 kg on 12/31/25 to 1/01/25 and agreed this was 147.48 pounds. R21 reported they had missed this. RD M was asked if they typically reviewed the hospital weight when a resident admitted to the facility, and acknowledged this was part of their typical process when completing the initial dietary assessment. RD M explained their typical resident weighing process was to obtain weekly weights for residents the first four weeks since their admission, and then monthly after, unless there were any significant changes. RD M reported they understood the concerns, and confirmed the facility had corrected the concerns. RD M understood the concern about referencing the hospital weight in their documentation accurately. Significant weight loss for R21 was not verified, given their admission weight was about 147 pounds per hospital documentation, with consistent weights obtained after 2/04/25. On 6/05/25 at 2:10 p.m., the concerns related to inaccurate weights and related process concerns for R21, and multiple facility residents were shared with the Nursing Home Administrator (NHA), and the Executive Director, NHA O, including RD M reporting the concerns had been addressed after they were discovered by February 2025 and the hospital and initial weight discrepancy. The NHA asked to follow-up with the Survey team after further review. On 6/05/25 at 2:35 p.m., the Director of Nursing (DON) shared with the survey team the inaccurate residents' weights were related to significant discrepancies from two of their standard scales, which maintenance verified. The DON reported they reweighed all the residents once this was discovered and ensured all facility residents had an accurate weight. This Surveyor shared there was a concern reported regarding how one staff member was weighing residents inaccurately. The DON clarified the scale inaccuracy was the root cause of the inaccurate weights. This Surveyor shared concerns about the hospital weight not being reflected accurately upon R21's admission by RD M, which may have helped the weight discrepancies for R21 to be discovered sooner. The DON shared sometimes hospital weights were not accurate, and they were not aware of this concern. The DON confirmed there was a Past Non-Compliance (PNC) which the facility had completed to address the concern, and they would have this loaded into the State Electronic Data share system. On 6/05/25 at 3:05 p.m., the DON shared with the survey team the scales were only off by three to five pounds, and there was a staff member who was weighing residents inaccurately, which had been addressed. The DON reported the staff member was reassigned to another department and they were not weighing facility residents since 2/04/25. The DON reported R21's denture concerns had been addressed, per recommendations of the dentist during the 4/2025 visit, and R21 declined diet modification and implants. A copy of the PNC document was received in the State Electronic data share system on 6/05/25 by 3:07 p.m. Review of the policy, Weight and Height Measurement, revised 2/10/24, revealed, Purpose: 1. To obtain a baseline weight and height for each resident upon admission. 2. To maintain constant control of weight changes. 3. To assess nutrition and hydration status of resident. 4. To identity significant changes in condition. Note: Residents are weighed on admission and weekly x (times) 4 weeks. Then monthly unless otherwise requested by nursing. The registered dietician or the attending physician to monitor the resident's condition. Resident's height is measured on admission and annually . There was no mention in the policy regarding obtaining the initial weight from the hospital, the calibration of scales, consistency regarding how to weigh residents, or documentation triggers when weight inconsistencies were noted. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: The identification of residents' weight inconsistencies and errors, given significant weight fluctuations for multiple facility residents discovered by facility staff. Registered Dietician (RD) M observed weight fluctuations ranging from 30 to 70 pounds on multiple residents over a short period of time. The root cause of the inaccurate weights was determined to be from staff error, per the PNC. Reeducation was provided to involved staff, and a consistent staff member was trained to take the residents' weights in the facility, per the facility weight policy. A one-time audit was completed on 2/04/25 to identify residents requiring a reweigh to ensure accuracy of prior weight changes, when noted. Ongoing audits were completed by the Registered Dietician and or designee for 12 weeks to ensure compliance, with reeducation and disciplinary action as warranted. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on interview and record review, the facility failed to consistently maintain a system that consistently met criteria for antibiotic use, this had the ability to affect any resident prescribed an antibiotic of the 107 residents that resided in the facility. Findings include: Review of the facility's Infection Surveillance books revealed multiple incidents of antibiotics prescribed that did not meet antibiotic use criteria, including residents treated for Urinary Tract Infections (UTI's) with no signs and symptoms of infection and no lab results to confirm an infection. On 6/4/25 at 3:00 PM, the facility's Infection Control Preventionist (ICP) C was interviewed and asked what criteria was used for antibiotic use. ICP C confirmed the facility used McGeer's Criteria. ICP C was asked about antibiotics prescribed for UTI's with no culture and sensitivity (C&S - to indicate if an infection was actually present and what antibiotic the bacteria was sensitive to). ICP C explained she was trying to educate the nurses' to ask for a C&S when calling the doctor, and to not just get a Urinalysis (UA). When asked if only a UA was ordered, how was it determined what antibiotic to use if there was no C&S. ICP C had no answer. Review of a facility policy titled, Infection Prevention and Control Program revised 11/2019 read in part, .Protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made .

Based on observation, interview and record review, the facility failed to provide a working clock for one (R67) of one resident reviewed for choices. Findings include: On 6/3/25 at 9:42 AM, R67 was observed lying in their bed. R67's bed was positioned so that R67 had a clear, direct view of the door. A clock was observed directly above the door. The time on the clock was 1:05, and the second hand was not moving. R67 was asked how long the clock had been broken. R67 explained it had never worked since they had been in that room, someone would put a new battery in the clock and it would work for 45 minutes then stop again. R67 was asked how they knew what time it was. R67 explained they had a cellular phone they could use for the time, but since the clock was above the door, every time they looked at the door they saw the broken clock and it was an annoyance. Review of the clinical record revealed R67 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: Parkinson's disease, kidney disease and diabetes. According to the Minimum Data Set (MDS) assessment dated [DATE], R67 was cognitively intact. Review of R67's census documentation, R67 had been in their room since 1/1/24. On 6/4/25 at 8:49 AM and on 6/5/25 at 8:40 AM, the clock in R67's room was at the same time of 1:05. On 5/5/25 at 10:10 AM, the Maintenance Supervisor was interviewed and asked about the clock in R67's room. The Maintenance Supervisor explained he was unaware of any issue with the clock in R67's room, and would check to see if it had been entered into their maintenance system (TELS). On 6/5/25 at 10:15 AM, Licensed Practical Nurse (LPN) E was interviewed and asked about the clock in R67's room. LPN E explained she remembered putting it into TELS a month or so ago that it needed a battery. LPN E was informed R67 had said it only worked for 45 minutes after a new battery was put in. LPN E explained it was probably more then 45 minutes, but she would put it into TELS to get R67 a new clock. On 6/5/25 at 11:35 AM, Certified Nursing Assistant (CNA) F was interviewed by phone and asked about the clock in R67's room. CNA F explained about a month ago, R67 had told her the clock was not working so she had told one of the maintenance men and they put a new battery in it, even though they had put a new one in not too long before that. When asked if she had put it into the TELS system, CNA F explained she had just told the maintenance man. On 6/5/25 at approximately 12:00 PM, the Maintenance Supervisor explained there was no ticket in the TELS system about the clock in R67's room. Review of a facility policy titled, Resident Rights revised 10/2009 read in part, .Residents are entitled to exercise their rights and privileges to the fullest extent possible .

Based on observation, interview, and record review, the facility failed to ensure a safe homelike environment for two Residents (R15 and R99) of two residents reviewed for equipment safety, when their toilet durable medical equipment was found in disrepair. Findings include: On 6/03/25 at 1:30 p.m., R99's bathroom was observed in room [ROOM NUMBER]-1. There was a gray metal toilet safety frame (bedside commode) over their toilet. The left plastic armrest (when seated on the commode) was observed with an opening where the occupant's hand would push from to stand up. The opening was cracked, with sharp, jagged edges, placing R99 and any occupants at risk for skin tears. On 6/03/25 at 1:33 p.m., R99 observed their bathroom, and stated, Oh, that needs to be fixed, as that could cut people (sitting) on it. On 6/03/25 at 3:03 p.m., R99 was observed dressed, seated in a manual wheelchair. On 6/03/25 at 3:04 p.m., R99 confirmed they used their bathroom for toileting occasionally. Review of R99's most recent skin assessment, dated 5/28/25, showed no skin tears or new skin concerns. Review of the Electronic Medical Record (EMR) revealed R99 scored 15/15 on the Brief Interview for Mental Status (BIMS) assessment, which showed they scored as cognitively intact. Further review revealed they were their own responsible party. Review of R99's Care Plan, accessed 6/05/25, revealed they required one-person assist for transfers and toileting. On 6/03/25 at 12:28 p.m., R15 was observed in the dining room, seated upright in a high back manual recline wheelchair. R15 was assisted by staff to eat their lunch. On 6/03/25 at 1:32 p.m., R15's adjoining bathroom was observed in room [ROOM NUMBER]. The same toilet safety frame over the toilet was observed in disrepair. On 6/03/25 at 1:35 p.m., Certified Nurse Aide (CNA) L reported they were R15's aide, and had not noticed the open, cracked left arm on R15 and R99's toilet safety frame over their toilet. CNA L reported this would place residents who used the commode at risk for a skin tear. On 6/03/25 at 1:44 p.m., the Director of Nursing (DON) reported they had observed the cracked armrest on R99's and R15's toilet safety frame in their adjoining bathroom on 6/03/25. The DON confirmed they were replacing the toilet safety frame. The DON reported they understood the concerns and risk for skin tears or injury from the disrepaired equipment. Review of a new work order, dated 6/03/25, revealed the raised toilet seat was replaced in room [ROOM NUMBER]. Review of the policy, Safe, Homelike Environment, revised October 2009, revealed, Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation Person-Centered Care Characteristics of a Personalized, Homelike Setting Characteristics .1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting .

Based on interview and record review the facility failed to notify the local state mental health authority of Preadmission Screening and Resident Review (PASARR) changes for one (R60) of two residents reviewed for PASARR. Findings include: Review of the clinical record revealed R60 was admitted into the facility on [DATE] with diagnoses that included schizophrenia, unspecified. According to the survey software, R60 was identified as having no PASARR II with a mental illness diagnosis. (PASARR Level II is a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has MD (Mental Disorder), ID (Intellectual Disorder) or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs.) Further review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented R60 scored a 14/15 on the Brief Interview for Mental Status Exam (BIMS) which indicated intact cognition, had a diagnosis of schizophrenia and received antipsychotic medication. However, the MDS section that prompted staff to respond yes or no for Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? was inaccurately marked as 0.No. Review of R60's mental health evaluations since admission included the following two consultations with contracted Psych Physician Assistant/PA 'J' in which neither assessments identified dementia as a primary diagnosis, but did identify the resident's MD. The psych consultation on 3/18/25 documented, in part: .Facility currently is utilizing the following psychiatric diagnosis for the resident: F20.9 SCHIZOPHRENIA, UNSPECIFIED Psychiatry/psychology are being asked to clarify the following: Pt (Patient) HX (history) and diagnoses; best medical intervention. Patient's daughter, who is her guardian, was reached via telephone and provided extensive past hx as well as past medication hx. Patient has long hx of schizophrenia, which was triggered by a car accident when she was a teenager. Following this; she had multiple episodes of psychosis where she became unintelligible and unable to communicate appropriately. She would improve and resolve and would not need the antipsychotic meds for long stretches and would maintain a normal mood & affect, eating well and doing well overall. Then she would relapse; with repetition of this cycle. Her daughter was raised by other family as the patient was unable to care for her children, and the children would have to help monitor their mother when she became psychotic. Pt has hx of paranoia, erratic and bizarre behaviors (stripping naked and leaving the house) and she did live with her sister for some time; and her sister (who had dementia) did not believe that the patient needed the medications for schizophrenia. However, with any small changes in the patient's own health or that of her sister (with whom she was residing), the patient would deteriorate mental. Dementia process was noted with cognitive decline starting in 2010/2011. Pt was moved to a facility and was wandering at her other facility. Ultimately she required a wanderguard as she did leave the facility one night for no reason .ASSESSMENT & PLAN Undifferentiated schizophrenia [F20.3] (worsening) Plan: Patient's schizophrenia appears to be undifferentiated, based on HX provided from daughter. She was medicated for many years with good control of psychosis . The psych consultation on 5/12/2025 documented, in part: .ORIENTATION-The patient is oriented to time, place, person, and situation (oriented x4). She is able to identify that yesterday was Mother's Day. There is no inconsistency or variability in orientation .Attention and concentration are good .Judgment is intact .Insight is intact, though patient does not believe her hoarding behaviors are problematic, stating she just keeps things she might need in the future .Impulse control is intact, There are no signs of resistance, impulsiveness, or oppositional behavior .Speech is slow but clear, coherent, and not slurred .Thought processes are organized and remain so with redirection .There are no delusions, paranoia, or hallucinations, The patient denies perceptual disturbances, No delusional or bizarre material is expressed .Immediate, recent, and remote memory are grossly intact without any impairment .The patient demonstrates a good fund of knowledge, There are no signs of impairment .Mood is normal, without signs of depression, anxiety, agitation or psychosis. The patient appears euthymic and reports doing very well at this time .There are no symptoms of delirium present, Patient exhibits hoarding behaviors .Diagnosis: Schizophrenia .Assessment and Plan F20.3 - Undifferentiated schizophrenia Status: Improving / Not at Goal .Patient was in the midst of a psychotic episode upon facility admission but appears more alert and communicative today. Currently on risperidone 25 mg twice daily. Hoarding behaviors are considered a component of her mental illness and dementia. No medication changes indicated; nonpharmacologic interventions have been successful with staff assisting patient in cleaning and organizing her room. Will continue to monitor for psychotic symptoms, though patient currently denies hallucinations and presents with organized thought processes . Review of the only available PASARR for R60 revealed a 3877 form dated 9/13/24 completed by Nurse 'K' (former Corporate Nurse) that documented yes for R60 having mental illness and dementia, and routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. The explanation for any yes responses documented, Dx (Diagnosis): Dementia, Adjustment disorder with mixed anxiety and depressive mood, Schizophrenia. Medications: Seroquel (an antipsychotic medication). Further review of the clinical record revealed there was no revision to the above 3877 or evidence the facility had submitted a change in condition to the local mental health agency for evaluation. On 6/3/25 at 2:49 PM, an interview was conducted with the Social Service Director (SSD 'A'). When asked about whether R60 had any additional PASARR documentation other than the forms from their previous facility, SSD 'A' reported they would follow-up. On 6/4/25 at 9:16 AM, an interview was conducted with SSD 'A'. When asked about R60's lack of level II evaluation, SSD 'A' confirmed there was none completed and repeated the reason was R60 had come from another facility with a dementia exemption and wouldn't be needed to be submitted again until next year. When asked why there was no review of the admission PASARR to determine if a change in condition should be considered given the psych evaluations and the facility's BIMS assessment which indicated intact cognition, SSD 'A' offered no further response. On 6/4/25 at 9:37 AM, SSD 'A' returned and further reported R60 did not need a level II evaluation due to the dementia diagnosis. There was no further evidence that a change of condition had been initiated and submitted to the local mental health for consideration of a level II evaluation. On 6/4/25 at 11:15 AM, an interview was conducted with the Administrator. They were informed of the interview with SSD 'A' and concerns with lack of change of condition for level II evaluation for R60 and reported they would follow-up with SSD 'A'. A that time, they were requested to provide a facility policy for PASARR. On 6/4/25 at 4:18 PM, the Administrator reported via email Policy for: PASARR- We follow regulations on PASARR.

Based on interview and record review, the facility failed to ensure freedom from unnecessary antibiotic therapy for three (R40, R85, and R86) of three residents reviewed for unnecessary antibiotic (ABT) use, resulting in the potential for the development of antimicrobial resistance. Findings include: On 6/4/25 at 3:00 PM, review of the facility's infection control program with Infection Control Preventionist (ICP) C revealed the following: R40 was documented in March 2025 as having a facility acquired infection listed as Urinary, the signs and symptoms were Fever-Low grade, Altered mental status, the comments included Criteria Not Met .No culture results . R40's March 2025 Medication Administration Record (MAR) included an order for Cipro Oral Tablet 500 MG (milligrams) .Give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 3 Days, and documented as given from 3/24/25-3/26/25. ICP C was asked if R40 had a culture and sensitivity (C&S) done to see if there was an infection and what was the low grade fever. ICP C explained no C&S was ordered, and she had found in a progress note on 3/14/25 a temperature of 100.1. ICP C was asked how a one time slightly elevated temperature 10 days before antibiotics were prescribed was documented as a sign or symptom. ICP C had no answer. When asked how was it determined which antibiotic to use when the organism was not identified by a C&S, ICP C explained she did not know. R85 was documented in April 2025 as having a facility acquired infection listed as Urinary, the signs and symptoms were Altered mental status, the comments included Criteria Not Met .Culture Results Pending .ABT (antibiotic therapy) started prior to culture . R85's April 2025 MAR included an order for Cipro Oral Tablet 500 MG .Give 1 tablet by mouth every morning and at bedtime for UTI for 5 Days, and documented as given 4/1/25-4/6/25. ICP C was asked what the C&S results were. ICP C explained there was a progress note dated 3/31/25 that read, .URINE COLLECTED ON 3/28 DROPED [sic] OFF ON 3.29 TO TOLD TO RUN .UA reordered. ICP C also explained a C&S was not reordered for R85. ICP C was asked if an altered mental status indicated a UTI. ICP C explained it did not. Review of R85's progress notes revealed a Nursing Note created 3/29/25 at 11:24 AM by the Director of Nursing (DON) that read, Urine sample pending collection. Per antibiotic stewardship guidelines, the resident is not having any signs or urinary symptoms. Abt will not be initiated without positive symptoms and culture as the risk outweighs the benefits at the current moment. Behaviors will continue to be monitored and nursing will continue to attempt retrieving urine sample. Provider agreeable to current plan. ICP C was asked why there was a progress note by the DON on 3/29/25 saying no antibiotics and then antibiotics were started on 4/1/25 without a C&S or additional signs or symptoms. ICP C had no answer. R86 was documented in April 2025 as having a facility acquired infection listed as Urinary, the signs and symptoms were Altered mental status, the comments included Criteria Not Met .Culture Result Pending, ABT started from abnormal UA . R86's April 2025 MAR included an order for Cipro Oral Tablet 500 MG .Give 1 tablet by mouth two times a day for UTI for 5 Days, and documented as given 4/24/25-4/29/25. ICP C was asked about the C&S results. ICP C explained the C&S came back negative for infection on 4/26/25. ICP C was asked if the C&S was negative on 4/26/25, why did R86 continue to get the antibiotic for the full five days until 4/29/25. ICP C agreed the antibiotics should have been stopped when the C&S came back negative and had not answer as to why they had not been stopped. On 6/5/25 at approximately 12:30 PM, the DON provided Risk Vs. (versus) Benefit for Antibiotic Use documents for R40, R85 and R86. The DON was asked how there was a benefit for R86 to receive an antibiotic when the C&S confirmed there was no infection. The DON acknowledged the concern. When asked about the benefit of antibiotics for R40 and R85 when the only symptom was altered mental status, the DON acknowledged the concern.

Based on observations, interview, and record review, the facility failed to ensure that wound care was completed according to physician's orders for two residents (R13 and R6) of three reviewed for impaired skin conditions (non pressure related). Findings include: R6 On 6/3/25 at 9:40 AM, R6 was observed in their room sitting in their chair located near the bed. R6 appeared to be dressed and ready for the day. With further observation of R6, there were two kerlex bandages around the resident's ankles that were dirty and unkempt with a date of 5/27 with initials that appeared to be a CN. R6 was asked if they knew why their legs were wrapped up and how often did the facility change the bandages but R6 could not recall or answer for either question. A review of the record revealed that R6 was admitted to the facility on [DATE] with a medical diagnosis of dementia, type two diabetes, and varicose veins. A further review of the record revealed that R6's dressings to the legs were to be changed daily. On 6/4/25 at 12:20 PM, an interview was conducted with the Unit Manager R and the [NAME] President of Clinical Operations (VP Q). When asked why did staff members document on a treatment that was not completed and should staff chart off on items that were not completed, the Unit Manager R and VP Q stated it should not have been charted as completed if it was not and they would have to find out more information as to why and who documented for six days that they were changing the bandages when they were not. R13 On 6/3/25 at 10:45 AM, R13 was observed in the bed resting with left foot propped on a pillow. It was wrapped in kerlex with an ace wrap over it and had a strong odor coming through the bandages. R13 was asked about the wound on the left foot and asked when was the last time the facility changed it (because it was an undated bandaged that was applied). R13 reported the staff had changed it on that Saturday (5/31/25) but it was to be done daily and that they are to use a solution called dakins so it would not stink. A review of the record revealed that R13 was admitted to the facility on [DATE] with the diagnosis of venous insufficiency, type two diabetes, and chronic pain due to trauma. R13 had a Brief Interview for Mental Status Score (BIMs) of 15 which indicated no cognitive impairments. A further review of the record revealed that R13 had a physician's order for daily dressing changes and that staff had signed off that treatments had been completed. However the observed treatment had no date of when it was last changed, had significant odor from the wound site, and the interview with R13 reported the wound dressing had not been changed since Saturday. On 6/4/25 at 12:20 PM, an interview with the Unit Manager R and VP Q was conducted and they were asked if they required staff to date the treatments when completed. Unit Manager R stated yes, staff should date the treatments to assure they are completed. Unit Manager R was then asked why the treatments had not been dated for R13 and they reported they would look into it. There was no additional information provided by the exit of the survey.

This citation pertains to Intake #MI00151195 Based on observation, interview and record review the facility failed to timely evaluate the competency of a resident and obtain legal guardianship for a resident with impaired cognition for one (R601) of three residents reviewed for Hospice Services. Findings include: A Complaint was filed with the State Agency (SA) that alleged R601 does not have a guardian, power of attorney, or conservator and they are receiving Hospice Services. On [DATE] at approximately 10:00 AM, R601 was observed sleeping in bed. The resident was alert but not able to answer any questions asked. A review of R601's clinical record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: chronic kidney disease, Chronic Obstructive Pulmonary Disease (COPD), altered mental state, type II diabetes and alcohol abuse. A review of R601's Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] (moderately intact cognition). The resident was noted as their own responsible party and had been receiving Hospice services starting on or about [DATE]. The resident was also noted as FULL CODE. Continued review of R601's clinical record noted, in part: [DATE]: Social Service Note: Writer met with resident .alert and oriented x2 with forgetfulness and confusion .Discussed end-of-life wishes, full code, she verbalized save my life. No current advanced directives discussed guardianship process with her husband (herein after Husband D) who was present-in-person. Provided copy of guardianship petition .BIMS score ,d+[DATE] (severely cognitively impaired) . [DATE]: Social Service Note: Residents Husband D, came to SW (social worker) office and informed writer that he has to turn my wife over to you guys, I just can't take care of her ,d+[DATE] no more, I have too much going on. Husband D also stated that he needs assistance with .petition for guardianship. He handed writer petition for guardianship not completed and signed his name at the bottom .Writer can smell alcohol on Husband Ds breath .Writer informed Husband D that she will have the business office follow-up with him and that the facility can initiate the petition for guardianship. [DATE]: Active Discharge Planning Note: Discharge care conference was conducted today. Husband D was not present. Resident was signed on to hospice services . *It should be noted that there was no documentation in R601's clinical electronic record that noted the resident and/or Husband D signed the resident onto hospice. There were no documents that noted who was R601's DPOA (Durable Power of Attorney). [DATE]: Psychiatric Service Notes: R601 .seen today for scheduled follow-up. Patient was last seen on [DATE] (prior to hospice services) .patient seen in her room .Patient is alert, oriented to herself .believing we are in a hospital but is confused about the date, believing it is [DATE] . [DATE]: Social Service Note: .Resident is currently her own RP (responsible party) no current advanced directive in place . [DATE]: Care Review/Care Conference (lock date [DATE]): .Guardianship discussed with husband due to resident's cognitive impairment/decline. Husband understands importance of guardianship and will let writer know when he is ready to file guardianship . [DATE]: Psychiatric Service Notes: .Patient was seen in her room resident in her bed and appeared very lethargic .patient was unable to answer questions . [DATE]: Initial Social Service Assessment: R601 Cognitive Abilities: Resident unable to engage in BIMS assessment, severely impaired cognition .unable to make needs know at this time .Plan to inquire about guardian . [DATE]: Hospital Records: History of Present Illness' .Patient is poor historian .Phone call placed to patients emergency contact/spouse (Husband D) with no answer .Patient was receiving hospice services .discharged from their service today .Palliative Care Progress Note: .Notes also indicating that there has been difficulty reaching patients spouse and may be concerns for domestic violence, patient may need legal guardian to make timely medical decisions on behalf of patient .patient at bedside, .nonverbal, unable to follow commands, unable to participate in goals of care discussion at this time . On [DATE] at approximately 12:32 PM, an interview and record review were conducted with Social Worker (SW)E and Social Service Employee (SSE) F. SW E reported that they were a licensed MSW and SSE F noted that they were not a licensed social worker. Both SSD E and SSE F were queried as to the facility policy(s) /protocol regarding guardianship, competency evaluations and end-of-life wishes including Hospice. SSE F was specifically queried as to their notes dated [DATE] and [DATE] that indicated they recommended starting legal guardianship why nothing had been completed for over 11 months. SSE F reported that they had attempted to have Husband D complete the paperwork, but it has still not been done. SSE F was asked if they had made any attempts to seek alternative Guardianship as they were not able to obtain paperwork from Husband D. SSE E stated they had not. When asked if attempts were made to seek a competency evaluation for R601, they noted that they had not. Both SSE E and SW F were asked to locate documentation pertaining to who agreed and signed off to place R601 on hospice services on or about [DATE] and again on [DATE] when R601 returned from a week's stay at the hospital. Both SW E and SSE F were not able to locate documentation at that time and were not sure on who completed the hospice forms. SSE F was asked if they had discussed Hospice services with R601, including their wishes for code status, hospitalization . On [DATE] at approximately 2:00 PM, a Hospice agreement signed by Husband D was provided. The document(s) dated [DATE] noted the following: .Admission Consent . Lists Patient Name: R601 .My designee is (has R601's name scratched out with Husband D's name in place) .Document titled Opioid Start Talking) .Patient name: [R601] .Name of controlled substance .Morphine Concentrate .Dosage 100 mg/5 .20 mg .) Signed by Husband D Physicians Orders for Scope of Treatment .DO NOT attempt Resuscitation/CPR (NO CPR, allow Natural Death) .Comfort-Focused treatment . On [DATE] at approximately 2:28 PM, a phone interview was conducted with Husband D. Husband D was asked about Guardianship and the Hospice consent form that was signed on [DATE]. Husband D reported that nobody at the facility was giving him assistance or contacting him about hospice. He reported that he did not have transportation and felt he was bamboozled into signing the hospice form when someone came to the house and wasn't even clear on what he was signing. He further noted that he had not seen R601 in over a month and wanted them to return home. On [DATE] at approximately 4:00 PM, the facility provided the original consent for Hospice (dated [DATE] signed by R601). The documents provided did not include consent for morphine or any document for Scope of Treatment. The facility policy titled, Job Description/Social Worker was reviewed and in part, read: .The social worker provides Social Services to residents, their families, and significant others to enable them to deal with the impact of illness and extended care plan .Assisting residents/responsible parties with financial and legal matters such as drafting petitions for guardianship/conservatorship .Assisting residents to determine how they would like to make decisions about their heath care, and whether or not they would like anyone else to be involved in those decisions .

This citation pertains to Intake(s): MI00151185 Based on observation, interview and record review, the facility failed to ensure an oxygen dependent resident was provided continuous physician ordered respiratory care for one (R601) of two residents reviewed for respiratory care, resulting in R601's SPO2 (blood oxygen saturation level) to have dropped to an abnormal range level and the resident being transferred to the hospital for a higher level of care. Findings include: A Complaint was filed with the State Agency (SA) that alleged that on 3/12/25, R601 was observed in the dining room unattended. R601 was found to be lethargic and slumped over the table with a puddle of urine underneath them. R601's oxygen tank was determined to be empty. In addition, the humidity bottle for the concentrator in their room was also empty. The Complainant noted that R601 was sent to the hospital as their 02 levels were not stable. On 3/26/25 at approximately 10:00 AM, R601 was observed sleeping in bed. The resident was alert but not able to answer any questions asked. The residents 02 concentrator was running at 3L (liters) via a nasal canula. A review of R601's clinical record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: chronic kidney disease, Chronic Obstructive Pulmonary Disease (COPD), altered mental state, type II diabetes and alcohol abuse. A review of R601's Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8/15 (moderately intact cognition). The resident was noted as their own responsible party and had been receiving Hospice services starting on or about 7/8/24. The resident was also noted as FULL CODE. Continued review of the R601's clinical record revealed, in part, the following: Order (start 6/20/24): Humidified Oxygen 3L/min via Nasal Canula every shift related to Chronic Obstructive Pulmonary Disease . Care Plan: Focus: Potential/Actual alteration in oxygen exchange due to COPD .Intervention: Humidified 02 as ordered: 3 L via Nasal Cannula (3/29/2024) .Focus: ADL (activities of daily living) deficit r/t (related to) COPD with oxygen .Interventions: Transfer 2 PA (person assist) Hoyer to Geri Chair . 3/12/25 (4:00 PM) Nurses Note: Received resident at shift change in dining room with empty oxygen tank and soiled brief. Mouth was very dry and and <sic> bloody. Authored by Nurse B O2 Sats (saturation): 3/12/24 (6:04 PM): 80% 3/12/25: Change in Condition Evaluation (11:23 PM Lock Date): Resident (R601) .Situation: Abnormal vital signs .Altered Mental Status .Pain .Shortness of Breath .Most Recent Blood Pressure: 60/48 .Most Recent 02 Sats .80% (3/12/2024) .Oxygen via Nasal Canula .Decreased level of consciousness' .Increased confusion .unable to eat or swallow .Describe respiratory changes .Shortness of breath .Abrupt onset of SOB (shortness of breath) .Lack of Oxygen for several hours .send to hospital . 3/12/25 (7:11 PM): Resident is full code and on Hospice .Hospice Nurse to evaluate resident. Agreed with decision to transfer out to hospital. Printable Discharge Hospital Form (Last Activity Date 3/19/25): .Chief Complaint: AMS (Altered Mental Status) .History of Present Illness: .diabetes, COPD on home oxygen .Patient is a poor historian .EMS (emergency medical services) was called for low blood pressure and hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) .Upon arrival BP (blood pressure) 88/61 .in ED (emergency department) patient was placed on non-rebreather (a medical device used to deliver a high concentration of oxygen in emergency situation) . On 3/26/25 at approximately 9:55 AM, the facility was asked to provide all IA (Incident/Accident) reports for R601. Reports were received at 11:58 AM. There were no IA's that addressed the incident involving an empty oxygen tank, causing respiratory concerns. On 3/26/25 at approximately 10:40 AM, the Director of Nursing (DON) was interviewed regarding the incident(s) involving R601. The DON was queried as to R601's not continuously receiving ordered 02 and sustaining a SPO2 drop to 80%, the DON reported that they were aware and noted that they had a document that detailed the incident. The DON stated they would forward the document. On 3/25/25 at approximately 12:45 PM, an untitled document provided by the DON was reviewed and documented, in part: .Staff were interviewed .Nurse B was providing care to other residents up until 4:00 PM when she noted resident in respiratory distress. She stated that her (R601) oxygen tank was empty, mouth had dried blood, and her brief needed to be changed. Resident was taken back to her room where she was placed on her concentrator at 3L .The resident was scoring high pain .At this time, the resident's pulse oximetry was 86%. Nurse B increased her oxygen flow to 5L/min and her oxygen level improved (*It should be noted that there is no documentation in the resident's clinical record of the 02 level increasing) .Hospice was contacted .Nurse B reported that when the hospice nurse arrived, she wanted to give PRN (as needed) morphine. When Nurse B checked her vital signs the resident's blood pressure was 60/48 .At this time, it was determined that the resident would be sent out to the hospital .Change in Condition Review .On 3/12/25 at approximately 4 PM, Nurse B, noticed that the resident had labored breathing and hypotension, which resulted in her being sent to the emergency room at approximately 7:44 PM .upon investigation, the resident was taken to the dining room around or shortly after breakfast. She remained in the dining room until approximately 4 PM .Facility has determined that the resources required to stabilize the resident were not available and she required higher level of care . On 3/25/25 at approximately 3:18 PM, an interview was conducted with Nurse B. Nurse B reported that they have been employed by the facility for about two years and worked as a Registered Nurse (RN) for over [AGE] years. Nurse B was asked about the incident involving R601's respiratory decline. Nurse B reported that they entered the building around 3:00 PM on 3/12/25. Upon entry they spoke with the outgoing nurse and then started to complete rounds. They were assigned to the hall where R601 resided. During their rounds they were approached by a nursing student who reported to them that R601's oxygen tank was empty. Nurse B reported that they went to the dining room and observed R601 slumped over in a wheelchair with an empty oxygen tank on the back of the chair and observed that their mouth was dry and bloody. Nurse B reported that R601 normally sits in a Geri Chair and was surprised to see them in a wheelchair with the empty oxygen tank. Nurse B also reported that the resident generally uses a 02 concentrator to alleviate dry mouth concerns and ensure continuous oxygen. Nurse B reported that concentrators are portable and should have accompanied the resident to the dining room. Nurse B further reported that when they noticed the resident was lethargic, had urinated themselves and appeared to be in pain, they took them back to their room to assess them. Nurse B noted that they hooked them up to their concentrator at the ordered 3 L and had trouble obtaining a pulse ox. R601's oxygen was noted at 80%. They increased it to 5 L and noted that they were able to get their 02 status up to 86%. Nurse B reported that R601's blood pressure was also very low (60/48) showing signs of hypoxia. Nurse B contacted the Hospice nurse who came to the facility and determined that the resident should be sent out to the Hospital. On 3/26/25 at approximately 3:48 PM, a phone interview was conducted with Physician C. Physician C was asked if they were aware of the incident that occurred on 3/12/25. Physician C recalled that R601 was sent to the hospital for hypoxia and low blood pressure. When asked if R601 should continuously be receiving 02, they noted that they should. The facility policy titled, Oxygen Administration was reviewed and documented: .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify there is a physician's order for the procedure .Steps in the Procedure .Turn on the Oxygen. Unless otherwise ordered start the flow of oxygen .place appropriate oxygen device on the resident . Adjust the oxygen device on the resident so that it is comfortable for the resident and the proper flow of oxygen is being administered .check the .tank .to be sure they are in good working order .

This citation pertains to Intake MI00148859 Based on observation, interview and record review, the facility failed to prevent pressure ulcer formation, document accurate skin assessments, implement interventions and complete pressure ulcer wound care per physician orders for two (R903 and R904) of three residents reviewed for pressure ulcers resulting in R903 acquiring one Stage 4 (full-thickness skin and tissue loss) which became infected and required antibiotics and acquired a Deep Tissue Pressure Injury (DTPI - persistent non-blanchable deep red, maroon or purple discoloration) and R904 who aquired an unstageable wound to their coccyx. Findings include: R903 A complaint was filed with the State Agency (SA) that alleged in part, .the resident . has developed a wound on (their) buttocks . it's the size of a silver dollar . can see deep inside the hole and it smells bad . On 12/30/24 at 10:02 AM, R903 was observed lying in bed. R903 was asked if they had any wounds or sores on their body. R903 indicated they did and pointed to their right buttock. Review of the clinical record revealed R903 was admitted into the facility on [DATE] with diagnoses that included: encephalopathy, diabetes and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R903 had severely impaired cognition and required the assistance of staff for all activities of daily living (ADL's), including bed mobility. The MDS assessment also indicated R903 had one facility acquired Unstageable (obscured full-thickness skin and tissue loss) pressure ulcer. On 12/30/24 at 10:12 AM, Licensed Practical Nurse (LPN) B, who served as the Wound Treatment Nurse, was interviewed and asked about R903's wounds. LPN B explained R903 was admitted with a wound on their left upper buttock, but that wound was resolved; a wound on their right ischium (lower back/hip) that was facility acquired, it had become necrotic (dead tissue) and required debridement (removal of dead, damaged, or infected tissue); and a DTPI on their left heel that was facility acquired. On 12/30/24 at 10:30 AM, observation of R903's wounds with LPN B and Certified Nursing Assistant (CNA) C revealed the wound on the right ischium appeared obscured by slough (non-viable tissue) approximately 3.5 centimeters (cm) x 3 cm and had depth. The wound on the left heel appeared to have an approximately 1.5 cm x 2.5 cm darkened area surrounded by an outer ring approximately 4 cm x 5.5 cm that appeared to have been from a blister. Review of documentation of R903's wounds revealed: A nursing progress note dated 11/724 at 10:22 PM read in part, .New wound identified. Right buttock . A Skin & Wound Evaluation dated 11/7/24 documented, .Type: .Moisture Associated Skin Damage (MASD) . Right Gluteus . New . Length: 2.4 cm . Width: 2.0 cm . 100% of wound covered, surface intact . A Wound Evaluation dated 11/7/24 at 7:54 PM documented .#4 - MASD . Right Gluteus a picture revealed an open area, obscured by slough A physician progress note dated 11/12/24 at 11:13 AM read in part, .Developed an unstageable ulcer to the right Ischial area. Covered entirely with yellow necrotic slough that is tightly adherent . A Wound Evaluation dated 11/12/24 at 11:11 AM documented, .#4 - Pressure - Unstageable . Right Gluteus . Length 2.83 cm . Width 1.7 cm . A physician progress note dated 11/26/24 at 12:02 PM read in part, .Stage 4 ulcer to the right Ischial area with scattered thin fibrinous exudate . A physician progress note dated 12/10/24 at 12:53 PM read in part, Stage 4 ulcer to the right Ischial area entirely covered with dark, necrotic eschar (dead or devitalized tissue). Requires a round of surgical debridement . Superficial layer of the necrotic eschar debrided at bedside using scalpel and forceps. At his point, patient started feeling pain. So debridement was discontinued although the base was still dark/necrotic. Depth 2.5 cm . Start PO (by mouth) Abx (antibiotics) Augmentin 875 mg (milligrams) bid (two times a day) x 1 week . A physician progress note dated 12/17/24 at 1:32 PM read in part, .Stage 4 ulcer to the right ischial fold with fibrinous necrotic slough that ' s hanging loose. Picked off the hanging slough using the scalpel and forceps . Current depth at 3 cm . Developed hemorrhagic blister with underlying [sic] dark discoloration to the left heel related to DTPI . A physician progress note dated 12/24/24 at 1:59 PM read in part, .Stage 4 ulcer to the right ischial fold with fibrinous necrotic slough that ' s coming loose. Picked off using the scalpel and forceps. Current depth at 3 cm . Hemorrhagic blister with underlying dark discoloration to the left heel related to DTPI . Review of R903's November 2024 Treatment Administration Record (TAR) revealed an order for Wound care: Rt (right) gluteal: Med Honey on 4x4 gauze and cover with dry border gauze daily and prn (as needed) - Start Date - 11/12/24 revealed blank boxes on 11/16/24 and 11/17/24, indicating the treatment was not done. Review of R903's December 2024 TAR revealed an order for Wound Nurse: Right Ischial loose packing with quarter strength Dakin's solution moistened gauze and cover with dry dressing daily and prn every day shift for wound care - Start Date - 12/11/24 revealed blank boxes 12/11/24, 12/12/24, 12/13/24, 12/14/24, 12/15/24. Review of R903's December 2024 Medication Administration Record (MAR) revealed an order for, Amoxicillin-Pot Clavulanate (Augmentin) Oral Tablet 875-125 MG . Give 1 tablet by mouth every 12 hours for wound infection . The Augmentin was started on 12/10/24 and ended on 12/17/24. On 12/30/24 at 1:45 PM, the Director of Nursing (DON) was interviewed and asked about the first identification of R903's right ischial wound being labeled as MASD when the picture showed an unstageable pressure ulcer. The DON agreed a wound should be identified before it became an unstageable pressure ulcer. When informed of the missing documentation on the TAR's, the DON explained he would look into it. On 12/30/24 at 2:56 PM, the DON explained LPN G had written a couple progress notes about the wound treatments were done on those days. The DON was asked if it was acceptable for a nurse to write a progress note instead of signing off on the TAR. The DON explained the TAR needed to be signed of whether there was a progress note or not. Review of nursing progress notes written by LPN G revealed a note dated 12/12/24 at 1:40 PM that read in part, .Writer gave resident PRN norco before doing wound tx (treatment) . On 12/30/24 at 3:29 PM, LPN G was interviewed by phone and asked if she had done the wound treatment for R903 on 12/12/24 when she wrote the progress note. LPN G explained she did not do the treatment, she only gave the resident the pain medication before the Wound Treatment Nurse did the treatment. LPN G was asked who signed off that the treatment was done, the Wound Treatment Nurse, or the floor nurse. LPN G explained the TAR is signed by the nurse that does the treatment, if the floor nurse does it, she signs it, if the treatment nurse does it, she signs it. On 12/30/24 at 3:47 PM, the DON was informed LPN G had been interviewed and said she had only given the pain medications, not completed the treatments. The DON had no explanation as to why there were five consecutive days with no treatments documented as done. 34275 R904 Complaints were filed with the SA that alleged residents were not provided with needed care to prevent pressure ulcers. A review of R904's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: alcohol induced chronic pancreatitis, depression and calorie malnutrition. Review of the resident's MDS noted the resident had a BIMS score of 10/15 (moderately cognitively impaired). An initial assessment noted that R904 had no skin conditions, including pressure ulcers. The original Braden Scale (a tool used to predict the risk of pressure ulcers in patients) dated 8/20/24 noted a score of 14 (Moderate Risk). Continued review of R904's clinical record revealed the following: 8/27/24: [NAME] Scale (updated): Score 11 (High Risk). *Noted change in the scale from Moderate to High. Care Plan: Focus: Skin management (date initiated 8/20/24) .Sacrum (revised 11/26/24) . Interventions: Assist me with floating my heels (8/20/24) .CNA's will check my skin daily with care and report anything unusual they notice to the nurse (8/20/24) .Encourage me to make small, shifts in my position (8/20/24) .Supplements as ordered (8/20/24) .Treatment mediation as ordered (8/20/24) . *It should be noted that there were no additional interventions in place other than those placed in the care plan on 8/20/24. 11/24/24 - Nurses Note: Nurse noted fragile area on sacrum . 11/24/24- Order NS (normal saline) cleanse to sacrum area apply triad paste QS (every shift) to fragile area every shift for wound care. A review of the MAR/TAR (Medication/Treatment Administration Record) noted the resident did not receive treatment to the sacrum as ordered on 11/25/24 (Day), 11/27/24 (Day), 11/28/24 (Evening), 12/1/24 (Day) . 11/27/24 - Skin and Wound Evaluation (Lock Date: 12/30/24): Describe - Type: other .Location (blank) .acquired: In-House Acquired .How long has this wound been present: New .Exact Date: (blank) .Staged by: health care provider .Wound Measurements: Area 4.4 cm .length 6.4 cm .Width cm .Granulation .Notes: Open area to sacrum. Dr (name redacted) to assess. 12/3/24 .Progress: New . *It should be noted that this evaluation was not fully complete and not locked until 12/30/24 over one month after it was started. 12/3/24: Physicians Note (late entry): Wound rounds correction/Addendum note: Developed non-intact area of dark discoloration to the coccyx and adjoining buttocks .related to DTPI .currently base with necrotic slough that's separating from the margin and appears as unstageable . 12/3/24 -Skin and Wound Evaluation (Lock Date: 12/30/34): Describe: Pressure .Stage: Deep Tissue Injury .Location: (blank) .acquired: In house acquired .How long has the wound been present (new) .exact date (blank) .Wound measurements: Area 14.1 mg .Length 6.1 cm .Width 3.0 cm .Wound bed (slough) .Type: Serosanguineous .Goal of care: Slow to heal Additional Care: (blank) .Progress: deteriorating .Notes (blank). *It should be noted that this evaluation was not completed/locked until 12/30/24 and the evaluation regarding the stage of the pressure ulcer. 12/6/24: Order: Wound Care: Coccyx and adjoining buttocks cleanse with wound cleanse with wound cleanse pat dry and apply Medi Honey to 4x4 gauze and cover with border gauze change daily and PRN .every day shift for wound care. The MAR/TAR noted the treatment was done only on 12/7/24 as the resident was discharged to the hospital on 12/7/24. On 12/30/24 at approximately 2:20 PM, an interview was conducted with Wound Nurse B. Nurse B was queried as to their involvement regarding treatment for residents with wounds. Nurse B noted that when facility staff notify them of a resident with skin/wound concerns they will assess the resident, attempt to determine the resident's nutrition status, ensure labs have been reviewed and then implement interventions into the resident's care plan. When asked if they had been informed by staff that the resident had a change in their Braden Scale early in August 2024, Nurse 'B stated they were not made aware. When asked if they had been made aware of any nutritional concerns prior to the finding of skin concerns, Nurse B reported that they had been made aware following the residents' wound status. Nurse B was asked if they were aware that the resident's MAR/TAR revealed several missing treatments. Nurse B responded that they had not been made aware, but noted documentation should have been noted in the resident's record. When asked about interventions that might have been put into place to attempt to reduce the chance of acquiring a wound at the facility, Nurse B noted that they believed that an order had been placed for an air loss mattress. *It should be noted that an order was placed on or about 12/1/24. The intervention was not placed in the resident's care plan. On 12/30/24 at approximately 3:06 PM, an interview was conducted with the DON. The DON was asked about R904's development of an unstageable pressure ulcer to their coccyx. The DON reported that they were aware of R904's pressure ulcer and was aware of concerns pertaining to their food and fluid intake. When queried as to what interventions other than those noted on 8/20/24 (admitted ) were put in to protect R904 from acquiring an unstageable pressure ulcer, the DON was able to confirm that an order for an air loss mattress was put in place on 12/1/24. However, when asked if R904 who had a documented change in their Braden Scale status and obvious concerns with food and fluid intake, should have received additional interventions, the DON noted that further attempts could have been made. When asked if treatment orders should be administrated as ordered, the DON noted that they should have been. The facility policy titled, Pressure Ulcer Prevention Program was reviewed and documented, in part: Policy: It is our policy that newly admitted residents will be assessed for the presence of pressure ulcers or other skin breakdown. Residents will also be assessed for risk of development of pressure ulcers. Interventions to eliminate, modify or minimize risk factors will be introduced at the earliest time possible. Our goal will be to prevent facility acquired pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable .A risk assessment will be completed .using the Braden Scale upon admission, weekly for four weeks, then quarterly .The Braden Scale will reflect the minimum interventions .

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices related to enhanced barrier precautions (EBP) for two residents (R903 and R904) of three residents reviewed for wounds, resulting in the potential for the spread of infection. Findings include: Review of a facility policy titled, Enhanced Barrier Precaution (EBP) Policy and Procedure dated 9/23/22 read in part, .Enhanced Barrier Precautions expand the use of PPE (personal protective equipment) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi-drug resistant organisms) to staff hands and clothing. High-Contact Resident Care Activities include: Dressing; Bathing/showering; Transferring; Providing hygiene; Changing linens; Changing briefs or assisting with toileting; Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; Wound care: any skin opening requiring a dressing . On 12/30/24 at 10:02 AM, R903 was observed lying in bed. No EBP sign was posted on the door into R903's room, the only PPE in R903's room was a box of gloves on the wall. No isolation cart of PPE supplies was observed inside or outside R903's room, in the hallway or at the nurse station. Review of the clinical record revealed R903 was admitted into the facility on [DATE] with diagnoses that included: encephalopathy, diabetes and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R903 had severely impaired cognition and required the assistance of staff for all activities of daily living (ADL's), including bed mobility. The MDS assessment also indicated R903 had one facility acquired Unstageable (obscured full-thickness skin and tissue loss) pressure ulcer. On 12/30/24 at 10:25 AM, Certified Nursing Assistant (CNA) C was observed in R903's room changing R903. CNA C was not wearing an isolation gown, the only PPE used were gloves. On 12/30/24 at 10:30 AM, observation of wound care for R903 with Licensed Practical Nurse (LPN) B, who served as the Wound Treatment Nurse, and CNA C revealed neither wearing isolation gowns while providing direct wound care to R903. Review of R903 ' s physician orders revealed an active order with a start date of 10/24/24 that read, enhanced barrier precautions as directed. This includes gowns and gloves for high-contact resident care activities, Specify why: wounds On 12/30/24 at 1:30 PM, LPN D, R903's assigned nurse, was interviewed and asked if R903 was on EBP. LPN D explained yes, since R903 had wounds, they would be on EBP. LPN D was asked why there was no sign on R903 ' s door, or PPE supplies. LPN D looked in R903's room and at the nurse station and found no PPE. LPN D explained when R903 was admitted into hospice, the hospice staff came and took all of the facility's supplies out of the room and brought their own, and explained the PPE supplies were probably removed at that time as well. On 12/30/24 at 1:35 PM, Registered Nurse (RN) F, who served as Unit Manager for R903's unit, was interviewed and asked if R903 was on EBP. RN F explained R903 was on EBP for wounds. When informed there was no sign, and no PPE available, RN F had no explanation. On 12/30/24 at 1:40 PM, RN E, who served as the Infection Control Nurse, was interviewed and informed there was no EBP sign on R903 ' s door, no available PPE, and hygiene care and wound care had been observed performed without staff wearing gowns, RN E had no answer. On 12/30/24 at 1:45 PM, the Director of Nursing (DON) was interviewed and informed of R903 having no EBP sign on their door, and no available PPE. The DON explained the PPE is usually stored at the nurse station on that unit. The DON was informed there was no PPE found at the nurse station and it had been observed R903 had received hygiene and wound care without staff wearing gowns. The DON had no explanation. 34275 R904 A review of R904s clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: alcohol induced chronic pancreatitis, depression and calorie malnutrition. Review of the resident's MDS noted the resident had a BIMS score of 10/15 (moderately cognitively impaired). An initial assessment noted that R904 had no skin conditions, including pressure ulcers. 11/24/24 - Nurses Note: Nurse noted fragile area on sacrum . 11/24/24- Order NS (normal saline) cleanse to sacrum area apply triad past QS (every shift) to fragile area every shift for wound care. A review of the MAR/TAR (Medication/Treatment Administration Record) noted the resident did not receive treatment to the sacrum as ordered on 11/25/24 (Day), 11/27/24 (Day), 11/28/24 (Evening), 12/1/24 (Day) . 11/27/24 - Skin and Wound Evaluation (Lock Date: 12/30/24): Describe - Type: other .Location (blank) .acquired: In-House Acquired .How long has this wound been present: New .Exact Date: (blank) .Staged by: health care provider .Wound Measurements: Area 4.4 cm (centimeters) .length 6.4 cm .Width cm .Granulation .Notes: Open area to sacrum. Dr (name redacted) to assess 12/3/24 .Progress: New . *It should be noted that this evaluation was not fully complete and not locked until 12/30/24 over one month after it was started. 12/3/24: Physicians Note (late entry): Wound rounds correction/Addendum note: Developed non-intact area of dark discoloration to the coccyx and adjoining buttocks .related to DTPI (deep tissue pressure injury) base with necrotic slough that's separating from the margin and appears as unstageable . There was no order placed for the resident to be on enhanced barrier precautions when treatment to the wound was ordered. On 12/30/24 at approximately 3:06 PM, an interview was conducted with the DON. The DON was asked if residents who were being treated for pressure wounds should be placed on Enhanced Barrier Precautions. The DON reported that was the facility's protocol to do so. The DON attempted to locate an order but nothing was found in R904's record prior to the end of the survey. The DON confirmed that an order should have been placed.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 4/29/24 between 8:30 AM-9:05 AM, during an initial tour of the kitchen, with Dietary Manager S and Culinary Specialist T present in the kitchen, the following items were observed: The bulk flour bin was observed with no label identifying the contents inside. Culinary Specialist T stated that another staff member had just wiped it down, and the label must have come off. According to the 2017 FDA Food Code section 3-302.12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. The 2 bulk rice bins located next to the flour bin, were observed with dried on food splatter on the lid and on the outside surface of the bin. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The milk cooler was observed with pooling milk on the interior bottom surface, underneath the milk crates. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The flooring in front of the stove was observed with a large spill of a white, granular substance. The flooring behind the trash can next to the coffee maker, was observed with a buildup of food debris. The flooring next to the spice rack was observed with a large pile of spilled thyme spices. The flooring in the dry storage room was observed with food debris underneath the racks. When queried about the cleaning of the floors, Dietary Manager S confirmed the food debris on the floor and stated staff is supposed to mop every night. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.

Based on observation, interview, and record review, the facility failed to ensure safe and secure storage of medication from three of three medication carts reviewed to assure medications are inaccessible to unauthorized staff and residents. Findings Include: On 4/30/24 at 8:35 AM, a medication administration observation was conducted with Registered Nurse (RN) E. Medications were prepared from the medication cart identified as Second Floor Short Hall. After medications were prepared for a resident, RN E proceeded into the resident's room leaving the medication cart unlocked, unattended, and out of sight. Review of the facilities policy, Medication Administration General Guidelines Section 7.1, 01/21 stated: . The medication cart is kept closed and locked when out of sight of the medication nurse . On 4/30/24 at 9:19 AM, A medication administration observation was conducted with Licensed Practical Nurse (LPN) I from the medication cart identified as Second Floor Middle. LPN I recognized an ordered medication was not available in the cart and proceeded to walk away, leaving the cart with previously pulled medications on top of the cart. A second medication administration observation with LPN I was conducted. During medication preparation, LPN I dropped two medication pills onto the floor, then placed them on top of the cart. The two loose pills remained on top of the cart as LPN I walked away to administer medications. Upon return to the medication cart LPN I was queried if medications are to remain on top of the cart unattended. LPN I acknowledged both administrations of medications were left unattended and confirmed medications are not to be left and then disposed of the loose medications. Review of the facility policy, Medication Administration General Guidelines Section 7.1, 01/21 stated: .During administration of medications .No medications are kept on top of cart . On 4/30/24 at 9:40 AM, The medication cart identified as Second Floor Long Hall was inspected with Licensed Practical Nurse (LPN) J. When LPN J opened the drawer of the medication cart a blue plastic container labeled 2N-227-1 was observed to have an unidentifiable pink pill laying in the top left corner. When queried of the loose pill, LPN J acknowledged it was unidentifiable and disposed of it. Review of the facility policy Medication Storage Section 4.1, 01/21 stated: .Medications without secure closures are immediately removed and disposed of according to medication disposal . On 4/30/24 at 4:49 PM, The Director of Nursing (DON) was informed of the medication administration and storage observations. The DON acknowledged medications are not to remain unattended and medication carts are to be locked when not visible with the nurse. The DON acknowledged loose medications pills should not be in the medication carts.

Based on observation, interview, and record review, the facility failed to ensure medications were administered, documented, and stored according to professional standards of practice for four (R215, R11, R95, and R265) residents reviewed. Findings include: R215 On 5/1/24 at 10:00 AM, R215 was observed lying in bed. R215's Pain Management Physician (Physician 'L') was at R215's bedside. At that time, R215 reported he was experiencing severe pain to his right knee and he wanted to know what was causing the pain. R215 had Jackson Pratt drains extending from the side of both knees (two on the left side and one on the right side) that contained small amounts of brownish-pink opaque drainage and immobilizer devices applied to both legs. When asked by Licensed Practical Nurse (LPN) 'N' if she could remove the immobilizers to observe R215's skin, R215 reported he would not allow her to remove them until he received his pain medication because it would be too painful. R215 reported that after he received his pain medication and waited 30 minutes he would allow removal of the immobilizers and treatment to be done to his knees. On 5/1/24 at 10:07 AM, a review of R215's physician's orders revealed the following order: An active order with a start date of 4/30/24 for (Oxycodone [with] Acetaminophen (a schedule II controlled substance - a regulated drug due to the high potential for abuse and dependence - used to treat moderate to severe pain) 10-325 MG (milligrams). Give 1 tablet by mouth every 4 hours as needed for pain. A review of R215's Medication Administration Records (MAR) for April 2024 and May 2024 revealed as of 10:07 AM on 5/1/24, R215 had not received pain medication (Oxycodone with acetaminophen) since 10:07 PM on 4/30/24. There was no documentation on R215's May 2024 MAR that indicated he received any pain medication on that day. Further review of R215's clinical record revealed R215 was readmitted into the facility on [DATE] with a diagnosis of septic arthritis to the bilateral knees. A review of R215's Minimum Data Set (MDS) assessment dated [DATE] revealed R215 had intact cognition. On 5/1/24 at 11:04 AM, an interview was conducted with the wound care nurse (LPN 'O'). LPN 'O' reported R215 preferred his wound treatments to be completed first thing in the morning, but he refused to have her do the treatment to his knees due to pain on that morning. At that time, R215 reported LPN 'N' gave him his pain medication approximately 45 minutes prior and he would allow LPN 'O' to remove the knee immobilizers and administer treatment to his knees. LPN 'O' administered wound care to R215's bilateral knees. R215 verbalized significant pain during the treatments, was unable to talk through the pain, was tearful, braced himself using the bilateral enabler bars, grimaced, and yelled out. On 5/1/24 at approximately 12:00 PM, an interview was conducted with the Director of Nursing (DON). When queried about R215's pain during wound treatment, the DON explained Nurse Practitioner (NP) 'M' changed R215's pain medication regimen the previous day due to increased pain and that the order was for every four hours as needed. When queried as to why R215 had not received pain medication since 10:07 PM on 4/30/24, the DON reported he would look into it. On 5/1/24 at 12:19 PM, the DON provided a Individual Resident's Controlled Substance Record (a form used to ensure all controlled substances are accounted for) for R215 for the Oxycodone-acetaminophen and explained that on 5/1/24, R215 received one dose at 2:10 AM, one dose at 6:10 AM, and one dose at 10:13 AM based on the nurses' signatures and documentation that they pulled one tablet from R215's medication supply. When queried about the lack of documentation on the MAR that would have indicated the nurses administered the medication after they pulled it from the supply, the DON reported it should be documented on the MAR, but because the nurses documented they pulled the medication from the supply that was evidence it was administered to the resident. On 5/1/24 at 12:25 PM, the DON followed up and reported he interviewed R215 who said he received the pain medication from the midnight nurse. The DON reported the midnight nurse should have signed out on the MAR that she administered the medication after pulling it from the supply. On 5/1/24 at approximately 1:30 PM, the DON followed up and reported the midnight nurse (LPN 'P') added documentation to the MAR to indicate the Oxycodone-acetaminophen was administered at 2:10 AM and 6:10 AM. There was no documentation on the MAR that showed LPN 'N' administered the 10:13 AM dose (although R215 did verbally confirm he received it). The DON explained the nurses had 24 hours to go back and document administration of medications, including controlled substances. When queried about whether that process would allow for identification of diversion of drugs, the DON did not offer a response. A policy regarding controlled substances was requested. However, the policy received did not include procedures on administration of controlled substances, only ordering. On 5/1/24 at 12:23 PM, during a nursing skin assessment for R215, a packaged medication identified as Diltiazem 30 milligram (mg) one tablet was observed on R215' tray table next to ostomy supplies and beverage cups. The DON entered the room at which time this surveyor pointed to the medication. As the DON removed the packaged medication, R215 indicated the medication was left on the table last night by the nurse. 34275 R265 On 4/29/24 at approximately 9:29 AM, R265 was observed lying in bed. The resident was not able to answer any questions asked and appeared to be in a catatonic state. Three family members were also in the room. One identified themselves as the resident's guardian and a second family member reported that they were a licensed pharmacist. They reported that R265 was admitted to the facility on [DATE] for physical therapy and nursing care. The family members were asked as to the care provided by the facility. One of the family members indicated that they were disappointed that the facility was administering the drug Klonopin/Clonazepam (a drug classified as a psychotropic medication) three times per day to the resident. The family member noted that the resident had been on other psychotropic medication for some time but felt there was no need to add Klonopin as another scheduled medication. The family continued to express concerns with the facility and noted that they were going to find another facility that would better accommodate the resident. A review of R265's Hospital Transfer Record located in their electronic record noted medications that were recommended to be continued in SNF (skilled nursing facility). The drug Klonopin/Clonazepam was not noted in that section, but a handwritten note read Clonazepam/Klonopin .5 mg 3xd (three times per day) PRN (as needed). Continued review of R265's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: failure to thrive and unspecified dementia without behavioral disturbances. The resident's record noted that the resident was severely cognitively impaired. An order dated 4/24/24 documented, Klonopin oral tablet .5 MG/Controlled substance -give 1 tablet by mouth every 8 hours for panic disorder. A review of R265's Medication Administration Record (MAR) recorded that the resident received Klonopin .5mg on 4/24/24 (2PM/10PM), 4/25/24 (6AM/2PM and 10PM), 4/26/24 (6AM/2PM and 10PM), 4/27/24 (6AM/2PM and 10PM), 4/28/24 (6AM/2PM and 10PM) and 4/29/24 (6AM). On 4/30/24 at approximately 8:14 AM, an interview was conducted with the DON. The DON was asked as to why R265 was placed on scheduled Klonopin three 3 times per day as opposed to the order noted in the Hospital records as PRN. The DON reported they would have to review the resident's records. The DON returned on 4/30/24 at approximately 8:49 AM and noted that the scheduled order for Klonopin appeared to be put in by Physician Q as scheduled and suggested contacting the physician. On 4/30/24 at approximately 3:25 PM, a phone interview was conducted with Physician Q. When asked about the scheduled Klonopin .5mg for R265, Physician Q reported that they remember receiving a call from nursing staff that the resident was exhibiting behavioral concerns when staff attempted to take their vitals. They noted that the order was supposed to be PRN and must have been put in wrong by the Nurse. Physician Q stated that the order sent to pharmacy would show that order was to be PRN. On 4/30/24 at approximately 3:49 PM, the DON was notified as to Physician Q's response. The DON was able to confirm that the order was noted as PRN and confirmed possibly Nurse R put the order in wrong. 39592 R11 On 4/29/24 at 9:58 AM, R11 was observed lying in bed. A medicine cup with four white tablets was observed on the three drawer bedside table. R11 was asked if they knew what medications were in the medicine cup. R11 explained they did not know. When asked how long the medications had been sitting there, R11 explained they did not know. Review of the clinical record revealed R11 was admitted into the facility on [DATE] with diagnoses that included: dementia, heart disease and hypertension. According to the MDS assessment dated [DATE], R11 had moderately impaired cognition and required the assistance of staff for activities of daily living (ADL's). On 5/1/24 at 10:05 AM, observation of R11's medications with LPN G revealed: Atorvastatin 10 mg (milligrams), a white tablet; Melatonin 5 mg, a white tablet; Metoprolol Succinate 25 mg, a white tablet; and Sennosides-Docusate Sodium 8.6-50 mg, a white tablet, were all ordered to be given at 9:00 PM. Review of R11's April 2024 MAR revealed all four medications, Atorvastatin, Melatonin, Metoprolol Succinate and Sennosides-Docusate Sodium were signed off as given on 4/28/24 at 9:00 PM. On 5/1/24 at 10:06 AM, the DON was interviewed and asked if nurses could leave medications at the bedside. The DON explained nurses should make sure resident took all medication before they were signed off as given. 49083 R95 On 4/29/24, a Clinical record review revealed R95 was admitted on [DATE] under Hospice Care services with a diagnosis of heart failure, end stage kidney disease, malnutrition, and chronic obstructive pulmonary disease (COPD). A Brief Interview for Mental Status (BIMS) score totaled 11 indicating R95 had moderate impaired cognition. On 4/29/24 at 10:14 AM, during the initial introduction to R95, an observation of the bedside table revealed a box containing a medication inhaler identified as Fluticasone-Salmeterol (a medication used to treat worsening of COPD). When asked if the medication was provided by the nurse, R95 replied it is kept on the table and it is taken by self whenever it is needed. On 4/29/24 at 4:28 PM, an observation with Registered Nurse (RN) K verified Fluticasone-Salmeterol Inhaler remained at R95's bedside. RN K reviewed the Electronic Medical Record (EMR) and confirmed there was no provider order for the medication to be self-administered and the medication should not be left at the bedside. On 4/29/24 at 4:39 PM, the Director of Nursing (DON) was informed a Fluticasone-Salmeterol Inhaler was observed at R95's bedside. The DON acknowledged resident medications that do not have self-administering orders are not to be left at a resident's bedside. Review of the facility Medication Administration Policy Section 7.1 01/21, stated .Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration . Review of the facilities Medication Administration Policy Section 7.1 01/21, stated: .Medications are administered as prescribed in accordance with good nursing principles and practices . A review of a facility policy titled, Medication Administration dated 1/2021, revealed, in part, the following: .The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medication .

Based on observation, interview, and record review, the facility failed to ensure all controlled substances were accounted for and accurately documented for one (215) resident reviewed. Findings include: R215 On 5/1/24 at 10:00 AM, R215 was observed lying in bed. R215's Pain Management Physician (Physician 'L') was at R215's bedside. At that time, R215 reported he was experiencing severe pain to his right knee and he wanted to know what was causing the pain. R215 had Jackson Pratt drains extending from the side of both knees (two on the left side and one on the right side) that contained small amounts of brownish-pink opaque drainage and immobilizer devices applied to both legs. When asked by Licensed Practical Nurse (LPN) 'N' if she could remove the immobilizers to observe R215's skin, R215 reported he would not allow her to remove them until he received his pain medication because it would be too painful. R215 reported that after he received his pain medication and waited 30 minutes he would allow removal of the immobilizers and treatment to be done to his knees. On 5/1/24 at 10:07 AM, a review of R215's physician's orders revealed the following order: An active order with a start date of 4/30/24 for (Oxycodone [with] Acetaminophen (a schedule II controlled substance - a regulated drug due to the high potential for abuse and dependence - used to treat moderate to severe pain) 10-325 MG (milligrams). Give 1 tablet by mouth every 4 hours as needed for pain. A review of R215's Medication Administration Records (MAR) for April 2024 and May 2024 revealed as of 10:07 AM on 5/1/24, R215 had not received pain medication (Oxycodone with acetaminophen) since 10:07 PM on 4/30/24. There was no documentation on R215's May 2024 MAR that indicated he received any pain medication on that day. Further review of R215's clinical record revealed R215 was readmitted into the facility on [DATE] with a diagnosis of septic arthritis to the bilateral knees. A review of R215's Minimum Data Set (MDS) assessment dated [DATE] revealed R215 had intact cognition. On 5/1/24 at 11:04 AM, an interview was conducted with the wound care nurse (LPN 'O'). LPN 'O' reported R215 preferred his wound treatments to be completed first thing in the morning, but he refused to have her do the treatment to his knees due to pain on that morning. At that time, R215 reported LPN 'N' gave him his pain medication approximately 45 minutes prior and he would allow LPN 'O' to remove the knee immobilizers and administer treatment to his knees. LPN 'O' administered wound care to R215's bilateral knees. R215 verbalized significant pain during the treatments, was unable to talk through the pain, was tearful, braced himself using the bilateral enabler bars, grimaced, and yelled out. On 5/1/24 at approximately 12:00 PM, an interview was conducted with the Director of Nursing (DON). When queried about R215's pain during wound treatment, the DON explained Nurse Practitioner (NP) 'M' changed R215's pain medication regimen the previous day due to increased pain and that the order was for every four hours as needed. When queried as to why R215 had not received pain medication since 10:07 PM on 4/30/24, the DON reported he would look into it. On 5/1/24 at 12:19 PM, the DON provided a Individual Resident's Controlled Substance Record (a form used to ensure all controlled substances are accounted for) for R215 for the Oxycodone-acetaminophen and explained that on 5/1/24, R215 received one dose at 2:10 AM, one dose at 6:10 AM, and one dose at 10:13 AM based on the nurses' signatures and documentation that they pulled one tablet from R215's medication supply. When queried about the lack of documentation on the MAR that would have indicated the nurses administered the medication after they pulled it from the supply, the DON reported it should be documented on the MAR, but because the nurses documented they pulled the medication from the supply that was evidence it was administered to the resident. On 5/1/24 at 12:25 PM, the DON followed up and reported he interviewed R215 who said he received the pain medication from the midnight nurse. The DON reported the midnight nurse should have signed out on the MAR that she administered the medication after pulling it from the supply. On 5/1/24 at approximately 1:30 PM, the DON followed up and reported the midnight nurse (LPN 'P') added documentation to the MAR to indicate the Oxycodone-acetaminophen was administered at 2:10 AM and 6:10 AM. There was no documentation on the MAR that showed LPN 'N' administered the 10:13 AM dose (although R215 did verbally confirm he received it). The DON explained the nurses had 24 hours to go back and document administration of medications, including controlled substances. When queried about whether that process would allow for identification of diversion of drugs, the DON did not offer a response. A policy regarding controlled substances was requested. However, the policy received did not include procedures on administration of controlled substances, only ordering. A review of a facility policy titled, Medication Administration dated 1/2021, revealed, in part, the following: .The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medication .

Based on observation, interview and record review, the facility failed to ensure continuous oxygen was provided per physician orders for one (R19) of one resident reviewed for oxygen therapy. Findings include: On 4/29/24 at 9:24 AM, R19 was observed sitting in a geriatric chair (geri-chair) in the corner of the dining room eating breakfast. An oxygen concentrator was observed next to R19 and nasal cannula tubing was connected to the concentrator providing oxygen to R19. On 4/29/24 at 9:41 AM, Certified Nursing Assistant (CNA) D was observed pulling R19 backward in the geri-chair in one hand while pulling the oxygen concentrator in the other hand from the dining room, down two hallways to a shower room. R19's nasal cannula tubing was still attached to the oxygen concentrator, no oxygen tank was observed. It should be noted, the oxygen concentrator had to be plugged in to work, it contained no battery power supply. Review of the clinical record revealed R19 was admitted into the facility on [DATE] with diagnoses that included: dementia, schizoaffective disorder and major depressive disorder. According to a Brief Interview for Mental Status (BIMS) assessment dated [DATE], R19 had severely impaired cognition. Review of R19's physician orders revealed an order for, O2 (oxygen) 2L (liters) every shift continuous. On 4/30/24 at 8:42 AM, R19 was observed sitting in a geri-chair in the corner of the dining room. The breakfast R19 was eating appeared to be mostly eaten. Licensed Practical Nurse (LPN) F was observed wheeling an oxygen concentrator into the dining room, plugging it in and attaching R19's nasal cannula tubing to it. No oxygen tank was observed to have been used before the oxygen concentrator was provided. On 4/30/24 at 8:47 AM, multiple oxygen tanks were observed at the nurse station on R19's unit. On 4/30/24 at 11:06 AM, R19 was observed sitting in a geri-chair in the common area. The wheel of the geri-chair was directly on the nasal cannula tubing, preventing oxygen from reaching R19 from the oxygen concentrator. On 4/30/24 at 11:10 AM, Licensed Practical Nurse (LPN) F was interviewed and asked why oxygen tanks were not utilized for residents on continuous oxygen therapy. LPN F explained they had tried using the oxygen tanks, but they would run out of oxygen quickly. On 5/1/24 at 9:30 AM, R19 was observed sitting in a geri-chair in the corner of the dining room eating breakfast. An oxygen tank was observed hanging from the back of the geri-chair. The nasal cannula tubing was observed completely wrapped around the oxygen tank, none of the tubing was attached to R19. On 5/1/24 at 10:06 AM, the Director of Nursing (DON) was interviewed and asked if a resident on continuous oxygen should be transported with an oxygen tank or concentrator. The DON explained oxygen tanks should be used when transporting residents. When informed oxygen tanks were not being used when transporting R19, the DON had no explanation. Review of a facility policy titled, Oxygen Administration revised 11/19/13 read in part, .Safely administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues . A Licensed Nurse will be responsible for the correct administration of oxygen to the resident but may delegate this task to another staff person trained and deemed competent in the use of oxygen . A reserve oxygen tank should e available on the unit to provide continuity of care .

Based on interview and record review, the facility failed to ensure a level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed accurately and sent to local community mental health for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one (R49) of one resident reviewed for PASARR's resulting in the potential for the resident to be excluded from receiving necessary care and services appropriate to meet their mental health and intellectual disability needs. Findings include: Review of the clinical record revealed R49 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: schizophrenia, adjustment disorder with mixed anxiety and depressed mood, psychotic disorder with delusions and hallucinations. According to the most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE], section A1500 for Preadmission Screening and Resident Review (PASRR) was left blank. Review of R49's Level I Screening dated 12/27/23 revealed the form was marked as Hospital Exemption Discharge . SECTION II - Screening Criteria . 1.Yes The person has a current diagnoses of Mental Illness . 2.Yes The person has received treatment for Mental Illness . 3.Yes The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days . If any answer to items 1 - 6 in SECTION II is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested . Further review of the clinical record revealed there was no evidence that a Level I evaluation had been completed by the facility. On 5/1/24 at 10:08 AM, the Social Worker Director (SWD) was interviewed and asked why a Level I evaluation had not been completed in January 2024 for R49. The SWD explained the Level I had been overlooked. On 5/1/24 at 10:32 AM, the Administrator was asked for a policy on PASARR. The Administrator explained they did not have a policy but the facility followed the Federal Regulations regarding PASARR.

This citation pertains to Intake MI00143763 Based on observation, interview and record review, the facility failed to treat a resident with dignity and respect for one (R19) of two residents reviewed for dignity. Findings include: On 4/29/24 at 9:24 AM, R19 was observed sitting in a geriatric chair (geri-chair) in the corner of the dining room eating breakfast along with ten other residents. R19 announced they had to go to the bathroom. Certified Nursing Assistant (CNA) D, from across the room told R19 they would have to wait until they were done eating before they could be taken to the bathroom. On 4/29/24 at 9:36 AM, R19 again announced they had to go to the bathroom. CNA D did not respond in any way to R19. On 4/29/24 at 9:38 AM, CNA D went over to R19, who was done eating their breakfast, and asked R19 why they had spilled their drink all over themselves as now she would have to change them. It was observed the table in front of R19 was wet along with R19's shirt, which also had food debris on it. On 4/29/24 at 9:41 AM, CNA D was observed to maneuver R19 in the geri-chair out of the corner of the dining room and pull R19 facing backwards through the dining room, to the end of the nurse station and down the hallway to the shower room. Review of the clinical record revealed R19 was admitted into the facility on [DATE] with diagnoses that included: dementia, schizoaffective disorder and major depressive disorder. According to a Brief Interview for Mental Status (BIMS) assessment dated [DATE], R19 had severely impaired cognition. Review of R19's Nutritional Preferences care plan included an intervention revised 4/15/24 that read in part, .supervision and assistance as needed. I tend to need 1:1 assistance near the end of my meal . On 5/1/24 at 10:06 AM, the Director of Nursing (DON) was interviewed and asked if it was appropriate to pull residents backwards in a geri-chair. The DON explained that residents should always be pushed so the resident is facing forward. When informed of the observations on 4/29/24, the DON had no explanation. Review of a facility document titled, Right of Resident in Michigan Nursing Facilities dated 11/28/16 read in part, .As a basic premise, all residents have the right to a dignified existence, self-determination, and communication with and and access to persons and services inside and outside of the facility .

Based on interview and record review, the facility failed to administer blood pressure medications according to physician ordered parameters for one (R59) of five residents reviewed for unnecessary medications, resulting in the resident receiving a medication used to treat low blood pressure when it was not needed. Findings include: A review of R59's clinical record revealed R59 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: hypertension (high blood pressure) and hypotension (low blood pressure). A review of a Pharmacy Recommendation progress note dated 12/14/23 revealed, The resident has an order for Midodrine 5mg PO (by mouth) BID (two times a day) (Hold for SBP >120). Please review administration record/hold orders with nursing staff with regards to compliance/accuracy, for medication safety. A review of a Pharmacy Recommendation progress note dated 4/18/24 revealed, The resident has order for Midodrine BID, with hold orders SBP >120. Please ensure the BP is being documented on the MAR along with each of these administrations . A review of R59's active physician's orders revealed the following: A discontinued order that was in place from 8/22/23 until 2/23/24 for Midodrine HCl .5 MG (milligrams). Give 1 tablet by mouth two times a day for low BP (blood pressure) hold for SBP (systolic blood pressure - top number) > (greater than) 120 mmHg (millimeters of mercury). An active order with a start date of 3/13/24 for Midodrine HCl .5 MG .1 tablet by mouth every morning and at bedtime for Hypotension. Hold for SBP greater than 120 . A review of R59's Medication Administration Records (MAR) revealed R59 received Midodrine outside of parameters (SBP greater than 120) on the following dates: January 2024 1/2/24 (5:00 PM dose) - 128/76 1/4/24 (5:00 PM dose) - 128/72 1/7/24 (8:00 AM dose) - 122/63 1/11/24 (5:00 PM dose) - 155/72 1/13/24 (8:00 AM dose) - 124/53 1/19/24 (8:00 AM dose) - 143/59 1/21/24 (8:00 AM dose) - 151/76 1/22/24 (5:00 PM dose) - 128/68 1/24/24 (8:00 AM dose) - 124/76 1/24/24 (5:00 PM dose) - 126/76 1/25/24 (5:00 PM dose) - 121/73 February 2024 2/1/24 (8:00 AM dose) - 126/59 2/11/24 (5:00 PM dose) - 123/62 2/12/24 (5:00 PM dose) - 123/77 2/14/24 (5:00 PM dose) - 121/72 2/17/24 (5:00 PM dose) - 122/85 2/20/24 (8:00 AM dose) - 125/64 A review of R59's March 2024 MAR revealed no documentation of R59's blood pressure. It was documented on the MAR that R59's morning dose of Midrodrine was held on 3/15/24, 3/30/24, and 3/31/24. However, no BP was documented on the MAR. A review of a progress note revealed R59's blood pressure was 118/60 which would have been within parameters to receive the medication (SBP was less than 120 mmHg). There was no documentation of R59's blood pressure on 3/30/24 and 3/31/24 to indicate why R59's Midodrine was held. There was no documented blood pressure in R59's clinical record to determine if R59's Midodrine should have been administered. A review of R59's April 2024 MAR revealed no documentation of R59's blood pressure at the time of Midodrine administration. It was documented on the MAR that R59's morning dose of Midrodrine was held on 4/3/24, 4/5/24, and 4/8/24. There was no progress note to indicate why the Midrodrine was held on 4/3/24 and 4/8/24. On 4/5/24, it was documented the Midrodrine was held when R59's blood pressure was 103/61 which was below the parameters for which it should have been held. There was no documented blood pressure in R59's clinical record to determine if R59's Midodrine should have been administered. On 4/30/24 at 8:15 AM, an interview was conducted with the Director of Nursing (DON). The DON reported nurses should administer medications according to physician ordered parameters. At that time R59's March 2024 and April 2024 MARs were reviewed with the DON. The DON reported there should be a space to document the blood pressure on the MAR to go along with the parameters ordered. The DON reviewed the vital's tab in the electronic medical record and the progress notes and confirmed R59's blood pressure was not documented. A review of a facility policy titled, Medication Administration dated 1/2021, revealed, in part, the following: .Medications are administered in accordance with written orders of the prescriber .Obtain and record any vital signs as necessary prior to medication administration .

This citation refers to Intake #MI00137826 Based on interview and record review, the facility failed to ensure a safe and proper transfer from the bed to Geri chair for one resident (R808) of two residents reviewed for falls/accidents, resulting in seven stitches over the left eye, two lumps (hematomas) on the forehead, bruising to the left side of their neck, bruising on the left side of their chest, pain, and a three-day hospital stay. Findings include: A Complaint was filed with the State Agency (SA) that alleged R808 was a two-person transfer in need of a Hoyer lift and was transferred by only one Certified Nursing Assistant (CNA) who used a sit-to-stand (a medical device that assists individuals with limited mobility in standing up from a seated position) and the resident fell during the transfer and sustained injuries requiring hospitalization . A review of R808's clinical record was conducted and revealed that the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: nontraumatic hemorrhage, laceration, unspecified fall and dementia. A review of the Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired and was a total dependent/two person assist for transfers. Continued review of R808's clinical record documented, in part: 4/29/23 (6:40 AM) Nurse Note: .writer was called to room by CNA, resident was on the floor bleeding, writer went in observed pt.(patient) lying with left face down on the left side of the bed in blood, resident was responsive at that time, writer asked CNA what happened and she said she got her dressed turn around to grab the sit-to-stand machine and pt. fell . Resident was assessed for injury left side forehead was swollen and bleeding .911 was called they arrived at (6:04 AM) and pt. was sent to (name redacted) Hospital . 5/1/23 Nurse Note: .Resident returned from .Hospital around 7:45 PM via ambulance .admitted to hospital d/t (due to) fall. Alert x2 .Skin assessed, 7 stitches over L (left) eye, 2 lumps on forehead, bruise on L side of neck, bruise on L side of chest, bruises on both arms . R708's Care Plan was reviewed and noted in part: Focus: I have an actual ADL/Mobility deficit r/t decreased mobility (9/2/21) .Interventions: Transfer 2 PA (person assist) with Hoyer lift (a total body medical device that is used for resident transfers) -Geri chair when out of bed . R808's Kardex (resident care list) was reviewed and read: Transfer: transfer 2 PA with Hoyer lift Geri chair when out of bed . The facility provided an Incident/Accident (IA) report that documented, in part: Date: 4/29/23 - 9AM -Person Preparing Report: Nurse J .Resident: R808 .Incident Description: Writer was called to room writer was called to room by CNA, resident was on the floor bleeding, writer went in observed pt. lying with left face down on the left side of the bed in blood . writer asked CNA what happened and she said she got her dressed turn around to grab the sit-to-stand machine and pt. fell .Immediate Action: resident assessed for injury left side forehead was swollen and bleeding .911 was called .resident requires increase of assist from 1 to 2 for ADLs. Therapy to screen .Root Cause analysis: .CNA educated; Care Plans reviewed .Was resident taken to Hospital: N . On 9/6/23 at approximately 1:34 PM, a phone call was made to Nurse J. Nurse J answered the phone but did not complete the interview. On 9/7/23 at approximately 11:05 AM, a phone interview was conducted with CNA K. CNA K reported that they no longer worked at the facility. CNA K was asked as to the incident pertaining to R808 and reported that on 4/29/23 they attempted to get the resident out of bed and into their Geri Chair. They thought R808 utilized a sit-to-stand, so prior to getting them in the sit-to-stand they placed the resident on the side of the bed. They then turned around to get the sit-to-stand that was in close proximity of the bed and when they turned around, R808 fell headfirst on to the floor. They noticed the resident was bleeding and went to get a Nurse. When asked if they were aware that the R808 care plan indicated the resident was a two person assist and needed a Hoyer lift for transfers, CNA K stated that at the time of the incident they were not aware of R808's transfer status as they did not have a password to get into the resident's Kardex. CNA K noted that when they could not get into the Kardex they asked another staff person who noted the resident utilized a sit-to-stand. When asked why they started the transfer on their own, CNA K reported that that is how they were going to transfer. When asked if they received any training following the incident, CNA K reported that the facility was supposed to provide a training packet but they never received one. On 9/7/23 at approximately 1:45 PM, an interview and record review were conducted with the DON (Director of Nursing) and Corporate Nurse I. When asked about the incident involving R708 that occurred on 4/29/23, the DON noted that the resident required a two person assist with a Hoyer for transfers. They reported that following the incident, CNA K received training on how to use the Kardex and transfers. An unsigned document was provided that noted: .Date 5/1/23 . Employee Name: CNA K . Supervisor: DON . Describe situation: CNA . transferring resident . 4/29/29 .Resident fell of side bed and had a laceration .Describe Desired/Expected Behavior: CNA educated to read Kardex before transferring resident for safety. CNA stated she knows how to use Kardex . The DON noted that the CNA refused to sign the document. Nurse I reported that it may be possible that R808 had enough trunk support to allow the CNA to place them at the side of the bed. On 9/7/23 at approximately 3:08 PM, an interview was conducted with Physical Therapy Manager (PTM) L. PTM L was asked as to R808's last therapy assessment and their ability to sit alone on the side of their bed. PTM L reported that the last PT provided to R808 ended on 1/4/23 and at that time the resident was discharged as needing Maximum assistance. They further stated that they had tried to work with the resident on trunk support, however the resident was not capable of sitting alone on the side of their bed. Further, the resident was not to be transferred by one person nor should a gait belt be used. The facility policy titled, Transfer Techniques (July 8, 2008) was reviewed and documented, in part: Purpose: To transfer a resident from bed to chair .Equipment: Mechanical lift if necessary .Obtain assistance of another individual if necessary for safe transfer .

This citation pertains to intake #MI00129778 This citation contains three Deficient Practice Statements (DPS). DPS #1 Based on interview and record review the facility failed to consistently monitor a resident in respiratory distress, notify the physician of ineffective interventions and failed to transfer the resident to a higher level of care for appropriate treatment for one (R312) of three residents reviewed for infection prevention and control, resulting in staff to not have completed and documented consistent respiratory assessments and monitoring once staff identified R312 with a low oxygen saturation rate of 72%, staff failed to inform the physician of the supplemental oxygen to not have been effective, and failed to transfer the resident to a higher level of care for further treatment causing Immediate Jeopardy (IJ), when R312 expired two hours and twenty five minutes after staff identified the change of condition. This continued practice puts other residents at risk for serious harm and/or death. Findings include: The IJ began on [DATE]. The IJ was identified on [DATE] at 1:30 PM, the Administrator was notified and a plan to remove the immediacy was requested. The immediacy was removed on [DATE] at 1:06 PM, based on the facility's implementation of an acceptable plan of removal verified on-site by the surveyor. Review of the medical record revealed R312 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia and Huntington's disease. A Minimum Data Set (MDS) assessment dated [DATE], documented severely impaired cognitive skills for daily decision making and required staff assistance for all Activities of Daily Living (ADLs). Review of a Nursing note dated [DATE] at 10:00 PM, documented in part . Resident observed having chest congestion with low SPO2 (oxygen saturation level) @ (at) 72% R/A (room air), writer applied non re-breather @10LPM (liters per minute), residents V/S (vital signs) ,d+[DATE], 60, 92.5, resident remains A/O (alert and oriented) non verbal, skin warm to touch, has no s/s (signs or symptoms) of pain, no facial grimace noted, HOB (head of bed) elevated to facilitate breathing, writer called and spoke with (Physician B name) and informed of change in condition, resident is a DNR (Do Not Resuscitate), gave v/o (verbal order) to keep 02 (oxygen) applied as needed, writer called and left message for Responsible party . DON (Director of Nursing) notified. This note was documented by Licensed Practical Nurse (LPN) A. Review of a Change in Condition Evaluation for dated [DATE] at 10:00 PM, documented in part . Abnormal vital signs . This started on: [DATE] . Primary Diagnosis (left blank) . Additional pertinent diagnosis(es) - Dementia . Specify other directives: DNR . Other resident or family preferences for care: DNR . Are these the most recent vital signs taken after the change in condition occurred? Yes . Blood Pressure ,d+[DATE] . [DATE] 22:00 . Position: Sitting r (right)/arm . Most Recent Pulse . Pulse: 60 bpm (beats per minute) . [DATE] 22:00 . Respiration: 16 (Breaths/min) . [DATE] 22:00 . Most Recent Temperature (section left blank) . Most Recent 02 sats . 02 sats: 72% . [DATE] 22:00 . Method: Room Air . Is oxygen saturation <90%? Yes . Mental Status Evaluation (compared to baseline .) Decreased level of consciousness (sleepy, lethargic) . Specify the decreased level of consciousness: Sudden change in level of consciousness or responsiveness . Describe respiratory changes: Labored breathing . Other respiratory changes . Describe labored breathing: Acute onset of change from usual pattern, OR with chest pain, labored respirations, or unstable vital signs . Describe respiratory signs and symptoms: CONGESTION WITH LABORED BREATHING . Complete the following 5 questions to evaluate the cognitively impaired resident . Breathing: (section left blank) . Negative vocalization: None . Facial expression: Smiling or inexpressive . Body language: Relaxed . Consolability: No need to console . Neurological Evaluation- No changes observed . Laboratory Tests/Diagnostic Procedures . Abnormal Results: None to report . Since the change in condition occurred have the symptoms or signs gotten: Better . Things that make the condition or symptoms better are: 02 APPLIED HOB ELEVATED . This condition, symptom or sign has occurred before: No . Other relevant information: RESIDENT IS A DNR . What do you think is going on with the resident . LPN (Licensed Practical Nurse): The resident appears: HAS SOME MILD CHEST CONGESTION, LABORED BREATHING . Have you reviewed and acknowledged the notifications? Yes . Reported to primary care clinician: (Physician B name) . Date and time of clinician notification: [DATE] 2200 (10 PM) . Orders obtained from the clinician: Oxygen . This change of condition was documented by LPN A. Review of the medical record revealed no follow up vitals obtained, no documentation of any follow up monitoring completed, no documentation of R312's SPO2 levels after the supplemental oxygen was applied, no documentation of the resident's respiration levels, no documentation of any further respiratory assessment or monitoring of the resident's condition. On [DATE] at 10:37 AM, LPN A was interviewed via telephone and asked about the change of condition incident with R312 on [DATE]. LPN A was asked about any follow up monitoring and vitals after the change of condition was identified and where it was documented at. LPN A stated they monitored the resident but didn't know why there was no documentation to reflect that. LPN A stated R312 oxygen saturation level never came back up and they were unable to stabilize R312's oxygen saturation level after providing the supplemental oxygen, when asked if the physician was aware that the supplemental oxygen was not effective, LPN A did not recall. When asked why R312 was not sent to the hospital if LPN A was unable to stabilize the resident oxygen saturation levels and LPN A documented the resident had congestion with labored breathing, LPN A stated because (R312) was a DNR. LPN A was asked to explain what a DNR is, LPN A replied Do Not Resuscitate, but if they're in distress we apply oxygen because (R312) is not resuscitated so we don't send (R312) out to the hospital . LPN A stated they realized it was difficult for the surveyor to understand but the nursing facility is different than the hospitals. LPN A stated it was the facility's protocol to try and maintain the resident at the nursing facility. When asked if they were aware of R312 to have had an Advance Directive in place, LPN A responded they did not know. LPN A stated in part . the change of condition (with R312) happened rapidly and unexpected . Review of a Advance Directive policy provided by the facility (revision date [DATE]) documented in part . Advance Directives allow residents to give directions for their care in the event that they become incapable of participating in their medical decisions due to their physical or mental condition. Often these directions deal with the resident's desires concerning end of life issues. These directives guide our health care team and allow the incapacitated resident to retain autonomy and privacy . Residents are under no obligation to provide Advance Directives. We offer the resident the opportunity to give us instruction for his/her care in the event the resident is unable to make decisions about his/her care during a terminal illness . We are obligated to follow the resident's wishes as expressed in valid Advance Directives . EMERGENCY CARE AND TREATMENT WITHOUT ADVANCE DIRECTIVES: If the resident does not have Advance Directives and a medical emergency arises, we will follow our policies to assure the resident received the emergency medical care necessary to prolong life . Call 911 and transfer to acute care hospital without prior notice to family or physician if condition is life threatening . 1:1 (one on one) care until emergency no longer exists, or resident transferred . Emergency Care not related to terminal illness with a DNR or No hospitalization order. In the event of a life threatening crisis that is unexpected and unrelated to end of life issues the facility will operate under a conservative approach and initiate measures to stabilize the resident . Review of the admission contract signed for R312, contained the same documentation as noted above in the facility's Advance Directive policy (as documented above) and was signed by R312's representative. Review of the medical record revealed no documentation that R312 or R312's legal representative had formulated an Advance Directive. Further review of the medical record revealed no Advance Directive on file and no changes made in the social worker notes or assessment that R312's representative requested any changes to be made. Review of the most recent Code Status Form in the medical record dated [DATE], documented in part . DO-NOT-RESUSCITATE ORDER . Patient Advocate Consent/Guardian Consent . I authorize that in the event the declarants/ward's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution . This order will remain in effect until it is revoked as provided by law . This form was signed by R312's daughter, Physician B and witnesses. The resident's breathing or heart did not stop when LPN A initially identified the change in condition with R312 and therefore continued monitoring, continued care and/or transfer to a higher level of care should have been provided to stabilize the resident. Review of a Nursing note dated [DATE] at 11:32 PM, documented in part . Writer has made several attempts to notify family of residents changed in condition without success, messages left for (R312's family member names) . to call facility, with no return calls, endorsed to oncoming nurse . Review of a Nursing note dated [DATE] at 12:25 AM, documented in part . At approximately 12:25am: unresponsive to physical and verbal stimuli, Skin warm to touch. Absent pulse, respiration, and blood pressure noted. Advance directives: DNR. Family aware of change in condition and stated they were on the way. Family arrived, support from staff given. [Local police department] called and made aware. Police arrived at approximately 12:40am. Police spoke with the facility medical Director. DON notified and made aware of resident's change in condition. At approximately 5:15am funeral home picked up remains, family present. Funeral home signed release order. Report given to oncoming nurse . Review of the medical record contained no documentation of any comfort medications or interventions provided to the resident after the change of condition was identified. On [DATE] at 10:57 AM, the DON (who was recently hired at the facility in February 2023 and was not employed at the facility at the time of R312's inpatient care), the Clinical Regional Director (CRD) C (who was the clinical director at the time of R312's incident, however as of the end of [DATE] was no longer overseeing the facility) and CRD D (who started on [DATE] and who is the current clinical regional director of the facility) was all interviewed together and asked the expectation of staff if they identify a change of condition with a resident who has a code status of a DNR and specifically identified with an oxygen saturation level of 72%, CRD D responded the resident should be assessed, oxygen applied, review the code status and call the physician. CRD D stated staff should complete a change of condition form and notify the family. CRD D stated pulse ox monitoring should be performed and a staff member with the resident monitoring them until they are stable. When asked, CRD D stated all documentation of monitoring should be documented in the medical chart. At this time, R312's change of condition as documented on [DATE] was reviewed with the DON, CRD C and CRD D. The concerns of the lack of monitoring, obtaining follow up vitals and documentation of R312 who was identified with an oxygen saturation level of 72% and who staff applied a non rebreather mask at 10 LPM, which was not effective in stabilizing the resident's respiratory status with no documentation of notifying the physician that the intervention was ineffective and the decision made to not send the resident out to a higher level of care for further treatment was reviewed. The DON, CRD C and CRD D acknowledged the concerns and stated they would look into it and follow back up. At 11:50 AM, CRD C returned and stated they reviewed the incident and were unable to find any additional information or documentation. CRD C stated they understood the concerns. On [DATE] at 1:30 PM, the facility's Administrator was served an Immediate Jeopardy template regarding R312's change of condition and the actions of the facility staff that followed the identified change of condition. On [DATE] at 2:11 PM, CRD D entered into the conference room where the surveyors worked and stated they wanted to know why R312's change of condition incident is categorized as an Immediate Jeopardy. CRD D stated they expected the incident to be categorized as a G harm level, but not Immediate Jeopardy and wanted the surveyor to explain why it was immediate jeopardy. All concerns that were initially presented to the DON, CRD D and CRD C were again repeated and CRD D was informed that an immediate action was necessary to prevent the incident from happening to any additional residents. On [DATE] at 2:47 PM, a telephone interview was conducted with Physician B (the physician who LPN A initially contacted regarding R312's change of condition and the physician who was assigned to R312 while at the facility). Physician B was presented with the concerns that involved the change of condition, follow up monitoring and follow up notification to the physician regarding the unstable respiratory status of R312. Physician B stated they honestly did not remember the incident. Physician B stated they remembered receiving a call about R312 but could not recall what it was regarding. When read the assessment of R312 as documented by LPN A and what directive they would have given to the staff, Physician B stated To be honest with you if they called me about a patient below 90 (SPO2) I would advised them to be sent out to the hospital. Physician B stated again that they could not remember the incident. On [DATE] at 3:07 PM, the Administrator escorted Physician B into the conference room where the surveyors worked and stated that Physician B would like to have a second interview with the surveyor. Physician B started off the conversation stating they had a chance to review the resident's medical record. Physician B then went on to state that if staff contacted them now (currently) regarding a resident who is a DNR with a pulse ox of 72% they would want to make that resident comfortable. When asked if the staff informed them that the initial order to apply the oxygen was ineffective and did not raise the SPO2 levels of R312, Physician B denied to have been notified of the oxygen not being effective. Physician B was then asked if they gave the staff directive to not send R312 to the hospital and the physician replied they could not remember. When asked why the facility did not follow the facility's policies regarding R312's change of condition, Physician B stated So I should have put an order to not send to the hospital? Physician B was informed that it was documented in the medical record that R312 had legal representatives in place and that conversation and decision is one that should have been conducted with the legal representatives so that the facility could implement their wishes, this is a decision that cannot be solely decided by the physician without involving the legal representatives. Physician B was asked once again if they gave the directive to the nursing staff to not send R312 to the hospital with the resident's change of condition as documented on [DATE] and Physician B stated in part . I didn't. I don't remember with this resident. I just don't . Physician B thanked the surveyors for their time and the surveyors thanked Physician B for their time and Physician B exited the conference room. Review of the medical record revealed no physician order that documented No hospitalization for R312. Review of a Physician note dated [DATE] at 4:24 PM, (the last physician note documented in R312's chart) documented in part . Reason for the visit E/M for dementia, anxiety, dysphagia, and Huntington's disease. Also seen for multiple medical condition more than 3 requiring monitoring and prevent decline. Patient seen and examined Vital signs, medications, labs, and chart reviewed . no reported hx (history) of vomiting, constipation, or diarrhea, no sob (shortness of breath) no hematuria (blood in urine) no loc (loss of consciousness) or seizure activity . awake, not aware, chronically debilitated . Lungs CTA (clear to auscultate) bilaterally, no acute distress, no rales, or wheezes; no clubbing/cyanosis . A&P (Assessment & Plan): 1. Dementia: no evidence of behavioral disturbances at time of exam. Continue supportive care 2. Anxiety: stable on current RX (medication). No anxiety/agitation noted on exam 3. Dysphagia: tolerating prescribed diet. Continue 1:1 feed. Maintain aspiration precautions 4. Huntington's disease: stable on current dose of Austedo. Continue supportive care . Review of the progress notes and Medical record revealed no documentation of the resident to have been under hospice services at the time of death, nor was there documentation in the medical record that indicated resident's health status to have been declining prior to the identification of the change of condition documented on [DATE], with death of the resident following two hours and twenty-five minutes later. Further review of the progress notes documented the following Infection Note dated [DATE] at 11:14 AM (four days before the resident expired), . Per CDC (Centers for Disease Control and Prevention) guidelines, all residents have been offered chemoprophylactic treatment for influenza outbreak. At this time, the pharmacy is unable to fulfill any prophylaxis orders due to national shortage of Tamiflu. Resident was made aware. DPS #2 Based on observation, interview, and record reviews the facility failed to identify left arm edema and notify the physician of the edema for one (R61) of one resident reviewed for edema. Findings include: On [DATE] at 10:46 AM, R61 was observed lying on their back in bed. The left arm was observed to have edema from the upper arm to the fingers, when compared to the right arm. Review of the medical record revealed R61 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses that included: dementia, dysphagia, gastrostomy, muscle weakness, history of transient ischemic attack and cerebral infarction without residual deficits and hypertension. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4 (which indicated severely impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of the physician orders documented orders for Metoprolol 25 MG (milligram) via PEG (percutaneous endoscopic gastrostomy) every 12 hours for hypertension and Losartan Potassium 100 MG once a day for hypertension. Review of the care plans revealed one intervention which was to report edema to the nurse. No further interventions were documented regarding any identified edema. Review of a Dietary note dated [DATE] at 10:59 AM, documented in part . Weight gradually increasing. Wt (weight) gain may be r/t (related to) excess energy intake via PEG . or possible edema . no labs to review . + (positive) trace edema noted ,d+[DATE] . The note does not specify where the trace edema is identified. Review of a Physician's Note dated [DATE] at 3:40 PM, documented in part . LEs (lower extremities): + trace Edema . Further review of the physician note revealed no documentation of directive given to staff regarding the monitoring or interventions for the trace edema identified in the lower extremities. Review of the medical record and progress notes revealed no documentation of the left arm edema identified by the facility staff. On [DATE] at 1:58 PM, the Director of Nursing (DON) was asked to go with the surveyor to the room of R61. It was explained to R61 that an observation would be made of their arms and legs. R61 shook their head yes. The DON then pulled down R61's top sheet revealing R61's arms and legs. Observation revealed both of R61's feet and left upper arm to fingers to have edema present. Once in the hallway the DON was asked why staff had not identified the edema on R61, documented it in the medical record and inform the physician. The DON stated they would look into it and follow back up. On [DATE] at 3:21 PM, the DON stated they completed an assessment on the resident and reported the findings to the physician. No further explanation or documentation was provided by the end of survey. 38271 Resident #4 Deficient Practice Statement #3 Based on interview and record review the facility failed to follow-up in a timely manner with Physician recommendations for one resident (R4) of three residents reviewed for quality of care. Findings include: On [DATE] at approximately 10:04 a.m., R4 was observed in their room and laying in their bed. R4 was observed to be in a hospital gown and had unclear speech. On [DATE] the medical record for R4 was reviewed and revealed the following: R4 was last admitted on [DATE] and had diagnoses including Dementia, Abdominal Pain and Constipation. A review of R4's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed R4 was dependent on staff for assistance with their activities of their daily living. R4 was documented as having severely impaired cognition. A Physical Medicine and Rehab (PM&R) evaluation dated [DATE] revealed the following: Physician's Note-Note Text: PM&R/ Pain Management at [facility] .Reason for Visit: I am seeing and treating the patient (pt) today to treat her for pain, as the pt needed her Norco pain meds refilled. Chief Complaint: Ouch when I moved her bilateral (b/l) contracted knees today. Pt seen & examined today on Tuesday [DATE]. Pt was complaining of pain, the location of the pain is to both her contracted knees, the duration of the pain has been for 16+ months, the pain is daily, the pain was described as ouch when I touched and moved her knees, the pain is worse with touching her knees and no pain meds, the pain is better with the pain meds, there is no radiation of the pain, and the pt did not rate the pain out of 10 today for me. Plan: 1.) Today I electronically prescribed the following Prescription (Rx) order online to the Pharmacy for:- Norco ,d+[DATE] mg, one (1) tab po q 8 (eight) hours prn: pain, #6 (six) count 7.) I recommend daily Senna & Colace to help prevent Opioid Induced Constipation from Norco Further review of the medical record for R4 did not reveal any Physician orders were implemented for Senna and Colace in R4's medication regimen. A review of R4's March and [DATE] medication administration record (MAR) revealed no opportunities of administration of Senna or Colace. Further review of R4's MAR revealed Norco was still a part of their medication regimen. On [DATE] at approximately 3:20 p.m. during a conversation with the Director of Nursing (DON), the DON was queried for information pertaining to the implementation delay in R4's senna and colace not being added to their medication regimen and they indicated they would have to look into the concern. On [DATE] at approximately 11:51 a.m., during a conversation with Regional Clinical Regional Director C (CRD C), CRD C followed up regarding the concern of providing senna and colace to R4. RCD C indicated that it was missed and should have been added to the medication regimen. RCD C indicated that the Nursing staff are supposed to review the reports in the clinical meetings but it was not done. RCD C indicated they would have to get it added to medication regimen.

This citation pertains to Intake Number MI 544, MI 585, MI 710, MI 658 and MI 222 and has two deficient practices. Deficient Practice #1 Based on interview and record review, the facility failed to respond timely to changes in condition for one (R801) of three residents reviewed for changes in condition that included an unstageable pressure ulcer that developed and worsened in the facility and critical lab results that indicated the resident had an infection; failed to coordinate care between nursing staff and multiple medical practitioners; and failed to implement new interventions and treatments in a timely manner when a pressure ulcer was identified; failed to identify the worsening condition of the pressure ulcer; and failed to revise treatment and interventions in a timely manner when critical laboratory results indicated the resident had an infection. This resulted in an immediate jeopardy (IJ) when R801 was sent to the hospital five days after the critical labs were received and was found to be in severe septic shock (a widespread infection that causes organ failure), had an infected pressure ulcer that had purulent drainage (pus), abscesses, and a foul odor that permeated throughout the emergency room , was in acute distress, and in agonizing pain. The resident was discharged to inpatient hospice (end-of-life). Findings include: The IJ began on 7/10/21. The facility was notified of the IJ on 8/12/21 at 8:10 AM and a plan to remove the immediacy was requested. The immediacy was removed on 8/12/21 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. A complaint was submitted to the State Agency that alleged the following: Pt (patient) was brought into the ER (emergency room ) of [hospital name redacted] on 7/20/21 from [facility name redacted] where pt is a long term care resident. She has a Legal Guardian of [name redacted]. Pt came in for abnormal labs, vital signs and being less responsive. Pt found to be in septic shock, high WBC (White Blood Cells), fever, left hip wound oozing copious amounts of foul smelling serosanguineous purulent material. Per staff odor permeated through the ER. She also has bilateral heel ulcers. Pt is severe protein malnutrition weighing 50kg (kilograms - 110 pounds). Dressings were soaked per staff and pt has very poor oral care. Pt is dx (diagnosed ) with Dementia, nonverbal, contracted, and bedbound .Concern is for neglect of care of pt at [facility name redacted] Per CM (case manager) [name redacted] for Legal Guardian of [name redacted] last Virtual Visit with pt was on 6/30/21. They had no concerns at that time and no concerns were brought to Legal Guardians attention since that visit. At this time, medical teams are recommending DNR/I (Do-Not-Resuscitate/Intubate) code status and hospice care for pt. An unannounced, onsite investigation was conducted at the facility on 8/10/21 through 8/13/21. Review of R801's clinical record revealed the following: R801 was admitted into the facility on [DATE] and discharged to the hospital on 7/20/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 was at risk for development of pressure ulcers but did not have any unhealed pressure ulcers at that time; had severely impaired cognition; was able to understand others and make self understood; had no behaviors; required extensive physical assistance from staff for bed mobility and all activities of daily living besides eating; and was totally dependent on staff assistance for transfers. It was documented R801 did not have any range of motion issues to the upper or lower extremities. A Wound Evaluation dated 7/10/21 and completed by Licensed Practical Nurse (LPN) A documented R801 had a pressure ulcer (unstageable (Full-thickness skin and tissue loss obscured by slough - non-viable tissue and/or eschar - dead or devitalized tissue) to the left trochanter (hip) that measured 6.07 cm in length by 4.02 cm in width and was covered with 100 percent eschar. The wound evaluation documented the pressure ulcer was three months old, deteriorating, and was present on admission. There was no documentation on any skin assessment, wound evaluation, or progress note that indicated the unstageable pressure ulcer on R801's left hip was identified or assessed prior to 7/10/21. The wound evaluation further revealed the treatment to the area was a debridement enzymatic. The evaluation was signed by LPN A on 7/19/21, nine days after the assessment was completed. Weekly skin assessments were reviewed and did not document any changes to R801's skin integrity prior to 7/10/21. Review of hospital records from R801's transfer to the hospital on 7/20/21 revealed the following: Discharge Documentation for R801 documented R801 was admitted into the hospital on 7/20/21 and discharged on [DATE]. The discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It was documented that R801 would be discharged to hospice that day (7/21/21). Emergency Documentation noted the following: .Date/Time of Evaluation: 07/20/21 12:05 (PM) .Chief Complaint: Altered mental status .History of Present Illness: presents to the emergency department by way of EMS (Emergency Medical Services) for abnormal blood work in <sic> not acting herself for the past 24 hours .Reportedly had high white blood cell count at outside facility. Patient is typically [NAME] <sic> (alert and oriented) x (times) 1 is currently nonverbal .Initial Vital Signs .HR (heart rate) 117 (bpm - beats per minute) .SBP (systolic blood pressure): 83mmHG (millimeters of mercury) .DBP (Diastolic Blood Pressure): 51mmHG .TEMP (temperature): 38.1 C (Celsius - 100.6 degrees Fahrenheit) .Physical Exam: General: Toxic in appearance, cachectic (physical wasting) .Head: Bitemporal wasting (muscle and fat loss in the temple region of the head) .Abdominal: .Guaiac positive (abnormal bleeding in the digestive tract) .Extremities: .Newly draining left necrotic hip wound, multiple wrapped heel wounds. Skin: Left necrotic actively draining hip wound with exudate and what appears to be possibly blood .currently protecting airway but lacks complete insight into present condition .Lab Results (Last 24 Hours) CBC (Complete Blood Count)/Coag/Blood Bank .WBC: 35.29 K/mcL(thousand cells per microliter - normal range is between 4 and 11 K/mcL) High .Hgb (Hemoglobin): 06.3 gm/dl (grams per deciliter - normal range is between 12 and 16 g/dl) Critical .ED Course/Medical Decision Making: .Patient was brought in for altered mental status possible abnormal blood work. Immediately recognized SIRS (Systemic [CONDITION(S)] Response Syndrome - an exaggerated defense response of the body to an infection) criteria and septic protocol was initialized, CBC shows significant leukocytosis (elevated white blood cell count) of 35,000 with a hemoglobin low at 6.3. I did guaiac her which was positive and ordered 2 units of blood .she had acute [CONDITION(S)] (abnormally low sodium level) with a sodium 159 any <sic> acute hyperchloremia (abnormally high chloride level) 122 .I do feel she is septic shock and ICU (intensive care unit) is going to accept her. I did give her [MEDICATION(S)] and [MEDICATION(S)] (antibiotic medications) in the ER .I spoke with admitting physician (Physician I from the nursing facility) as well. Patient will be going to the ICU in critical condition. Urinalysis currently pending however I do feel 1 source can be of the necrotic left actively draining exudative hip wound .Final Impression: Septic shock secondary to necrotic ulcer versus other, acute kidney injury, Acute [CONDITION(S)], Acute Upper GI (gastrointestinal) bleed, Acute [CONDITION(S)], acute hyperchloremia .Final Disposition .ICU critical care . A History & Physical document signed on 7/21/21 by Attending Physician I (who saw R801 in the hospital and was also their attending physician at the facility) noted the following: .Assessment/Plan: Septic shock .Acute left hip infected decubitus ulceration with large abscesses .acute blood loss [CONDITION(S)] .blood transfusion .poor prognosis; hospice appropriate .Chief Complaint: [CONDITION(S)] .Physical Exam: .grimacing in pain, nonverbal, in acute distress, leaning towards her right side, cachectic .[CONDITION(S)] (increased heart rate) .Skin: Large left eft <sic> hip ulcer/wound draining copious amounts of serosanguineous (thin, watery fluid with red blood cells) and pustular looking material .CT (Computed Tomography) Abd (abdomen)/Pelvis w/o (without) contrast IMPRESSION: Large left gluteal (buttock) air/fluid collection compatible with abscess with a component extending to the greater trochanter (hip) of the left femur and lucency (less dense than normal) involving the trochanter raising concern for [CONDITION(S)] (bone infection) . A Critical Care Progress Note dated 7/21/21 documented, .Septic shock .[CONDITION(S)] with likely source left hip ulcer .Left hip pressure ulcers status post [MEDICAL RECORD OR PHYSICIAN ORDER] .Suspected GI bleed on admission .Severe debility with contractures . An Admit/Progress Note dated 7/20/21 documented, .presents from outside facility for septic shock likely due to multiple abscesses and ulcerations .Assessment: Leukocytosis over 30,000 .[CONDITION(S)] which appears macrocytic, consistent with malnutrition and neglect, improved after transfusion early this morning .Severe electrolyte derangements (imbalance) .consistent with severe dehydration .Many excoriated and chronic appearing wounds all over the gravity dependent and bony protrusions of the patient's body .Likely neglect given patient's condition .Poor prognosis .Appears to be in extreme agony .Not a candidate for aggressive medical therapy .patient should be under comfort care to reduce her suffering .Multiple comorbidities for this patient including severe cachexia as well as chronic infections, lack of social support, severe dementia with no notable baseline mentation reveals this patient to have extremely poor prognosis .Plan: .Patient is a candidate for hospice, hospice was consulted by the palliative team, legal guardian is allowing this .CODE STATUS was changed and no code .We are awaiting inpatient hospice admission versus outpatient hospice care .Subjective .was severely contracted screaming in pain anytime any of the staff touched her in most of her body. Patient especially screams in pain when we examine her belly as well as try to move any of her lower extremities. Her lower extremities are twisted, she does not say any words .Patient does not nod or shake head, when wound care came by to the bridge <sic> and examined some of her sacral and trochanteric wounds, she did scream, 'help me' at one point Physical Exam ,General: Cachectic, malnourished, agonizing pain, pain still present after IV narcotics .Eyes closed most of the time grimacing in pain .Extremities: .significant ulcerations at nearly every bony protrusion .Purulent and foul-smelling abscesses were present initially, seems improved from yesterday. No meaningful movements from any limbs, not able to interact even with handholding. Screaming in pain when touching arms and forearms .moaning in despair . An Infectious Disease Consultation dated 7/21/21 documented, .Reason for Consultation Left hip infected decubitus ulceration .Assessment and Plan .Septic shock with MODS (multiple organ dysfunction syndrome), present upon arrival .due to left hip abscess/infected ulcer .Acute left hip infected decubitus ulceration with large abscesses formation with deep tunnelling .Severe dehydration .Acute blood loss [CONDITION(S)] .s/p blood transfusion .Addendum .Patient is demented and moaning. On exam she has dry mouth .Left hip his <sic> large skin ulceration circumferential with tunneling and skin undermining noted .Has boggy appearance of the tissue with possible underlying abscess present .Patient has several other pressure ulcers on bony prominences all over including bilateral hip shoulders knees and feet. She is here with Sirs and [CONDITION(S)] possible septic shock related to infected wound with left hip abscess .I am concerned if she has underlying abscess further in between tissue which is loculated as the tissue is boggy and fluctuant on exam. Also concern for [CONDITION(S)] . A Wound Care Consultation dated 7/21/21 documented, .L (left). trochanter: Stage 4 pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) s/p bedside I&D .8cm x 5cm x 1.5cm with circumferential undermining; greatest depth ~8cm .boggy and concerning for abscess .Patient was yelling in pain throughout dressing changes in spite of [MEDICATION(S)] (a medication used to treat severe pain) IVP (intravenous push) premedication for pain management .Heel boots and positioning wedge requested for optimal pressure off-loading. [brand name redacted] high flow air mattress (air fluidized) bed ordered . A Procedure Note dated 7/20/21 documented R801 had an excisional debridement, incision and drainage of abscess to the infected decubitus ulcer over left hip. Computed Tomography Reports dated 7/20/21 documented, .CT Abd/Pelvis w/o Contrast .FINDINGS .In the left gluteus region there is a large subcutaneous gas and fluid collection measuring approximately 6.8 x 16.6 x 14cm which extends to the level of the greater trochanter of the left femur with mild subtle lucency raising possibility for [CONDITION(S)] . Further review of R801's full clinical record was conducted and revealed the following: A Physician's Note dated 5/19/21 written by Physician B (the facility's Medical Director and Wound Physician) documented R801 was seen for a wound to the right buttock, and it was documented at that time that the wound was closed. At that time, Physician B changed the treatment to [MEDICATION(S)] foam every four days and as needed (PRN) and documented the following interventions: low air loss mattress, Continue nutritional interventions . A Physician's Note dated 7/14/21 written by Physician B documented, Wound rounds .Seen on wound rounds re open area to left upper outer buttock. (Note: the previous healed wound was on the right buttock) .Developed an unstageable ulcer to the left upper outer buttock. Covered almost entirely with dark necrotic slough. Scant drainage. Rx (treat) with Santyl (a medication that removes dead tissue from wounds) on 4 x 4 and cover with bordered gauze dressing daily. LAL (low air loss) mattress in place. Will repeat labs. Eating poorly. Weight loss. Has severe contractures at hips and knees .Poor mobility. Dementia with inability to comprehend directions. PCM (protein calorie malnutrition). [CONDITION(S)]. Skin breakdown unavoidable. (Note: Physician B's note from 5/19/21 documented R801 had dementia, [CONDITION(S)], adult failure to thrive at that time and a stage III pressure ulcer was healed). The progress note did not include any measurements of the pressure ulcer. Review of Physician Ordered treatments for R801's left trochanter revealed the following orders: (L) hip pressure wound: CLEANSE WITH SAF CLENS & pat dry. APPLY A+ + [MEDICATION(S)] foam. Change Q(every) 2 & prn. Every day shift every other day for (L) hip pressure wound. The order was started on 6/30/21 and discontinued on 7/15/21. There was no documentation of any change in R801's skin to the left trochanter prior to what was documented on the 7/10/21 Wound Evaluation and there was no evidence that a new treatment was implemented on 7/10/21 when the Unstageable pressure ulcer was first documented. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . APPLY Santyl daily and prn. Every day shift for (L) hip pressure wound was started on 7/16/21 (six days after LPN A documented R801 had an unstageable pressure ulcer to the left trochanter). On 8/10/21 at 3:45 PM, an interview was conducted with LPN A and R801's clinical record including the Wound Evaluation completed on 7/10/21 were reviewed. LPN A reported they were the wound care nurse for the facility and explained their role was to do treatments and rounded with Physician B, the wound physician, on Wednesdays. When queried about the facility's protocols when nursing staff identified new areas of concern with residents' skin, LPN B reported the staff notified him (LPN A) and LPN A notified Physician B. LPN A reported head to toe skin assessments were completed on all residents one time per week by the floor nurses. LPN A further reported that in the evenings and on weekends, the floor nurses completed wound treatments. At that time, LPN A was further interviewed regarding R801's unstageable pressure ulcer that was documented on the wound evaluation dated 7/10/21. LPN A reported R801 was extremely contracted and hard to reposition and once we saw the wound, we switched her to the other side. LPN A reported R801 previously had a stage III pressure ulcer to the right buttock that was resolved on 5/17/21. When queried about when LPN A became aware of any changes in skin integrity to R801's left trochanter/hip, LPN A reported Nurse J (a nurse who was no longer employed by the facility) notified LPN A of a wound on R801's left hip. LPN A reported they assessed the wound on 7/10/21 and Physician B assessed the wound on 7/14/21. When queried about the order for [MEDICATION(S)] foam that was started on 6/30/21, LPN A reported R801 did not have a wound to the left hip at that time and that order was a preventative treatment. Review of the Treatment Administration Record (TAR) for July 2021 revealed LPN A administered the preventative treatment to R801 on 7/8/21. When queried about what the skin on R801's left hip looked like on that date, LPN A reported there was unblanchable redness and then later reported it was blanchable. LPN A reported there was no open area to R801's left hip on 7/8/21 two days before it was assessed to be a 6.07 cm by 4.02 cm unstageable pressure ulcer covered with 100% eschar. When queried about the documentation on the Wound Evaluation that noted the wound was present on admission, Deteriorating, and slow to heal if on 7/10/21 it was identified as a new wound, LPN A did not offer a response. When queried about who determined the treatments for pressure ulcers, LPN A reported Physician B did. When queried about why the treatment stayed the same on 7/10/21 after R801 was discovered to have an unstageable pressure ulcer, LPN A stated, (Physician B) saw her on 7/14/21 and changed the order. (Four days later). On 8/11/21 at 9:13 AM, Physician B was interviewed regarding R801's pressure ulcer to the left hip. Physician B reported they first evaluated R801 on 7/14/21. When queried about whether the nursing staff or LPN A contacted him to determine the treatment when new wounds were identified on residents, Physician B stated, Sometimes they call me, sometimes they don't. When queried about the pressure ulcer that R801 developed to their left hip, Physician B reported it was unavoidable. When queried about the clinical rationale to determine it was unavoidable, Physician B reported the resident had contractures and weight loss. When queried about whether R801 was evaluated for the underlying reason for the weight loss, Physician B reported he did not evaluate R801 for weight loss but ordered labs the day he evaluated the wound on 7/14/21. When queried about the treatment orders for R801's left hip and whether the treatment should have changed on 7/10/21 when it was identified that R801's left hip developed an unstageable pressure ulcer, Physician B stated, Sometimes treatment is the same for preventative as it is for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician B reported LPN A did not contact him, and he did not make the decision to keep the same treatment. When queried about the labs that Physician B ordered, Physician B reported they came back showing R801 had low prealbumin. Physician B reported R801's pressure ulcer did not appear infected on 7/14/21. Review of R801's Lab Results Report with a collection and reported date of 7/15/21 revealed R801 had a critical abnormal White Blood Cell (WBC) count of 27.9 (normal range is between 4.00 and 11.00 - an elevated WBC count typically indicates there is an infection). Review of a Nurses Note dated 7/15/21 at 3:13 PM documented, .Resident had elevated WBC. Physician notified and ordered STAT (right away), UA (Urinalysis) C$ <sic>S (culture and sensitivity), Blood culture x 2. Also, to monitor temp (temperature) every four hours x 4 days. Incoming nurse given report and orders endorsed to nurse. Review of R801's Lab Results Report with a collection and reported date of 7/16/21 revealed R801 had a critical WBC count of 39.4 and a critical Hemoglobin level of 7.2 g/dL (grams per deciliter - normal range is between 12.0 and 16.0). Review of a Nurses Note dated 7/17/21 at 2:02 AM, written by LPN D, revealed documentation that noted, .WBC and Hemoglobin Critical, WBC 39.4, Hemoglobin 7.2, on call provider (Nurse Practitioner K) notified. Monitor for signs of Bleeding and repeat CBC (Complete Blood Count) in one week, order was put in for THURSDAY 22, 2021. Review of a Nurses Note dated 7/19/21 at 8:46 AM (four days after the first critical lab results) written by the first floor Unit Manager, revealed documentation that noted, .Spoke to (Physician I) regarding elevated WBC and BUN he stated he will review the chart and call back with instructions. Review of a Nurses Note dated 7/20/21 at 11:45 AM documented, Rec'd (received) resident in bed lethargic. V/S (vital signs) 92/58, HR 100, T98.2, RR23, SpO2 93% RA (room air). Report rec'd from previous nurse that resident is declining. MD called for follow up orders regarding plan of care no answer/message left. DON (Director of Nursing) notified of resident condition orders rec'd to transfer pt to hospital for further evaluation . On 8/11/21 at 10:10 AM, an interview was conducted with the DON. When queried about the facility's protocols for managing pressure ulcers, the DON reported LPN A was the facility's wound nurse and he provided wound treatments to residents and rounded with Physician B on a weekly basis. The DON reported LPN A was not qualified to stage pressure ulcers but did treatments for pressure ulcers staged II and above. The DON stated, The actual wound care doctor can stage the wounds and reported LPN A took pictures of wounds prior to Physician B's evaluations and either Physician B or the wound NP would determine the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . When queried about why R801 was transferred to the hospital on 7/20/21, the DON reported she had abnormal labs. At that time, the hospital transfer form and the temperature monitoring every four hours documented on 7/15/21 was requested from the DON. On 8/11/21 at approximately 10:30 AM, the DON provided R801's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Weights and Vitals Summary revealed R801 had a temperature of 99.4 degrees F on 7/15/21 and a temperature of 99.1 degrees F on 7/19/21 at 9:31 AM and 11:41 AM. There were no progress notes that addressed R801 having a fever. On 8/11/21 at 10:41 AM, an interview was conducted with the first floor Unit Manager, Registered Nurse (RN) L. RN L documented they contacted Physician I on 7/19/21 regarding R801's critical lab results. RN L reported they covered the second floor on 7/19/21 and contacted Physician I on 7/19/21 because they looked like they needed to be addressed. When queried about Physician I's response, RN L reported Physician I said they would review R801's chart and call back. RN L reported they did not know if Physician I called back because they only worked on that floor until 11:00 AM and then returned to the first floor. RN L reported the second floor Unit Manager would have followed up. On 8/11/21 at 12:00 PM, an interview was conducted with LPN D, the nurse who documented they contacted NP K regarding the second report of critical labs for R801 on 7/16/21. LPN D reported they were alerted of R801's critical lab results during the midnight shift on 7/16/21. LPN D reported they contacted the on-call provider, NP K, told her about R801's lab results and NP K said to watch for bleeding and repeat the labs a week later. When queried about whether LPN D notified NP K of the WBC count of 39.4 and LPN D reported they did. LPN D reported they put an order to repeat R801's labs in one week. On 8/11/21 at 12:05 PM, an interview was conducted with NP K via the telephone. NP K reported herself and other practitioners work for a company and covered off hours shifts from 7:00 PM through 7:00 AM on the weekdays and all day on the weekends. NP K reported they cover a total of 28 facilities and their role was to respond to tiger texts or phone calls regarding critical conditions. NP K reported they had access to residents' electronic clinical record but mostly relied on the nurses to present the clinical information via phone or text. NP K stated, I am not familiar with the residents. I only know what they tell me. When queried about R801 and if they recalled being notified about critical lab results on 7/17/21. NP K reported they recalled being contacted and stated, I got about 50 messages and 5 phone calls that night. Actually, the DON called me this morning and asked me about this and said the nurse wrote that she told me about a WBC. She (LPN D) did not. She only told me about the Hemoglobin and since it was not under 7, I said to watch for bleeding and check CBC in one week. NP K reported they did not know R801's baseline or that this was a second set of labs and that they would not know unless the nurse told her. When queried about R801's WBC count of 39.4, NP K reported that would have indicated there was an infection. NP K further reported if they would have known R801 had a WBC of 39.4 they would have asked the nurse more questions to figure out if there was an active infection, what the source of the infection was, and to understand what was going on. They (the nurses) have to bring me all the information in order for me to make the decisions. We cover 28 facilities. It's hard to follow all the residents. When queried about whether the on-call providers communicated with the facility's attending physicians, NP K reported they do not and only cover after hours to address critical situations. On 8/11/21 at 12:21 PM, an interview was conducted with R801's attending physician, Physician I via the telephone. When queried about R801 and the critical labs obtained on 7/15/21 and 7/16/21, Physician I reported he recalled the nurse called him about the labs and R801 was sent to the hospital the next day. Physician I stated, I saw (R801) when she was at her baseline and apparently, she had a significant change. I was asking the nurse about her (R801) situation and the nurse was not helpful in answering my questions, so I had to hang up and review the chart. It looked like (R801) was sick for a couple of weeks, but I had no idea. Nobody called me. Physician I further reported they saw R801 when she was in the hospital. Physician I further stated, By the time she got to the hospital, it was too late. She ended up dying. When queried about the condition of R801's pressure ulcer, Physician I reported they were unaware R801 had wounds and questioned why the facility did not send R801 out sooner. Physician I stated, Her wounds were so bad that she was septic. When queried about the possibility of R801 developing an unstageable pressure ulcer within two days and then worsening to the condition it was in when R801 was sent to the hospital, Physician I stated, There is no way that wound developed in two days. No way. That wound was not new, and they never told me about it. Physician I reported he saw R801's pressure ulcer the first day she was in the hospital (7/20/21). On 8/12/21 at 1:30 PM, the DON was interviewed about R801's changes in condition. When queried about the communication between the nurses and the medical practitioners regarding R801's critical lab results, the DON reported the nurses needed to be clear with the medical practitioners about what was going on with R801 and if they were concerned about the resident, they should have clarified with the practitioner or could have contacted the DON or Medical Director. The DON reported Physician B and Physician I should have followed up on the lab results because they ordered them. When queried about when [CONDITION(S)] screenings were completed for residents, the DON reported on admission up to seven days every shift, upon starting antibiotic medication, or if any signs and symptoms of an infection were recognized with a change in condition. The DON reported [CONDITION(S)] screening should have absolutely been started for R801. Further review of R801's clinical record revealed the following: There were no [CONDITION(S)] Screening Tool assessments completed for R801 since 11/11/20. A SKIN MANAGEMENT care plan initiated on 5/10/19 and revised on 2/4/21 documented, I was developed skin on my R-buttock pressure wound. I am at high risk for further skin break down and delayed wound healing R/t (related to) Decreased Mobility, Incontinent of B/B (bowel/bladder) and co-morbidities. There was no care plan that addressed the unstageable pressure ulcer to R801's left hip and no new interventions after 11/24/20 when the low air loss mattress was initiated. The care plan documented the following interventions: CNA's (certified nursing assistants) will check my skin daily with care and report anything unusual they notice to the nurse (initiated on 5/10/19); Please help me get turned and repositioned while in bed or in my wheelchair (individualize as needed) (initiated on 11/17/20 and did not specify any individualized turning and repositioning that addressed R801's contractures mentioned by LPN A and Physician B). There were no progress notes, evaluations, or assessments in the electronic medical record that identified the worsening of the pressure ulcer present on R801's left hip as documented in the hospital record upon arrival to the ER (as having a copious amount of purulent drainage or foul odor, as documented in the hospital record upon arrival to the ER). The assessment documented by Physician B did not include any measurements of the pressure ulcer and was four days after the initial measurements were taken by LPN A. Review of a form titled, eINTERACT Change in Condition Evaluation dated 7/15/21 was started and incomplete. The SITUATION section documented R801 had a fever on 7/15/21 in the afternoon. The ASSESSMENT section documented R801 had a temperature of 99.4 degrees F. It was documented in the Skin Evaluation section that there were no changes observed for R801 and nothing was documented in the location and details section that included a body diagram to mark any skin alterations. The form documented R801 had a WBC count of 27 on 7/15/21 and the section for the RN or LPN to document what they thick is going on with the resident was left blank. It was documented NP M

This citation pertains to Intake Numbers: MI 544, MI 563, MI 585, MI 664, MI 710 Based on interview and record review, the facility failed to implement treatment and interventions in a timely manner for a facility acquired pressure ulcer; identify and treat the worsening condition of a pressure ulcer; and ensure pressure ulcer monitoring and assessment was completed, thorough, and accurate for two (R801 and R802) of six residents reviewed for pressure ulcers resulting in R801 being transferred to the hospital where they were diagnosed with septic shock due to an infection of the pressure ulcer; and undetected formation of deep tissue injuries (DTIs) to R801's sacrum, right hip, right scapula, left big toe, left foot, left ankle, and left lower extremity and Stage II pressure ulcers to R802's right elbow, left and right buttocks, and DTIs to R802's right and left heels. Findings include: R801 A complaint was submitted to the State Agency that alleged the following: Pt (patient) was brought into the ER (emergency room ) of [hospital name redacted] on 7/20/21 from [facility name redacted] where pt is a long term care resident. She has a Legal Guardian of [name redacted]. Pt came in for abnormal labs, vital signs and being less responsive. Pt found to be in septic shock, high WBC (White Blood Cells), fever, left hip wound oozing copious amounts of foul smelling serosanguineous purulent material. Per staff odor permeated through the ER. She also has bilateral heel ulcers .Dressings were soaked per staff .Pt is dx (diagnosed ) with Dementia, non verbal, contracted and bedbound .Concern is for neglect of care of pt at [facility name redacted] Per CM (case manager) [name redacted] for Legal Guardian of [name redacted] last Virtual Visit with pt was on 6/30/21. They had no concerns at that time and no concerns were brought to Legal Guardians attention since that visit. At this time, medical teams are recommending DNR/I (Do-Not-Resuscitate/Intubate) code status and hospice care for pt. Review of R801's clinical record revealed the following: R801 was admitted into the facility on [DATE] and discharged to the hospital on 7/20/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 was at risk for development of pressure ulcers but did not have any unhealed pressure ulcers at that time; had severely impaired cognition; was able to understand others and make self-understood; had no behaviors; required extensive physical assistance from staff for bed mobility and all activities of daily living besides eating; and was totally dependent on staff assistance for transfers. It was documented R801 did not have any range of motion issues to the upper or lower extremities. Review of progress notes written by Physician B (the facility's wound physician and also the medical director) and LPN A (the facility's wound nurse) revealed R801 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of weekly skin assessments for R801 since 5/19/21 did not document any changes to R801's skin integrity. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] (L) hip pressure wound: CLEANSE WITH SAF CLENS & pat dry. APPLY A+ + [MEDICATION(S)] foam. Change Q(every) 2 & prn (as needed). Every day shift every other day for (L) hip pressure wound. The order was started on 6/30/21 and discontinued on 7/15/21. There was no documentation in R801's clinical record that indicated there was any change to R801's skin integrity on 6/30/21. A Wound Evaluation dated 7/10/21 completed by Licensed Practical Nurse (LPN) A documented R801 had a pressure ulcer (unstageable (Full-thickness skin and tissue loss obscured by slough - non-viable tissue and/or eschar - dead or devitalized tissue) to the left trochanter (hip) that measured 6.07 cm in length by 4.02 cm in width and was covered with 100 percent eschar. The wound evaluation documented the pressure ulcer was three months old, deteriorating, and was present on admission. There was no documentation on any weekly skin assessment, wound evaluation, or progress note that indicated the unstageable pressure ulcer on R801's left hip was identified or assessed prior to 7/10/21. The wound evaluation further revealed the treatment to the area was a debridement enzymatic. The evaluation was signed by LPN A on 7/19/21, nine days after the assessment was completed. Further review of R801's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for [MEDICATION(S)] foam every 2 days and PRN remained active until 7/15/21 when it was discontinued. On 7/16/21 (six days after LPN A documented R801 had an unstageable pressure ulcer to the left hip), a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APPLY Santyl (an enzymatic [MEDICATION(S)] medication to remove dead tissue from a wound) daily and prn. Further review of R801's full clinical record was conducted and revealed the following: A Physician's Note dated 5/19/21 written by Physician B (the facility's Medical Director and designated Wound Physician) documented R801 was seen for a wound to the right buttock, and it was documented at that time that the wound was closed. At that time, Physician B changed the treatment to [MEDICATION(S)] foam every four days and as needed (PRN) and documented the following interventions: low air loss mattress, Continue nutritional interventions . A Physician's Note dated 7/14/21 written by Physician B documented, Wound rounds .Seen on wound rounds re open area to left upper outer buttock. (Note: the previously healed wound was on the right buttock. There was no documentation in the clinical record that revealed R801 previously had a pressure ulcer to the left hip) .Developed an unstageable ulcer to the left upper outer buttock (trochanter/hip). Covered almost entirely with dark necrotic slough. Scant drainage. Rx (treat) with Santyl on 4 x 4 and cover with bordered gauze dressing daily. LAL (low air loss) mattress in place. Will repeat labs. Eating poorly. Weight loss. Has severe contractures at hips and knees .Poor mobility. Dementia with inability to comprehend directions. PCM (protein calorie malnutrition). [CONDITION(S)]. Skin breakdown unavoidable. (Note: Physician B's note from 5/19/21 documented R801 had dementia, [CONDITION(S)], adult failure to thrive at that time and a stage III pressure ulcer was healed. Also note: there was no change in treatment between 7/10/21 and 7/16/21). The progress note did not include any measurements of the pressure ulcer and was completed four days after LPN A measured the pressure ulcer. On 8/10/21 at 3:45 PM, an interview was conducted with LPN A and R801's clinical record including the Wound Evaluation completed on 7/10/21 were reviewed. LPN A reported they were the wound care nurse for the facility and explained their role was to do treatments and they rounded with Physician B, the wound physician, on Wednesdays. When queried about the facility's protocols when nursing staff identified new areas of concern with residents' skin, LPN B reported the staff notified him (LPN A) and LPN A then notified Physician B so they could evaluate the resident. LPN A reported head to toe skin assessments were completed on all residents one time per week by the floor nurses. LPN A further reported that in the evenings and on weekends, the floor nurses completed wound treatments. At that time, LPN A was further interviewed regarding R801's unstageable pressure ulcer that was documented on the Wound Evaluation dated 7/10/21. LPN A reported R801 was extremely contracted and hard to reposition and once we saw the wound, we switched her to the other side. LPN A reported R801 previously had a stage III pressure ulcer to the right buttock that was resolved on 5/17/21. When queried about any specific interventions that were in place to accommodate R801's contractions and difficult repositioning to prevent any further breakdown after the pressure ulcer to the right buttock was resolved, LPN A did not offer a response When queried about when LPN A became aware of any changes in skin integrity to R801's left trochanter/hip, LPN A reported Nurse J (a nurse who was no longer employed by the facility) notified LPN A of the wound on R801's left hip. LPN A reported they assessed the wound on 7/10/21 and at that time it was an unstageable pressure ulcer. LPN A reported Physician B assessed the wound on 7/14/21 and changed the treatment order at that time. When queried about the order for [MEDICATION(S)] foam that was started on 6/30/21 and if there were any changes to R801's skin integrity at that time, LPN A reported R801 did not have any wounds to the left hip at that time and that order was a preventative treatment. Review of the Treatment Administration Record (TAR) for July 2021 was conducted with LPN A at that time and revealed LPN A administered the preventative treatment to R801 on 7/8/21. When queried about what the skin on R801's left hip looked like on that date, LPN A reported there was unblanchable redness and then later reported it was blanchable. LPN A reported there was no open area to R801's left hip on 7/8/21, two days before it was assessed to be a 6.07 cm by 4.02 cm unstageable pressure ulcer covered with 100% eschar. When queried about the documentation on the Wound Evaluation that noted the wound was present on admission, Deteriorating, and slow to heal if on 7/10/21 it was identified as a new wound, LPN A did not offer a response. When queried about who determined the treatments for pressure ulcers, LPN A reported Physician B did. When queried about why the treatment stayed the same on 7/10/21 after R801 was discovered to have an unstageable pressure ulcer, LPN A stated, (Physician B) saw her on 7/14/21 and changed the order. LPN A did not offer a response as to why the treatment remained preventative after the development of an unstageable pressure ulcer. When queried about any changes to the pressure ulcer after it was first assessed on 7/10/21, LPN A did not offer a response. On 8/11/21 at 9:13 AM, Physician B was interviewed regarding R801's pressure ulcer to the left hip. Physician B reported they first evaluated R801 on 7/14/21. When queried about whether the nursing staff or LPN A contacted him to determine the treatment when new wounds were identified on residents, Physician B stated, Sometimes they call me, sometimes they don't. When queried about the pressure ulcer that R801 developed to their left hip, Physician B reported it was unavoidable. When queried about the clinical rationale to determine it was unavoidable, Physician B reported the resident had contractures and weight loss. When queried about whether R801 was evaluated for the underlying reason for the weight loss, Physician B reported he did not evaluate R801 for weight loss but ordered labs the day he evaluated the wound on 7/14/21. When queried about the treatment orders for R801's left hip and whether the treatment should have changed on 7/10/21 when it was identified that R801's left hip developed an unstageable pressure ulcer, Physician B stated, Sometimes treatment is the same for preventative as it is for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician B reported LPN A did not contact him, and he did not make the decision to keep the same treatment. When queried about the labs that Physician B ordered on 7/15/21, Physician B reported they came back showing R801 had low prealbumin. Physician B reported R801's pressure ulcer did not appear infected on 7/14/21. There were no documented assessments or progress notes after 7/14/21 that addressed any changes to the pressure ulcer on R801's left hip or any other skin alterations. Review of hospital records from R801's transfer to the hospital on 7/20/21 revealed the following: . R801 was admitted into the hospital on 7/20/21 and discharged on [DATE]. The discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It was documented that R801 would be discharged to hospice that day (7/21/21). Emergency Documentation noted the following: .Date/Time of Evaluation: 07/20/21 12:05 (PM) .Chief Complaint: Altered mental status .History of Present Illness: presents to the emergency department by way of EMS (Emergency Medical Services) for abnormal blood work in <sic> not acting herself for the past 24 hours .Reportedly had high white blood cell count at outside facility. Patient is typically [NAME] <sic> (alert and oriented) x (times) 1 is currently nonverbal .Initial Vital Signs .HR (heart rate) 117 (bpm - beats per minute) .SBP (systolic blood pressure): 83mmHG (millimeters of mercury) .DBP (Diastolic Blood Pressure): 51mmHG .TEMP (temperature): 38.1 C (Celsius - 100.6 degrees Fahrenheit) .Physical Exam .Extremities: .Newly draining left necrotic hip wound, multiple wrapped heel wounds. Skin: Left necrotic actively draining hip wound with exudate and what appears to be possibly blood .Lab Results (Last 24 Hours) CBC (Complete Blood Count)/Coag/Blood Bank .WBC: 35.29 K/mcL(thousand cells per microliter - normal range is between 4 and 11 K/mcL) High .Hgb (Hemoglobin): 06.3 gm/dl (grams per deciliter - normal range is between 12 and 16 g/dl) Critical .ED Course/Medical Decision Making: .Patient was brought in for altered mental status possible abnormal blood work. Immediately recognized SIRS (Systemic [CONDITION(S)] Response Syndrome - an exaggerated defense response of the body to an infection) criteria and septic protocol was initialized, CBC shows significant leukocytosis (elevated white blood cell count) of 35,000 .I do feel she is septic shock and ICU (intensive care unit) is going to accept her. I did give her [MEDICATION(S)] and [MEDICATION(S)] (antibiotic medications) in the ER .I spoke with admitting physician (Physician I from the nursing facility) as well. Patient will be going to the ICU in critical condition. Urinalysis currently pending however I do feel 1 source can be of the necrotic left actively draining exudative hip wound .Final Impression: Septic shock secondary to necrotic ulcer versus other .Final Disposition .ICU critical care . A History & Physical document signed on 7/21/21 by Attending Physician I (who saw R801 in the hospital and was also their attending physician at the facility) noted the following: .Assessment/Plan: Septic shock .Acute left hip infected decubitus ulceration with large abscesses .poor prognosis; hospice appropriate .Chief Complaint: [CONDITION(S)] .Physical Exam: .grimacing in pain, nonverbal, in acute distress, leaning towards her right side, cachectic .[CONDITION(S)] (increased heart rate) .Skin: Large left eft <sic> hip ulcer/wound draining copious amounts of serosanguineous (thin, watery fluid with red blood cells) and pustular looking material .CT (Computed Tomography) Abd (abdomen)/Pelvis w/o (without) contrast IMPRESSION: Large left gluteal (buttock) air/fluid collection compatible with abscess with a component extending to the greater trochanter (hip) of the left femur and lucency (less dense than normal) involving the trochanter raising concern for [CONDITION(S)] (bone infection) . An Admit/Progress Note dated 7/20/21 documented, .presents from outside facility for septic shock likely due to multiple abscesses and ulcerations .Many excoriated and chronic appearing wounds all over the gravity dependent and bony protrusions of the patient's body .Likely neglect given patient's condition .Poor prognosis .Appears to be in extreme agony .Not a candidate for aggressive medical therapy .patient should be under comfort care to reduce her suffering .Her lower extremities are twisted, she does not say any words .Patient does not nod or shake head, when wound care came by to the bridge <sic> and examined some of her sacral and trochanteric wounds, she did scream, 'help me' at one point Physical Exam ,General: Cachectic, malnourished, agonizing pain, pain still present after IV narcotics .Eyes closed most of the time grimacing in pain .Extremities: .significant ulcerations at nearly every bony protrusion .Purulent and foul-smelling abscesses were present initially, seems improved from yesterday. No meaningful movements from any limbs, not able to interact even with hand holding. Screaming in pain when touching arms and forearms .moaning in despair . An Infectious Disease Consultation dated 7/21/21 documented, .Reason for Consultation Left hip infected decubitus ulceration .Assessment and Plan .Septic shock with MODS (multiple organ dysfunction syndrome), present upon arrival .due to left hip abscess/infected ulcer .Acute left hip infected decubitus ulceration with large abscesses formation with deep tunneling .Left hip his <sic> large skin ulceration circumferential with tunneling and skin undermining noted .Has boggy appearance of the tissue with possible underlying abscess present .Patient has several other pressure ulcers on bony prominences all over including bilateral hip shoulders knees and feet. She is here with Sirs and [CONDITION(S)] possible septic shock related to infected wound with left hip abscess .I am concerned if she has underlying abscess further in between tissue which is =0iy as the tissue is boggy and fluctuant on exam. Also concern for [CONDITION(S)] . A Wound Care Consultation dated 7/21/21 documented, .The following wounds are Deep Tissue Injuries (DTI) and were present on admit. All are indeterminable depth. Sacrum: 11.5cm (centimeters) x (by) 6.5cm maroon wound base with patient and full-thickness wound as wound is evolving .R. (right) trochanter: 9cm x 14cm overall with full-thickness wound evolving at posterior aspect .R. scapula (shoulder blade): 0.5cm x 0.5cm .L.(left) Hallux (big toe): 2.5cm x 2cm purple/maroon .L. medial (middle) foot: 2 DTI largest is 1.5cm x 1cm maroon base .L. Medial malleolus (ankle): 1.5cm x 2.3cm purple maroon .L. LE (lower extremity); most medial: 2.5cm x 0.5cm lateral (side) 3.5cm x 0.3cm maroon wound base .L. trochanter: Stage 4 pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] ~8cm .boggy and concerning for abscess .Patient was yelling in pain throughout dressing changes in spite of [MEDICATION(S)] (a medication used to treat severe pain) IVP (intravenous push) premedication for pain management .Heel boots and positioning wedge requested for optimal pressure off-loading. [brand name redacted] high flow air mattress (air fluidized) bed ordered . Review of R801's Lab Results Report with a collection and reported date of 7/15/21 revealed R801 had a critical abnormal White Blood Cell (WBC) count of 27.9 (normal range is between 4.00 and 11.00 - an elevated WBC count typically indicates there is an infection). Review of R801's Lab Results Report with a collection and reported date of 7/16/21 revealed R801 had a critical WBC count of 39.4. Review of Nurses Notes between 7/15/21 and 7/20/21 did not document any changes to R801's already identified left hip pressure ulcer or any other areas of concern to R801's skin. The progress notes did not reveal any documentation that a physician or LPN A was notified of a worsening condition of R801's pressure ulcer. Review of a Nurses Note dated 7/20/21 at 11:45 AM documented, Rec'd (received) resident in bed lethargic. V/S (vital signs) 92/58, HR 100, T98.2, RR23, SpO2 93% RA (room air). Report rec'd from previous nurse that resident is declining. MD called for follow up orders regarding plan of care no answer/message left. DON (Director of Nursing) notified of resident condition orders rec'd to transfer pt to hospital for further evaluation . On 8/11/21 at 10:10 AM, an interview was conducted with the DON. When queried about the facility's protocols for managing pressure ulcers, the DON reported LPN A was the facility's wound nurse and he provided wound treatments to residents and rounded with Physician B on a weekly basis. The DON reported LPN A was not qualified to stage pressure ulcers but did treatments for pressure ulcers staged II and above. The DON stated, The actual wound care doctor can stage the wounds and reported LPN A took pictures of wounds prior to Physician B's evaluations and either Physician B or the wound NP would determine the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported when new wounds were identified, the nurse was to contact LPN A and the physician. LPN A was responsible to notify Physician B to evaluate the wound and determine treatment. On 8/11/21 at 12:21 PM, an interview was conducted with R801's attending physician, Physician I via the telephone. When queried about R801, Physician I reported he recalled a nurse called him about critical lab results for R801 and reported he believed the resident was sent to the hospital the following day. Physician I stated, I saw (R801) when she was at her baseline and apparently, she had a significant change. I was asking the nurse about her (R801) situation and the nurse was not helpful in answering my questions, so I had to hang up and review the chart. It looked like (R801) was sick for a couple of weeks, but I had no idea. Nobody called me. Nobody told me about the wounds. Physician I further reported they saw R801 when she was in the hospital. Physician I further stated, By the time she got to the hospital, it was too late. She ended up dying. When queried about the condition of R801's pressure ulcer, Physician I reported they were unaware R801 had wounds and questioned why the facility did not send R801 out sooner. Physician I stated, Her wounds were so bad that she was septic. If you see someone with wounds that bad, you send them out. When queried about the possibility of R801 developing an unstageable pressure ulcer within two days and then worsening to the condition it was in when R801 was sent to the hospital, Physician I stated, There is no way that wound developed in two days. No way! That wound was not new, and they never told me about it. Physician I reported he saw R801's pressure ulcer the day R801 was transferred to the hospital (7/20/21). Further review of R801's clinical record revealed the following: A SKIN MANAGEMENT care plan initiated on 5/10/19 and revised on 2/4/21 documented, I was developed skin on my R-buttock pressure wound. I am at high risk for further skin break down and delayed wound healing R/t (related to) Decreased Mobility, Incontinent of B/B (bowel/bladder) and co-morbidities. There was no care plan that addressed the unstageable pressure ulcer to R801's left hip and no new interventions after 11/24/20 when the low air loss mattress was initiated. The care plan documented the following interventions: CNA's (certified nursing assistants) will check my skin daily with care and report anything unusual they notice to the nurse (initiated on 5/10/19); Please help me get turned and repositioned while in bed or in my wheelchair (individualize as needed) (initiated on 11/17/20 and did not specify any individualized turning and repositioning that addressed R801's contractures mentioned by LPN A and Physician B). There were no progress notes, evaluations, or assessments in the electronic medical record that identified the worsening of the pressure ulcer present on R801's left hip as documented in the hospital record upon arrival to the ER (as having a copious amount of purulent drainage or foul odor). The assessment documented by Physician B did not include any measurements of the pressure ulcer and was four days after the initial measurements were taken by LPN A. R802 Multiple complaints were reported to the State Agency that alleged R802 was discharged to the hospital with several pressure ulcers on their buttocks, heels, and elbows. Review of the closed record revealed R802 was originally admitted into the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R802 had severely impaired cognition. The MDS assessment also indicated R802 was totally dependent on staff for all activities of daily living (ADL's), including bed mobility. Review of assessment for R802 revealed a Skin & Wound Evaluation dated 6/15/21 that indicated R802's skin was intact and all previous pressure ulcers had been resolved. It should be noted there were no further skin assessments for R802 through their discharge date on 7/27/21. Review of an eINTERACT Transfer Form for R802 dated 7/27/21 revealed the box Pressure Ulcer(s) was left unchecked in the Risk Alerts section. Also, Pressure Ulcers (stage, location, appearance, treatments) was left blank in the Skin/Wound Care section. On 8/10/21 at 3:48 PM, Licensed Practical Nurse (LPN) A, who served as the wound care treatment nurse, was interviewed and asked about R802's skin while a resident at the facility. LPN A explained R802 had preventative skin treatments ordered that he applied, and R802 had intact skin when they were discharged on [DATE]. LPN A was asked who did skin assessments on the residents. LPN A explained the floor nurses did a weekly skin assessment on residents. When informed of the lack of skin assessment for R802 from 6/15/21 to 7/27/21, LPN A had no answer. Review of R802's July 2021 Treatment Administration Record (TAR) revealed two skin treatments that read: Cleanse discoloration to Coccyx with safe cleans pat dry. Apply Duoderm Change Q (every) 3 daysor [sic] prn (as needed) every day shift every 3 days(s) for Coccyx pressure wound Start date 6/4/21, discontinued 7/22/21. It should be noted the documented last treatment on the TAR was on 7/19/21, eight days before R802 was discharged to the hospital. Cleanse left heel discoloration with safe cleans pat dry. Apply [sic] Aquceal [sic] foam + [MEDICATION(S)] Q 3 daysor [sic] prn every day shift every 3 day(s) for left heel discoloration. Start date 6/4/21, discontinued 7/10/21. It should be noted the documented last treatment on the TAR was on 7/10/21, 17 days before R802 was discharged . On 8/11/21 at 9:40 AM, Physician B, who served as the facility's Wound Care Doctor, was interviewed and asked about R802's skin. Physician B explained he had signed off on R802 on 6/2/21 and had not seen R802 again. On 8/11/21 at 10:21 AM, the DON was interviewed and asked how often skin assessments should be completed. The DON explained they should be done every week. The DON was asked to provide any skin assessment for R802 from 6/15/21 to their discharge on 7/27/21. None were provided by the end of the survey. Review of R802's hospital records from [Name Redacted - local hospital] revealed R802 had multiple pressure injuries that were assessed on 7/28/21 at 3:56 AM as Present on Admission to Hospital that read in part: Elbow Right- Site Assessment, No Bleeding; Pink . Staging, Stage 2 . (partial-thickness skin loss with exposed dermis) Heel Right - Site Assessment, Ecchymotic (bruising); Black . Staging, Deep tissue injury (persistent non-bleachable deep red, maroon or purple discoloration) . Surrounding Tissue Assessment, boggy and very dry . Left Buttock - Site Assessment, No Bleeding . Staging, Stage 2 . Length, 5 cm (centimeters) . Width 17 cm . Buttock Right - Site Assessment, No Bleeding . Staging, Stage 2 . Heel Left - Site Assessment, Ecchymotic . Staging, Deep tissue injury . Surrounding Tissue Assessment, boggy and dry . On 8/13/21 at 12:56 PM, the DON was interviewed and asked about the lack of skin assessments for R802. The DON confirmed there were no skin assessments completed on R802 between 6/15/21 and 7/27/21. When informed there were multiple pressure injuries documented by the hospital, the DON did not reply. Review of a facility policy titled, Wound Management Program revised on 8/17/17 revealed the following: .POLICY: To assure that resident who are admitted with, or acquire, wound receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing .Monitor skin changes during routine daily care .Complete Weekly Hydration and Skin Assessment according to schedule .Report any abnormal findings to the physician .Initiate treatment according to physician guidance .Monitor any acute illness or change in condition .Update Care Plan to reflect new risks and interventions .Complete the following steps is pressure ulcer identified: .Develop an individualized plan of care .Complete the following steps if pressure ulcer fails to show evidence of improvement/healing within 2-4 weeks .Review the record to identify any new clinical risks that may have developed .Contact the physician to consider change in treatment .Review residents with pressure ulcers at Risk Meeting .A wound care physician is not required unless recommended by the attending physician .

This citation pertains to Intake #MI 5823 and MI 5948 Based on observation, interview, and record review, the facility failed to protect the resident's debit card information from being misappropriated for one (R#704) of two residents reviewed for abuse, neglect, and misappropriation of resident's personal property, resulting in the resident's debit card being used by employees. Findings Include: Review of a FRI (Facility Reported Incident) dated 11/9/20 revealed reported the resident alleges missing money, and a Complaint reported to the State Agency (SA) on 11/17/20 by Complainant (R#704's Daughter 'G') alleged facility staff misappropriated funds from the resident's bank account. On 12/15/20 at 1:40 p.m., R#704 was observed laying across the bed watching television. When asked about the reported incident, R#704 stated, I gave a lady (Certified Nurse Assistant - CNA 'I') my debit card because I trusted her. I gave her the card to go get me some food one time. The big guy (Initials Redacted) CNA 'J' used to go get all the food for everybody. She (CNA 'I') gave me my card back. My Daughter ('G') called the bank and said all the money they were using was mine . My oldest Daughter ('H') came and got my card from me and sent it to my Daughter 'G' in Atlanta the same day . They took over $7000.00 out of my account. I wish they would give me my money back, so I can get the F**k out of here . I'm so disgusted . That hurt me real bad. A review of the electronic clinical record revealed R#704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed R#704 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition and required one-person physical assist for activities of daily living. On 12/15/20 at approximately 12:15 p.m., an investigation file provided by the facility was reviewed and it revealed the following: . On Thursday, October 1, 2020, (Name Redacted) R#704 alleged that he had a bank Card with three thousand dollars ($3000) on it and someone has used it and the balance is zero ($0). (Name Redacted) R#704 called his family and they sent the Police Department 'M' to do a wellness check. (Name Redacted) Officer 'N'. The Police came out to the facility and interviewed R#704. They didn't substantiate R#704's claims. They stated that they needed a copy of the bank statements to pursue any investigation. The Executive Director (Administrator), DON (Director of Nursing), family Members, and Physician were notified. Additionally, the facility also notified Police Department 'M'. When questioned by the police (Named Redacted) R#704 didn't have a lot of answers. (Named Redacted) Officer 'O' was then asked by R#704 to contact his Daughter 'G'. The officer stated that since Daughter 'G' lived out of state she should contact her sister, (Daughter 'H') in Michigan to file a report in reference to the above Report. The officer stated that they could not move forward without proof of any funds. Resident was referred to Social Services for evaluation and follow up. On Thursday, October 29, 2020 R#704's Daughter 'G' alleged that R#704's bank card had been used this week. Daughter 'G' contacted the Police Department 'M' (Officer 'P') to do a wellness check. The Police came out and spoke with R#704 and the Daughter 'H' in the parking lot. The Police department was not able to substantiate the allegations. They stated that they would look into the allegations. The Executive Director, DON Family Members, and Physician were notified. When I (Executive Director) interviewed R#704 he stated that the bank card had not been out of his possession since the first allegation was made (October 1st, 2020). On October 29, 2020, the Daughter 'H' came to the facility and was given the bank card to keep in her possession. (Named Redacted) R#704 stated that he has never given his Bank Card to anyone but CENA (Name Redacted) CNA 'I' and (Named Redacted) Housekeeper 'Q'. . (Name redacted) CNA 'I' stated that on one occasion she gave the card to (Name Redacted) Housekeeper 'K' because she didn't have time to go get food for R#704. That R#704 agreed that Laundry/Housekeeper 'K' could go pick up the food. That this was the only time she gave the card to Laundry/Housekeeper 'K'. Housekeeper 'Q' stated that she was asked by R#704 on a couple of occasions in August 2020 to go pick up his breakfast for him. Each time she brought him a receipt for the purchase. Near the end of August R#704 approached her (Housekeeper 'Q') and asked again if she could pick up a breakfast and she told him that she didn't feel comfortable and wasn't able to go out for him anymore. (Name Redacted) R#704 has not asked her to go out since August . I (Executive Director) interviewed another CENA (Name Redacted) CNA 'R' who stated that he had gone to get food for R#704 about March 2020. That he purchased a Corn Beef sandwich and a Juice for him .That this was the only time he purchased food for R#704. That R#704 gave him the card and he returned it when he returned. That no self-purchases were made on the card. I (Executive Director) interviewed (Name Redacted) CNA 'J' who stated that he had never purchased any food or any other items for R#704 nor did he ever use his bank card. No other staff reported using R#704's bank card or any knowledge of the allegations. I (Executive Director) contacted Laundry/Housekeeper 'K' who stated that she had used the card as referenced above on one occasion. That it was about 4 to 5 months ago. That CNA 'I' had given her the card to purchase lunch for R#704. That Laundry/Housekeeper 'K' stated she had no knowledge of any other unauthorized purchases related to the bank card. I (Executive Director) interviewed (Name Redacted) CNA 'L' (Via Telephone) who has not worked for the company since July 22, 2020. CNA 'L' stated that she was the person responsible for using R#704's bank card information. That she has never possessed the physical card. That she found the information written on a piece of paper that she found in the elevator. That CNA 'L' relocated to Tennessee in July and started to use the bank card information. That she made several online purchases some delivered to her mother's address (Laundry/Housekeeper 'K'). CNA 'L' stated that she accepts full responsibility of the transactions and that her mom didn't have any knowledge of the card usage. That CNA 'L' stated that she never used the card while in Michigan. That she last used the banking information in September 2020. That no staff person ever gave her the bank card. When I (Executive Director) asked Daughter 'G' about providing detailed statements to verify specific transactions allegedly made by staff and CNA 'L; she stated that the (Named Redacted) County Police Department 'S' was doing their investigation . On 12/16/20 at 10:32 a.m., during a telephone interview, Daughter 'G' stated, My sister, R#704's (Daughter 'H') had the debit card. When she got ill, she gave him (R#704) the card back in March. My dad (R#704) gave the card to CNA 'I' to go get some food . Complainant/Daughter 'G' further reported there were receipts with CNA 'I', Laundry/Housekeeper 'K', and CNA 'L' personal information on the receipts . On 12/16/20 at approximately 2:00 p.m., personnel records for CNA 'I', Laundry/Housekeeper 'K' and CNA 'L' were requested for review and revealed the following: CNA 'I' - Date: 10/2/2020 EMPLOYEE CORRECTIVE ACTION. Final Written Warning with Suspension and Probation 90 Days (5 Day suspension) . Supervisor: (Name Redacted) DON. Describe situation and/or concerns: Group 2 Rule 29. Employee exhibited unacceptable conduct by accepting gifts or gratuities from residents, their relatives, or vendors. Employee accepted gratuities of lunch and gas on several occasions from resident without speaking with your supervisor and the Executive Director for approval and guidance . CNA 'I' - Date: 11/19/2020 EMPLOYEE CORRECTIVE ACTION. Termination. Supervisor: (Name Redacted) DON. Describe situation and/or concerns: (Named Redacted) CNA 'I' violated the Corporate Compliance Code of Conduct by misappropriation of a resident's property. Laundry/Housekeeper 'K' - Date: 11/19/20 EMPLOYEE CORRECTIVE ACTION. Termination. Supervisor: (Name Redacted) DON. Describe situation and/or concerns: (Named Redacted) Laundry/Housekeeper 'K' was found to be in violation of the Corporate Compliance Code of conduct. Employment Action .: Due to the severity of these violations, the employment status of (Named Redacted) Laundry/Housekeeper 'K' with (Name of Facility) is termination, effective 11/19/2020. CNA 'L' - Date: 7/9/20 Letter of Resignation . Submitting two weeks resignation . Last day will be Wednesday, July 22, 2020 . During the telephone interview with Daughter 'G', she explained that an investigation was being conducted by Detective 'U' of Police Department 'M', On 12/16/20 at 3:53 p.m., A telephone call was placed to Detective 'U' and a message was left on the voicemail. On 12/16/20 at 4:10 p.m., during an interview with the DON, when asked if staff were permitted to use a residents' debit card to make purchases for them, the DON stated, No. If he (R#704) asked CNA 'I' to go and get food, she should have told the nurse, unit manager, DON, or Executive Director. The DON further explained the resident (R#704) stated, 'I sent her (CNA 'I') to go get my food, but not do what she did with my card .' The DON said, The Daughter 'G' reported to me as she received information. She gave me Laundry/Housekeeper 'K's name, address, and phone number from the Apple charges. The DON further stated, They were passing his (R#704's) card around and did not report that he (R#704) was asking them to purchase or pick-up his food. The DON explained that after she had spoken to CNA 'I' and Laundry/Housekeeper 'K' regarding termination, Laundry/Housekeeper 'K' called back and stated, CNA 'L' admitted to using R#704's card information. The DON further stated, He (R#704) never lost possession the card. The DON provided and explained, in the facility's Employee Handbook - EPIC dated November 2018, it documented as follows: .4.8 Gifts & Gratuities . You are not permitted to borrow money or personal item(s) from any resident, family member of a resident, vendor, or outside provider. If you are offered gifts or gratuities, please politely decline the offer and notify your supervisor or Executive Director . On 12/16/20 at 4:46 p.m., an interview was conducted with the Executive Director (Administrator) regarding the use of R#704's debit card. The Administrator explained that CNA 'L' call him and admitted to everything . The Administrator further stated, CNA 'L' renewed her CNA Certification in Tennessee (where she moved) with R#704's debit card information in the amount of $20.00. The Administrator reported CNA 'I' should have never used R#704's card/information, and he asked CNA 'I' if she thought it was appropriate to use a client's card or information, and CNA 'I' stated, 'They (R#704) offered it to me.' A review of the facility's policy titled ABUSE, NEGLECT AND/OR MISAPPROPRIATION OF RESIDENT FUNDS OR PROPERTY revised on 12/10/18, the following was documented: . a) DEFINITIONS . v) Misappropriation means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belonging or money . PROTECTION & IDENTIFICATION . ii) (Name Redacted) Corporation Name - will take all action necessary to prevent the abuse, neglect, or misappropriation of the resident's funds or property from occurring while it is conducting its investigation of the incident, and will also take appropriate action to attempt to prevent similar incidents in the future.

This citation pertains to MI 0: Based on observation, interview, and record review the facility failed to ensure resident transfer status was communicated and performed per resident assessed need and failed to thoroughly investigate the root cause of a resident's tibia/fibula fracture for two (R#503, R#505) of two residents reviewed for accidents, resulting in R#503 being found with left fractures of the tibia and fibula, complaints of pain, transfer to the hospital, and the potential for injury for R#505. Findings include: R#503: A complaint was received by the State Agency which alleged the complainant had been contacted by a physician at the facility, who indicated R#503 had complained of pain in the foot and/or leg. The physician stated they were sending R#503 for x-rays, and the complainant had received a call from the hospital who stated R#503 had a broken/fractured leg and the resident was in a cast from the knee down. Per the complaint, R#503 had not walked or stood for a minimum of five years, and it was not understood how the resident had sustained the injury when they had been bedridden for years. Review of an incident/accident (I/A) report authored by the facility's Director of Nursing (DON) dated 10/2/20 at 9:58AM documented, Resident alert and verbally responsive sitting up in bed. Resident denies pain and discomfort at this time. Writer assessed resident left foot in (Brand Name) boots and wrapped in gauze. Writer lifted resident left foot and leg; resident grimace and reach out toward leg. Resident skin intact with raised area to inner leg near ankle. Writer ask resident if her leg was hurting. Resident stated when you touch it. Writer ask on scale 0/10 how bad did her leg hurt resident stated not that bad. Writer asked resident did she know what happen to her leg resident stated I hit it on the stick pointing to the wheelchair when I got in the bed. Writer asked resident did anyone help you, Resident stated no I did it by myself. Per the I/A, location of injury was documented as Left ankle (inner), level of pain was 2, related to the resident displaying facial grimacing. Review of a transfer form for R#503 dated 10/2/20 for the purpose of discharge to the hospital documented reason for transfer as follows: possible <sic> fraction of LLL (Left Lower Leg). Review of referral information from (Name Redacted) hospital documented, in part, an admission date of [DATE]. Review of documentation for an ER arrival date of 10/2/20 documented, in part, Chief Complaint left closed distal oblique comminuted fractures of the tibia and fibula History of Present Illness (Age redacted) year old (Gender redacted) presents to the (City Redacted) ED (emergency department) with left closed distal oblique comminuted fractures of the tibia and fibula .She does not remember the incident; does not remember if she hit her head; does not remember possible LOC (loss of consciousness) .On evaluation patient left lower leg with palpable deformity, fracture. Patient in severe pain upon palpation with moderate [MEDICAL CONDITION]. Patient was transported from nursing home . Per the Diagnostic Results section of the information it was documented, in part, XR Tibia/Fibula Left IMPRESSION: 1. Oblique [MEDICAL CONDITION] shaft of tibia and comminuted [MEDICAL CONDITION] shaft of the fibula with one shaft width lateral displacement of each .Electronically signed 10/02/2020 . Review of the clinical record for R#503 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of R#503's quarterly minimum data set (MDS) assessment dated [DATE] the resident scored three out of fifteen on a brief interview for mental status exam, which indicated R#503 was severely cognitively impaired. Also, per this assessment it was documented R#503 required extensive assistance of one person for bed mobility and transfers. Review of guardianship papers dated 9/10/18 by the judge active through 11/5/20 revealed R#503, documented on the form as a legally incapacitated individual, had been appointed a full guardian. Review of progress notes for R#503 revealed, in part, the following: -9/30/20 at 9:46AM: .Wound/skin Rounds .seeing pt (patient) for her left heel wound .Currently comfortable in bed. Very combative with care . -9/30/20 at 12:12PM: Received resident in bed awake alert and verbally responsive, bilateral (brand name) boots in use, resident up and dressed with 2PA (person assist) .no c/o (complaints of) pain nor discomfort at this time . -10/1/20 at 3:53AM: .no c/o discomfort will continue with POC (plan of care) . -10/1/20 at 11:41AM: Received resident in bed awake alert and verbally responsive, and very noisy, bilateral (Brand Name) boots in use, resident up and dressed with 2PA .no c/o pain nor discomfort at this time . -10/2/20 at 7:44AM (authored by wound care nurse- Licensed Practical Nurse (LPN) 'B'): .Wound care: resident in bed resting, awake, alert and verbally responsive and confused. denied pain in this time .during wound care writer observed L (left)-lower leg flapping and called Floor nurse and told to do stat x-ray and inform (Dr Name Redacted) also, unit manager informed . -10/2/20 at 7:52AM: Resident received in the bed on my shift show no sign of discomfort or pain. Resident slept good all night without no problem. Wound care nurse alerted writer during rounds about resident change in condition, wound care nurse observed resident left lower extremity with the appearance of disfiguration .resident c/o pain during shift change . -10/2/20 at 4:22PM: .I talked to the ER (emergency room ) nurse and the patient is being admitted to the hospital. Both bones in the LLE (left lower extremity) are broken. On 10/27/20 at approximately 8:35AM Occupational Therapist (OT) 'D' was requested to provide R#503's discharge paperwork from physical therapy. Review of R#503's Physical Therapy (PT) PT Discharge Summary dated 7/13/20 documented dates of service for R#503 as 6/16/20 to 7/13/20. Review of a short term goal for R#503 discontinued on 7/13/20 documented, Patient will improve ability to safely transfer from lying on the back to sitting on the side of the bed, feet flat on the floor with Substantial/ Maximal Assistance in order to decrease the risk of skin breakdown and participate in edge of bed activities. It was documented that R#503 was dependent for lying to sitting on the side of the bed at baseline (6/16/20) and remained dependent at time of discharge (7/13/20). It was documented per the comments: able to <sic> terat <sic>siting for more than <sic> 10minsonce assisted to situp. Per the Assessment and Summary of Skilled Services section of the form it documented, in part, .Progress & Response to Tx (treatment): participated, but difficulty following the commands. Review of Discharge Recommendations documented, .hoyer for transfers. Review of a care guide for R#503 (print date 10/27/20) documented, Transfers 2 Person Assist. Review of a plan of care for R#503 initiated 3/10/20 and revised 4/8/20 documented, I have a potential/actual ADL (activities of daily living) deficit R/T (related to): Cognitive impairment, Mobility deficit, refuses/resists care. Per an intervention dated 3/10/20 it was documented, Transfers 2 Persons Assist. Review of TRANSFER: SUPPORT PROVIDED task documentation R#503 for 9/28/20 through 10/2/20 revealed the following: -9/28/20: Options were selected for ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time and Resident not available. -9/29/20: Options were selected for ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time and Resident not available. -9/30/20: Options were selected for ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time and Resident not available. -10/1/20: No documentation present. -10/2/20: Option selected for two plus persons On 10/27/20 at approximately 8:35AM Occupational Therapist (OT) 'D' was queried in regard to R#503, and explained, in part, that R#503 could not follow one step directions. OT 'D' was queried if the resident was able to get themselves out of bed, responded no, and said if they could the resident would probably end up on the floor. On 10/27/20 at 9:42AM the facility's Director of Nursing (DON) was queried in regard to the above incident and explained the following: On that morning she had arrived and the facility's wound care nurse (LPN 'B') and (Nurse name) had said to come down to the room. Per the DON, LPN 'B' had done a dressing and had seen an abnormality on R#503's foot. Per the DON, when she got down there (Nurse name) asked if she saw her (the resident's) foot, and the DON acknowledged she did. The DON explained the first time she went to move R#503's left foot it was ok, the DON spoke with R#503, and the resident denied pain. When the DON went to touch the resident's heel and lifted the back part of R#503's calf, the DON observed grimacing in the resident's eyes and the resident reached out. The DON asked the resident if it hurt, and the resident responded only when you touch it. The DON explained she felt a lump on the resident's left inner ankle area, the DON palpated the area. The DON asked R#503 about it, and R#503 said she had hit it on a stick and pointed to the wheelchair. The DON asked R#503 when the event happened, and the resident responded it occurred when the resident was getting into bed. The DON asked R#503 if they had help getting into bed, and R#503 explained they did not, and they had gotten into the bed themselves. The DON explained R#503 had requested for them (the DON) to leave. The DON was queried as to whether R#503 walked and responded the resident did not. When queried as to whether R#503 was able to stand and pivot alone, the DON said it was never stated the resident could stand/pivot alone, and staff had never observed this. The DON was queried as to how R#503 transferred, and explained the resident was a two-person transfer (with no lift). The DON explained she had gone to talk to (Nurse name) and told her to call the doctor, let them know about the resident's pain, and see if he was ok with getting an x-ray. Per the DON the doctor ordered the resident sent out to rule out fracture. The DON was queried as to whether the R#503's account of the event could be viewed as reliable, and the DON responded, Not really. Per the DON R#503 would answer and talk appropriately and would change subjects. The DON explained the resident held the conversation appropriately that moment and would split and talk about something else. The DON explained according to R#503's BIMS she couldn't say that she could account for that statement, and that was what prompted the DON to interview staff members. The DON was queried as to when the resident's injury occurred, and explained she believed it occurred 10/1/20 related to complaint and location of pain. The DON was queried in regard to transfer status and explained when a resident first admitted therapy would input put the transfer status. Per the DON if transfer status changed then the nurse could make the change, as long as it was to an increased, and not decreased, status (more assistance required). The DON acknowledged R#503 was a two person assist for transfers. When queried as to the process if physical therapy increased the level of assistance required, the DON explained it would be changed in the care plan. The DON was queried as to whether they had reviewed the resident's physical therapy information as part of the investigation and explained they had not. The DON was notified of R#503's physical therapy discharge recommendation for use of a hoyer lift for transfers, and the DON acknowledged she was not notified of the recommendation for use of a hoyer lift for R#503. The DON also explained that only therapy would be able to decrease the level of assistance for transfers for a resident. A file of the incident was reviewed with the DON, and information from Physical Therapy was not observed to be present. Staff statements provided in the file documented the following: Date 10/2/20: To whom it may <sic> Cencern I (Name Redacted) and another employee got (R#503 name) up yesterday and she didn't <sic> complain of any pain. Date 10/2/20: Came in before my shift started. sometime before 11pm. Started rounds w/ (with) the CNA from the previous shift. We put the resident in bed <sic> a long with changing resident. Resident never complained of pain. I came back to change resident around 2-3. Resident still didn't complain of any pain or discomfort. The statement was not noted to clarify which date the employee had worked with the resident. Date 10/2/20: I started ADL (activities of daily living) care on resident (Room and bed number redacted) around 3:45/4:00 on 9/30/20 while she was sitting in her wheel chair she seem to be okay through out the day but kept complaining about her left leg. I Ask for <sic> assiant from the nurse when we transfer her to the bed he performed range of motion on her Left Leg and suggested to give her some <sic> medcine for her pain. I returned for my next shift on 10/1/20 and notice the bandage on her Left Leg. Checked on her through out the day and feeding! me and the relief Cena <sic> transferred her to the bed. around 11:00pm The resident rubbed her Leg and then Started to go to Sleep. Date 10/2/20: On 9/27/20 afternoon shift, writer received report from cna that (R#503) complain of pain after being transfer, upon assessment pain noted in left knee. No <sic> or swelling at that time. PRN (as needed) (Brand Name narcotic pain medication) given Resident <sic> rassesed after 1hr (hour) no sign of discomfort or pain at this time. On 9/30/20 Resident didn't complain of pain or no report .that she in pain 10/2/20 midnight shift (11-7) writer received the resident (R#503 name) on shift without no sign of pain or discomfort. wound nurse alerted writer during rounds in the morning about resident change in condition, wound care nurse observed resident left lower extremity with appearance of disfiguration. (Dr Name Redacted) informed New order for stat x-ray, Resident c/o (complain of) pain during shift change on coming shift nurse gave pain medication per order . Date 10/2/20: DON statement: Writer in to visit resident to conduct interview. Resident alert and verbally responsive sitting up in bed. Resident denies pain and discomfort at this time. Writer interviewed resident regarding resident change in conditions to left ankle. Writer assessed resident left foot in (Brand Name) boots and wrapped in gauze. Writer lifted resident left foot and leg.; resident grimace and reach out toward leg. Writer ask resident if her leg was hurting. Resident stated when you touch it. Writer asked resident did she know what happen to her leg resident stated I hit it on the stick pointing to the wheelchair. Writer asked resident when did she hit it resident stated when I got in the bed. Writer asked resident how did you get in bed did you have help. Resident stated she got in bed by herself. Writer asked resident did anyone help you. Resident stated no I did it by myself. Writer asked resident did she notify or let anyone know she hit her leg on the stick (pointing to the wheelchair). Resident stated no just you. Writer asked resident was there a reason you did not let anyone know about hitting her leg. Resident stated no I just did not say anything now go you go out of here. Writer explained to resident her concern for her leg and being safe. Resident stated it is all right now go on. Writer informed Charge Nurse to call physician and request stat X-ray to left leg and ankle. Charge Nurse notified physician and received order to send to hospital to r/o (rule out) fracture .Resident is a two-person assist . On 10/27/20 at 11:14AM wound care nurse LPN 'B' was queried regarding the situation and explained, in part, that R#503 complained of pain in their leg. Per LPN 'B' he had looked at the resident, and the resident complained of pain. LPN 'B' explained he could see a gap and the resident's leg was flapping somewhere above the ankle. Per LPN 'B' he had asked the nurses if they were aware of this and they responded they were not. LPN 'B' explained that if you did not touch the area or move the resident you would not be aware of what was going on. LPN 'B' stated you would tell there was a gap there, and the area was discovered on assessment. On 10/27/20 at 1:30PM the facility's Administrator was queried in regard to the incident and explained they had not been at the facility the day of the incident and were not involved with the situation. R#505: On 10/27/20 at 8:57AM R#505 was observed in their room sitting in their wheelchair. The clinical record for R#505 was reviewed and revealed the resident was admitted to the facility 3/8/18 with [DIAGNOSES REDACTED]. Per review of R#505's annual MDS assessment dated [DATE] the resident scored 3 out of 15 on a BIMS assessment, which indicated R#505 was severely cognitively impaired. Per this assessment R#505 required the extensive assistance of one person for transfers. Review of an incident/accident report for R#505 dated 9/3/20 documented, CNA (Certified Nursing Assistant) summoned writer to the room, CNA stated that she was attempting to transfer resident from the wheelchair to the commode and resident began to urinate and slip down to the floor. CNA stated that she lowered resident to the floor, and nothing was injured on the resident . Per the Immediate Action Taken section of the form it was documented, in part, .Care plan updated for two person assist for transfers, bed mobility and toileting . Review of a FALLS ASSESSMENT for the resident also dated 9/3/20 documented, in part, .IDT (interdisciplinary team) Team met to review this fall. RCA (root cause analysis): Patient was a one person assist for transfers and now requires a two person assist to safely transfer. Intervention: Careplan updated to Two <sic> Peerson assist for transfers as needed . Review of transferring documentation for the last thirty days per the tasks section of the clinical record for R#505 revealed transfer support provided as One person physical assist on the following dates and times: -9/28/20: 6:25AM, 2:40PM, 10:26PM -9/29/20: 2:15PM, 5:10PM -9/30/20: 11:17AM, 11:02PM -10/4/20: 2:29PM -10/5/20: 9:50AM -10/6/20: 11:21AM -10/7/20: 10:40AM -10/8/20: 3:53AM, 9:52AM, 10:58PM -10/9/20: 10:45AM -10/10/20: 3:07PM -10/11/20: 3:08AM, 2:20PM -10/12/20: 12:00PM -10/13/20: 3:31AM, 3:00PM, 10:19PM -10/15/20: 3:00PM, 5:22PM -10/17/20: 2:52AM -10/19/20: 5:40AM -10/20/20: 1:49PM -10/21/20: 1:56AM, 10:41AM, 11:25PM -10/22/20: 1:46AM, 10:57AM, 7:57PM -10/23/20: 7:24AM, 11:35AM -10/25/20: 11:42AM -10/26/20: 1:38AM, 2:21PM It was noted R#505 had one instance of two plus person physical assist for support provided for transferring during the thirty day lookback period. On 10/27/20 at 1:25PM the DON was queried in regard to transfer status for R#505 and acknowledged all transfers for the resident should be completed with two persons. The DON stated she would need to do a full inservice. Review of a facility policy titled, TRANSFER TECHNIQUES dated 7/1/08 revealed, in part, the following: PURPOSE: To transfer a resident from bed to chair, toilet or tub safely. EQUIPMENT .2. Mechanical lift, if necessary . Review of a facility policy titled, Unusual Occurrences dated 2/3/14 and revised 5/10/19 documented, in part, PURPOSE: The center staff shall conduct a professional review of unusual occurrences/incidents for the purpose of reduction of risk of morbidity and mortality and the improvement of resident care. PROCEDURES: The center shall investigate each incident involving a resident to ensure safety issues are addressed and to reduce the risk of reoccurrence .

This citation pertains to MI 931: Based on observation, interview, and record review the facility failed to ensure prompt identification and treatment of [REDACTED].#502, R#505) of three residents reviewed for assessment and monitoring of skin, resulting in R#502's wound which was debrided on 12/11/19 being next addressed on the resident's date of discharge (4/22/20) when the wound was necrotic and draining, and R#505 having no physician ordered treatment for [REDACTED]. R#502: Review of a complaint received by the State Agency alleged concerns with care to R#502's feet. The complaint alleged the resident had calluses removed from the resident's feet and was hospitalized because of infection in the feet, and alleged the physician had said this was due to the resident's feet not having been properly cared for. Review of a podiatry consult for R#502 with an exam 12/11/20 revealed, in part, the following: .SKIN LEFT: Abnormal-dry skin, large callus medial 1st mpj (Metatarsal Phalangeal Joint) left foot . Per the care plan section of the form it was documented, .ADDITIONAL NOTES: the callus on the left 1st mpj was debrided (removal of devitalized/necrotic tissue and foreign matter from wound) and a full thickness skin defect was noted, approx 2 cc (cubic centimeters) purulent (containing pus) drainage was expressed, the lesion was approx 1 cm (centimeter) across, 5-6 mm (millimeter) deep, the periphery contained white and green [MEDICATION NAME] debris, no signs [MEDICAL CONDITION], a portion of debris was debrided sharply, the attending nurse was notified and she observed the wound, she stated she would refer to the wound care dr (doctor) who was present in the building. Review of the clinical record for R#502 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of R#502's quarterly minimum data set (MDS) assessment dated [DATE] the resident scored 7 out of 15 on a brief interview for mental status (BIMS) exam, which indicated the resident was severely cognitively impaired. Review of progress notes for R#502 for 12/10/19 through 12/24/20 revealed no mention of R#502's callous having been debrided by podiatry, or any follow up or treatment to address the site. R#502 had no progress notes observed in the clinical record for the date of 12/11/19. Review of a (Computer system) Skin & Wound-Total Body Skin Assessment form dated 12/17/19 at 12:07PM documented R#502 had zero new wounds. Per a note dated 12/17/19 at 12:08PM it was documented, .Resident received bed bath, no new skin issues noted. Review of Treatment Administration Records (TARs) for R#502 for December 2019, January 2020, February 2020, and March 2020 did not reveal any treatment present on the TAR to address R#502's debrided callus. Review of a physician's note dated 4/22/20 at 10:47AM documented, in part, .Wound rounds .Ulcerated callus on the left foot bunion currently with necrotic slough (non-viable yellow, tan, gray, green or brown tissue) and serosanguineous (blood and fluid) drainage. Likely vascular insufficiency. Will start Rx with (Brand Name Ointment for Debridement) on a 4 x 4 daily and cover with bordered gauze dressing . Review of R#502's Medication Administration Record [REDACTED].Apply to Left foot bunion topically one time a day for Vascular Ulcer. Per an additional physician order with a start date of 4/23/20 it was documented, Cleanse ulcerated callus on the left foot bunion with (Brand Name Wound Cleanser) and pat dry. Apply (Brand Name Ointment for Debridement) on a 4 x 4 and cover with bordered gauze daily. It was noted R#502 discharged from the facility 4/22/20, prior to the start date of these orders. On 10/26/20 at 2:38PM the facility's wound care nurse, Licensed Practical Nurse (LPN) 'B' was queried in regard to what wound sites he followed for R#502. The areas of skin impairment mentioned by LPN 'B' were noted to not include the callus on R#502's foot which had been debrided. The information in the resident's record was reviewed with LPN 'B'. LPN 'B' explained the nurse would have had to enter a note as to what they had observed. On 10/26/20 at 4:48PM the facility's Director of Nursing (DON) explained they would look for information from the previous DON (who was DON at the time of this incident) regarding the situation. On 10/26/20 at 7:50AM the DON explained the podiatrist said information had been reported to the charge nurse, the nurse said that they did not remember the information having been communicated to them in regards to the resident's callous, and per the DON wound care was saying they had not known about it. No additional information was provided by the end of the survey to address the concern. R#505: On 10/27/20 at 8:57AM R#505 was observed in their room sitting in their wheelchair. The resident was observed to be dressed in a hospital gown, and an undated white dressing was present to the right forearm above R#505's right wrist. The dressing was observed to have some yellow stains on it, and an area was visible through the dressing which appeared to be blood on the inside of the dressing. R#505 was queried as to the area on their skin and replied it was like that when they woke up. The clinical record for R#505 was reviewed and revealed the resident was admitted to the facility 3/8/18 with [DIAGNOSES REDACTED]. Per review of R#505's annual MDS assessment dated [DATE] the resident scored 3 out of 15 on a BIMS assessment, which indicated R#505 was severely cognitively impaired. On 10/27/20 at 11:01AM physician orders were reviewed for R#505 and did not reveal a treatment order for the resident's right arm above the wrist. Review of a progress note for R#505 dated 10/24/20 at 11:27PM documented, Skin tear on right arm, abrasion with a few drops of blood noted and area clean and dry dressing applied. On 10/27/20 at 11:20AM wound care nurse LPN 'B' was queried in regard to the area observed on the resident's skin and explained they had just called the doctor and were waiting on an order. On 10/27/20 at 12:13PM the DON explained they had called the nurse who had put in the note above to complete documentation and explained that verbal education had been provided. Review of a facility policy titled, WOUND MANAGEMENT PROGRAM dated 7/1/08 and revised 8/17/17 revealed, in part, PURPOSE: To eliminate, modify or minimize factors that place residents at risk for skin breakdown. POLICY: To assure that residents who are admitted with, or acquire, wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing.

Based on observation, interview, and record review the facility failed to ensure facility staff consistently respond to a resident's distressed behavior for one (R#30) of two residents reviewed for mood and behavior, resulting in the resident crying out and yelling for a prolonged period of time, and exhibited feelings of frustration. Findings include: On 3/10/20 at 9:33 AM R#30 was observed in a specialized wheelchair with adaptive head rest and built up arms in the television area on the second floor. The resident was observed to be yelling and crying out, and four other residents and a staff member were observed to be in the television room as well. A staff member was observed to be passing by the television area towards the secured unit at the facility, and R#30 was observed to be yelling out in a louder tone. The staff member who was passing by approached the resident, and asked R#30 they were ok. Unit Manager (UM) 'H' passed by the television area, and was not observed to interact with R#30. R#30 was observed to be crying out and yelling. On 3/10/20 at 9:36 AM, a staff member came into the television room and interacted with another resident in the area. The staff member gave the other resident breakfast, and was speaking with the other resident about which breakfast foods the resident would like. On 3/10/20 at 9:37 AM, R#30 was observed to be crying out and yelling. On 3/10/20 at 9:38 AM, R#30 was observed to be crying out and yelling and staff were not observed to be in the television room or interacting with the resident. A staff member who had assisted another resident in the room with breakfast returned to deliver breakfast items to the other resident, and told the other resident (not R#30) they would be back to check on them. This staff member was not observed to interact with R#30. Then Licensed Practical Nurse (LPN) 'D' approached R#30 and attempted to administer medications and a supplement to R#30. R#30 was not receptive to taking their medications and the nurse was observed to leave. R#30 was observed to continue to cry and yell. On 3/10/20 at 9:41 AM, the staff member who had brought another resident their breakfast approached the other resident (not R#30) with cereal, and then left the area, not interacting with R#30. At 9:43 AM, R#30 was observed to be yelling out in a loud tone. A staff member was heard to say, She'll calm down in a little while. R#30 continued to yell out, and the staff member asked the resident why they did not want to eat. The breakfast tray was set by the resident. 03/10/20 at 9:44 AM, Certified Nursing Assistant (CNA) 'E' said, She's in a bad mood today Ms. (Staff member name) she in a little bad mood today, she'll be singing in a couple hours . CNA 'E' was then observed to say to R#30, You're going to hurt your throat. The resident was observed to be yelling. On 3/10/20 at 9:46 AM, CNA 'E' was observed to walk out with the resident's tray, and the resident continue to yell out from their specialized wheelchair. On 3/10/20 at 9:53 AM, R#30 was observed in the second floor television area yelling out. LPN 'D' approached R#30 and was observed to tell R#30, If I can't talk to you I can't help you, what do you want? LPN 'D' was observed to say the resident wanted to be back in bed. At 9:55 AM, R#30 was observed to continue to yell and scream. At 9:57 AM, CNA 'E' and another staff member were observed in the television area, and both staff members were observed to leave out of the room. R#30 remained in the television area and was yelling out. At 9:58 AM, Unit Manager (UM) 'H' entered the television area, looked into the television area while the resident was yelling, and walked back towards the nursing station. On 3/10/20 at approximately 9:59 AM, CNA 'E' approached R#30 and said, Do you want to go back to your room for awhile? (LPN 'D') going to give you your medicine. R#30 was observed to be taken out of the activity room at that time. The clinical record for R#30 was reviewed and revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's quarterly minimum data set (MDS) assessment dated [DATE], R#30 had moderately impaired cognition, and it was documented the resident had no hallucinations, no delusions, no physical behavioral symptoms, no verbal behavioral symptoms, and no other behavioral symptoms. Review of a plan of care for R#30 dated 2/5/20 documented the following: I may present with verbal outbursts at times not directed towards others. I am noted with speaking out loud in my room, seemingly having a conversation with myself. I do not engage often with others during interactions unless I choose to. I can verbalize however at times it is unrelated to subject matter. I can be resistant to care at times. I have dx (diagnosis) of Mild Intellectual Disability, MDD (major [MEDICAL CONDITION]), and GAD (generalized anxiety disorder) which contributes to my behavioral s/s (signs/symptoms). At times I will refuse to eat my meals if I do not like what is offered even with multiple choices/options provided as I do not understand the consequences of refusing nutrition and hydration. Interventions per the plan of care included, in part, the following: -Observe for Combative/Verbal/Rejection of Care/Other. Report and document observations, -Provide diversional activities of choice, -Approach resident in a calm and friendly manner, inform resident of care tasks prior to starting are and speak with resident throughout care task to promote compliance, -Do not confront, or argue: respond calmly and set boundaries. Re-approach as needed. On 3/11/20 at approximately 1:45 PM, the facility's Director of Nursing (DON) was queried in regard to the observation of R#30 yelling out. The DON explained the resident should be assessed to see the underlying factor and to determine what kind of interventions could take place (examples: pain, anxiety). The DON explained that a behavior note would be completed so that it could be discussed the next morning in morning report, and could be reviewed by the interdisciplinary team (IDT). Review of a nurses note dated 3/10/20 at 11:41 (AM) documented, in part, Received in bed awake and alert Treatment done by Wound Nurse. The resident became restless after treatment was done. Had initially refused all medication including her scheduled pain medication, however, after several attempts,the resident took all of her meds. Assisted OOB (out of bed) into w/c (wheelchair) by two persons. Pillows used for positioning. The resident has a poor tolerance for sitting up in her w/c. Yelling and crying. Asking to be put back in bed less than 20 minutes after the CNA assisted her up in her w/c. Calmed down and sat up in w/c without further complaints after her meds were given . On 3/11/20 at 4:25PM Social Work Director (SWD) 'B' was queried in regards to R#30. SWD 'B' explained that the resident talked out loud to herself when in her room, and explained the resident would come out at times. SWD 'B' explained the resident sometimes had outbursts, and per SWD 'B' the resident liked to be alone or in their room. SWD 'B' explained the resident's family would come to visit the resident and would take the resident out of the facility. Per SWD 'B' the resident had intellectual disability. The interactions documented above were shared with SWD 'B', and SWD 'B' explained the resident could be approached to see if the resident was in pain, the resident could be provided privacy to go back to their room, and it could be ruled out if the resident was having pain or had been incontinent. SWD 'B' explained that she was going to add an intervention to the resident's plan of care. Review of a facility policy titled, ASSESSMENT AND INTERVENTION FOR MOOD AND BEHAVIOR SYMPTOMS dated 2/24/09 documented, in part, the following: III. MONITORING BEHAVIOR SYMPTOMS A. Document symptom. Use concrete description including an action verb instead of a label for behavioral symptom .B. Record occurrence on shift when it happened. C. Document individual interventions as identified on care plan and as care givers try, EXAMPLES: 'Toileted', 'Hot chocolate/cookie', 'Distracted with family album' D. Record effectiveness of interventions. E. Review monitoring and document patterns and effectiveness of interventions F. Discuss monitoring information with resident, family and care givers to determine effectiveness of care plan. G. Include discussion in IDT meeting to determine appropriateness of current care plan, document progress toward goals, and make changes to treatment plan as appropriate. H. Define and set treatment goals resulting from discussions with the resident and Interdisciplinary team to maintain the highest practicable quality of life.

This citation pertains to intake MI 6 Based on interview, and record review, the facility failed to ensure freedom from abuse for one resident (R#70) of 12 residents reviewed for abuse, resulting in R#70 being physically abused by a staff member. Findings include: On 3/11/20 at 8:45 AM, the facility's Administrator was requested to provide all investigative material and documents for the Facility Reported Incident that was reported to the State Agency on 2/21/20 regarding R#70. At approximately 10:45 AM, the facility's Administrator provided a folder and confirmed all documentation regarding the investigation was contained in the folder. On 3/11/20 at 11:00 AM, a review of the investigation file provided by the facility's Administrator was reviewed. The file was noted to contain 6 individual documents: 1. R#70's face sheet, 2. A typed 24 hour summary report, 3. A typed, unsigned, undated statement from Certified Nursing Assistant (CNA) 'K', the alleged perpetrator, 4. A typed, unsigned, undated statement from the facility's Administrator, 5. A document regarding information for victims of domestic violence with the reporting police officer's name and incident number, and 6. A typed document titled 5 Day Investigative Findings. Review of the documents revealed: The 24 hour summary report read, .On February 21, 2020 at approximately 12:00PM, a staff member alleged that she saw another staff member hit resident (R#70) in the forehead while providing him care. The nurse manager immediately reported the allegation to the Executive Director (Administrator) and Director of Nursing . CNA 'K's statement read, I went to get the resident up for breakfast and he said no. He cursed at me. He hit me several times while trying to get him up that morning. At some point he punched me in the face. I grabbed both his hands and held him down. I told the resident that 'men don't hit woman <sic>'. After the incident I continued providing care and making up his bed . The facility Administrator's statement read, On February 21, 2020, I was in the room when the resident was interviewed by the (City Name) Police Department .When I interviewed (R#70) in my office he stated that he was hit by a woman but was not able to identify the staff person. I also had the (City Name) Police Department talk to (R#70), (CNA 'K') and (CNA 'M') who were present in the room at the time of incident. The Police stated that because the resident was hitting the CENA (CNA) and the CENA reacted .that he would not be able to substantiate an abuse allegation . The 5 Day Investigative Findings Document read, On February 21, 2020 at approximately 12:00PM, a staff member alleged that she saw another staff member hit resident (R#70) in the forehead while providing him care. The nurse manager immediately reported the allegation to the Executive Director and Director of Nursing .Upon further investigation, it was reported that the resident was combative at the time that AM (morning) care was being rendered. The CNA that witnessed the incident (CNA 'M') and the alleged perpetrator (CNA 'K') both stated that the resident was striking and hitting the alleged perpetrator during care. Both CNAs stated the alleged perpetrator was struck in the face by the resident during care. The alleged perpetrator stated that at no time, did she strike the resident back. The alleged perpetrator did state that when she was hit in the face, her initial reaction was to close her eyes and put her hands out in front of her to stop any further blows from the resident. She did not, however, report that she made contact with the resident's face in an attempt to physically redirect the resident .In conclusion, the resident had no injury or harm resulting from the incident. The alleged perpetrator stated that she does not recall making contact with the resident's face but does state that her eyes were closed due to her being struck in the cheek by the resident .The alleged perpetrator, if contact was made, had no intent to harm the resident, but rather was physically redirecting the resident to protect herself from another strike .Education has been provided to staff to re-approach the resident if he becomes combative with care in the future . It was noted the Administrator/Abuse Coordinator's 5 day summary did not address the CNA's statement that read, . I grabbed both his hands and held him down. I told the resident that 'men don't hit woman <sic>' . On 3/11/20 at 4:10 PM, a telephone interview with CNA 'M' was conducted. During the interview, CNA 'M' was asked to recall the events surrounding the allegation of abuse she reported to the Unit Manager (Unit Manager 'I'). CNA 'M' explained that she was in orientation and she was working with CNA 'K'. She continued to explain that she and CNA 'K' were in R#70's room to assist him with morning care. CNA 'M' said that R#70 became combative during care and had hit CNA 'K' several times. CNA 'M' indicated that she told CNA 'K' they should leave, but CNA 'K' refused. CNA 'M' said R#70 kept saying Stop but CNA 'K' didn't. CNA 'M' stated, She kept grabbing him and telling him he had to get up, and that he was going to get up no matter what. CNA 'M' said R#70 then threatened to hit CNA 'K' and told her he was going to throw her into the wall. CNA 'M' continued to explain that R#70 did hit CNA 'M' again, and CNA 'M' stated, After he hit her that time, she hit him back straight in the middle of his forehead. CNA 'M' was asked who they reported the incident to and indicated they reported it to Unit Manager/Licensed Practical Nurse 'I'. CNA 'M' was then asked if they were interviewed or prepared any type of statement regarding the incident and indicated she signed and dated a statement regarding what she had witnessed. A review of CNA 'K's personnel file was conducted on 3/11/20 at approximately 3:30 PM. The file contained a document titled, EMPLOYEE CORRECTIVE ACTION that indicated CNA 'K' had been terminated from employment. The EMPLOYEE CORRECTIVE ACTION form read, .Describe situation and/or concerns: .CNA reported to ED (Executive Director) and DON (Director of Nursing) that on 2/20/2020 while providing care, resident was noted to be combative. CNA reported that the Kardex (care guide) says to reapproach <sic> for cares when combative but the CNA, by her own admission, did not follow this procedure leading to possible psychosocial harm by <sic>the resident during cares. CNA reported that she told the new CNA that she was going to provide care to the resident despite the combative behavior . A review of R#70's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. R#70's most recent Minimum Data Set assessment dated [DATE] indicated R#70 had moderate cognitive impairment, did not exhibit any physical, verbal, or rejection of care behaviors, was non-ambulatory, and required extensive assistance of one to two staff members for activities of daily living. On 3/11/20 at 4:20 PM, an interview with the facility's Administrator, DON, and Unit Manager 'I' was conducted regarding the allegation from CNA 'M' that CNA 'K' had hit R#70 in the head. It was explained that the police were called, responded, and since they couldn't substantiate abuse, the facility did not substantiate abuse. When asked about CNA 'K's statement that she had, held him down , and told R#70, .men don't hit woman <sic> . and whether those could be considered abusive behaviors, no response was provided. During the interview, Unit Manager 'I' was queried about the incident. Unit Manager 'I' explained that CNA 'M' reported to her that she saw CNA 'K' hit R#70, and she (CNA 'M') heard CNA 'K' tell CNA 'L' that after he hit her, she hit him back. At that time, the Administrator was asked how CNA 'L' was involved in the incident and if it had been overheard that CNA 'K' told CNA 'L' she hit the resident, why wasn't there an interview or statement from CNA 'L'. The Administrator had no response to the questions. A review of a facility provided policy titled, ABUSE, NEGLECT, AND/OR MISAPPROPRIATION OF RESIDENT FUNDS OR PROPERTY with a revision date of 12/10/18 was conducted and read, .PURPOSE: To assure each resident in the center is free from abuse, neglect and exploitation . The facility was asked if they had any additional information to provide regarding the concern; none was provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to perform accurate and timely skin assessments (including wound measurements), ensure timely interventions to reduce the risk of pressure ulcer development, and ensure ordered interventions were being implemented for one residents, (R#'s 106 ) of five residents reviewed for pressure ulcers, resulting in the development of a stage three pressure ulcer (full thickness loss of the skin and may extend into the subcutaneous tissue layer, there may be undermining and/or tunneling that makes the wound much larger than it may seem on the surface) and the potential for the additional development and or worsening of pressure ulcers. Findings include: Resident #106 On 3/9/20 at approximately 10:00 AM, R#106 was observed in their bed. R#106 was observed to have a [MEDICAL CONDITION] and tube feeding being delivered through a pump for nutrition. Attempts at verbal communication with R#106 were not successful. A review of R#106's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. It was noted R#106 did not have a [DIAGNOSES REDACTED]. A review of R#106's Nursing admission assessment was conducted and SECTION C. Skin Integrity did not indicate R#106 admitted to the facility with any wounds. R#106's Braden Score (a score calculated to determine risk for pressure ulcer development) upon admission was 11, and indicted R#106 was at a high risk for pressure ulcer development. A review of R#106's admission orders [REDACTED]. Continued review of R#106's record was conducted and a Skin & Wound Evaluation dated 2/17/20 (6 days after admission) indicated R#106 had a stage three pressure ulcer to their coccyx that was Present On Admission and measured 11.7 cm (centimeters) by 7.2 cm. The sections for Depth of wound, Undermining or Tunneling were noted to have Not Applicable documented. Continued review of Skin & Wound Evaluation forms revealed the following: 2/26/20 A stage three pressure ulcer on the coccyx that measured 10.4 cm x 3.9 cm. Not Applicable was noted to be documented in the sections for depth, undermining, or tunneling. 3/3/20 A stage three pressure ulcer on the coccyx that measured 1.8 cm x 1.0 cm. Not Applicable was noted to be documented in the sections for depth, undermining, or tunneling. A review of R#106's care plans was conducted and the first care plans and interventions to address skin integrity or pressure ulcers for R#106 were also noted to have begun on 2/17/20, upon first evidence of R#106's stage three pressure ulcer. On 3/10/20 at 11:30 AM, a wound care observation for R#106 was conducted with Licensed Practical Nurse (LPN) 'G' (facility wound care nurse) and Wound Care Nurse Practitioner (NP) 'J'. The wound was observed to be approximately 4-5 cm in length, 3-4 cm in width with with a pink base, scant drainage, and small areas of necrotic tissue and fragile skin surrounding the wound. At that time, staff were not observed to measure the wound. Upon completion of the wound care, an interview was conducted with NP 'J' and LPN 'G'. They were asked about their procedure for measuring wounds and LPN 'G' indicated they used a camera to photograph the wound and the camera calculated the size. When queried about the measurement changes and if they compared them from week to week, especially the change from 2/26/20 (10.4 cm x 3.9 cm) to 3/3/20 (1.8 cm x 1.0 cm) NP 'J' explained that because the facility staff don't do manual measurements, there would be discrepancies. Continued interview with LPN 'G' was conducted and LPN 'G' was asked about the order on 2/13/20 for the cream to the skin tear. LPN 'G' stated, She must have had something there if the (brand name cream) was ordered. LPN 'G' was then asked how he determined the wound was present upon admission based on his assessment on 2/17/20 when the admission skin assessment did not address any skin concerns and the first documentation of the wound occurred on 2/17/20, 6 days after admission to the facility. LPN 'G' had no explanation. On 3/11/20 at approximately 2:00 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding R#106's stage three pressure ulcer. The DON was asked how it was determined that R#106 admitted with the wound. The DON did not offer any explanation and indicated it was a concern that the identification came six days after admission. A review of a facility provided policy titled, WOUND MANAGEMENT PROGRAM revised 8/17/17 was conducted and read, .POLICY: To assure that residents who are admitted with, or acquire, wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing .PROCESS (PREVENTION): .2. Complete Skin Assessment as a portion of the admission assessment. 3. Place initial interventions for residents at risk for development of skin breakdown in Care Plan . The facility was asked if they had any additional information to provide regarding the concern; none was provided by the end of the survey.

Based on interview and record review the facility failed to follow a resident's plan of care based on the resident's assessed needs for transfer status for one (#602) of four residents reviewed for accidents from a total sample of four, resulting the resident sustaining a preventable femur fracture, decreased range of motion, complaints of pain, a decline in mobility and appetite, and an emergency transfer to the hospital. Findings include: On 8/22/17 at approximately 12:30pm the clinical record for Resident #602 was reviewed and revealed the resident had been admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's annual minimum data set (MDS) assessment dated [DATE], the resident scored 7 out of 15 on a brief interview for mental status (BIMs) exam, which indicated that the resident was severely cognitively impaired. Per review of this MDS assessment, Resident #602 required the extensive assistance of two persons for transfers, and had no impairment in the resident's range of motion for the upper or lower extremities, and required the extensive assistance of one person for bed mobility. On 8/22/17 at 1:06pm review of a facility reported incident investigation (FRI) for Resident #602 signed by the facility Administrator on 8/8/17 was reviewed and revealed, in part, the following: On Thursday, August 3, 2017 (about 7:20pm), (staff member name) was made aware of residents' refusal to get out of bed due to pain and discomfort. When (staff member name) interviewed (Resident #602) about her pain, (Resident #602) stated: I don't know, he just dropped me on the floor I guess when he tried to put me in the bed from my chair. (Resident #602) stated the alleged incident occurred two nights ago . Further review of the investigation revealed that per review of staff assignment sheets for the prior two days (completed by the facility), it was determined that the only one male CNA that had been assigned to care for Resident #602 during the time period had been identified as CNA 'E'. Continued review of the FRI investigation revealed the following: Per a typed, unsigned statement by CNA 'E' dated 8/7/17, the following was documented: On Tuesday, August 1, 2017, I was assigned to provide care to (Resident #602) on (unit identifier). I did not drop the resident during transfer. I used a sit-to stand (lift) each time I transferred the resident. Review of a signed statement by the facility's Director of Nursing (DON) dated 8/4/17 revealed the following: Resident (#602) reported that her legs were hurting because he dropped me a couple of nights ago The physician was called, an assessment was completed. X-rays were done and completed in the facility. When results were faxed over to the facility the resident was then transferred to the hospital .When I called and interviewed the CENA (identifier of CNA 'E', CENA 'E') stated that he had no knowledge of (Resident #602) falling, or any injury or incident while taking care of her. Review of a Radiology Results Report with an examination date of 8/4/17 at 1:10am revealed, in part, the following: Femur 1 View, Left: Results: Oblique fracture of the mid to distal femoral shaft with slight lateral apex angulation. Conclusion: Acute femoral shaft fracture. Also per this report was the following: Knee ap (anterior-posterior) or lat (lateral) 1-2V (1-2 view), Left: Results: No acute fracture or dislocation. The osseous (related to bone) structures appear intact. Joint space narrowing. Soft tissues are unremarkable. No significant joint effusion. Conclusion: No acute osseous abnormality. Moderate degenerative changes. Incidental healing fractures of the proximal tibial shaft and fibula head noted but incompletely visualized. On 8/22/17 at 1:31pm the facility's Director of Nursing (DON) was queried in regards to the facility's investigation for Resident #602. The DON stated that Resident #602 was to be transferred using a hoyer lift since May of 2017. Per the DON, CNA 'E' was identified as the only male who worked night shift on the unit where the resident resided. The DON stated that CNA 'E' was to receive inservice education before returning to work on the floor. The DON further explained that CNA 'E' had transferred Resident #602 alone and with a different lift (then per the resident's plan of care). On 8/22/17 at approximately 2:42pm a review of the activities of daily living (ADL) careplan for Resident #602 revealed, in part, the following: ADL's/Diabetes: I have generalized weakness r/t (related to) CHF (congestive heart failure), Diabetes, HTN (hypertension), hx (history) of PVD (peripheral vascular disease) and DVT (deep vein thrombosis); has confusion r/t Dementia and I require staff assistance with my ADL's . Per a careplan intervention dated 6/17/15 with a revision date of 5/10/17, it was noted, Transfers 2 PA (person assist) hoyer lift machine. At this time, a copy of Resident #602's kardex (care guide) was requested from the facility's Director of Nursing (DON). Continued review of the resident's clinical record and kardex on 8/22/17 documented the following: Per the Transfer section of the resident's kardex, it was documented, Transfers 2 PA (person assist) hoyer lift machine. On 8/22/17 at 2:44pm review of an Employee Action Improvement Process (EAIP) form for CNA 'E' signed by the facility's DON on 8/11/17 was reviewed and documented the following: Describe Situation or Concerns: (CNA 'E') transferred a resident using a sit to stand lift, which requires 2 person assistance, alone. The resident is coded to be transferred using a hoyer lift with 2 person assistance. Employees are to look at the kardex in (computer system) to obtain the transfer status before transferring the resident. All lifts/ Hoyers require 2 person assistance. Per the Describe Desired/Expected Behavior section of the EAIP report, the following was documented: Nursing staff are to transfer residents according to their kardex and plan of care. Staff is expected to follow policy of having the proper number of staff present when transferring residents. On 8/22/17 at 3:01pm CNA 'E' was queried via telephone in regards to how the staff member transferred Resident #602. CNA 'E' stated that he transferred Resident #602 via a sit-to-stand lift. When queried as to how many people were present when such a type of lift was used, CNA 'E' responded that if staff got busy, he would transfer the resident alone. Continued review of the clinical record for Resident #602 on 8/22/17 reviewed the following: Per an eMar-Medication Administration Note dated 8/3/17 at 5:22am the following was documented: Acetaminophen Tablet 500mg Give 1 tablet by mouth as needed for Pain 3 times a day complain of pain in legs 8 out of 10. Per an incident/accident report dated 8/3/17 at 7:20pm, the following was documented: Per the Incident Description, Writer was made aware by assigned day shift cena of resident refusal to get out of bed d/t (due to) pain/discomfort. Writer noted swelling of left knee with tenderness to touch. Resident interviewed, resident stated: I don't know. Per the Immediate Action Taken section of the report it had been documented, Resident assessed-left knee swelling with tenderness to touch. no redness or bruising noted. ROM (range of motion) performed of all four extremities-bilat (bilateral) upper extremities-tolerated well, abduction (movement away from body midline) and adduction (movement towards body midline) tolerated of right lower extremity, pain rated at 8/10 stated upon abduction of left lower extremity (physician name) made aware of unusual occurrence. Vitals obtained states radiating pain in left leg-(physician name) gave order for one time only dose of (brand name ibuprofen) 400 mg (milligrams) to be administered and monitor with re-assessment of pain . Also per this I/A report it was documented that no injuries were observed, the resident was alert, and the resident was ambulatory without assistance after the incident. Per a nurse's note dated 8/3/17 at 7:46pm the following was documented: .Writer received resident at 730p (7:30pm). Writer noted residents lt (left) leg with abduction, warm to touch, edematous and painful to touch. Resident moans and facial grimacing upon palpitation. States pain is 10/10 when moved. Scheduled (brand name ibuprofen) given. Dr. paged to stronger pain med. Awaiting return call. Leg stabilized with pillow. Per communication log xray scheduled. To con't (continue) to monitor with safety and comfort maintained. Per an eMar-Medication Administration Note dated 8/4/17 at 1:20am, the following was documented: Acetaminophen Tablet 500mg Give 1 tablet by mouth as needed for Pain 3 times a day pain 9 out of 10 in legs. Per a nurses note dated 8/4/17 at 4:51am the following was documented: When arriving on shift resident resting in bed x-ray arrived around 1245am states report will be sent soon patient complaining of pain in L. leg 9 out of 10 (brand name acetaminophen) administered x-ray confirmed patient has a L. femoral shaft fracture On 8/22/17 at 4:23pm review of a Change in Condition Evaluation dated 8/4/17 at 2:05am was reviewed and revealed, in part, the following: Per the evaluation, a box was checked that indicated trauma (fall related or other), and documented that this started on 8/2/17. Per an additional information section of the form, it was noted that the resident had a positive x-ray and a femoral shaft fracture. Also documented was the following: Guarding lt. (left) leg. c/o (complains of) increased pain. No mobility. Also noted per the evaluation was that the resident had a pain level of 10, was crying, moaning, and experienced decreased appetite. Factors which made the pain worse were noted as mobility and touching. Per the nurse's assessment of the situation, the following was documented: in pain with facial grimaces and moans. On 8/22/17 at 5:00pm a review of a facility policy titled ADL Documentation dated October 2005 and revised on September 2016 was reviewed and revealed, in part, the following: .1. RAI (resident assessment instrument) Coordinator, Clinical Care Coordinator, or designee shall initiate ADL instructions in Point of Care under the Kardex to staff to reference each resident's care needs and care plan.

This citation refers to intake number MI 099. Based on interview and record review, the facility failed to ensure laboratory tests to recheck blood coagulation were performed according to physician's orders [REDACTED].#804) of three residents reviewed for assessment and monitoring, from a total sample of four, resulting in [MEDICAL CONDITION] and required emergency hospitalization . Findings include: On 8/8/17 at 2:02 P.M., Resident #804's clinical record was reviewed and revealed the following: Resident #804 was admitted into the facility on [DATE], readmitted on [DATE], and discharged from the facility on 7/23/17 with [DIAGNOSES REDACTED]. A Minumum Data Set (MDS) assessment dated [DATE] documented Resident #804 had severely impaired cognition and required total physical assistance from one to two staff members for bed mobility, transfers, and all activities of daily living. physician's orders [REDACTED]. [MEDICATION NAME] sodium (an anticoagulant medication) 2 milligrams (mg) via PEG (percutaneous endoscopic gastrostomy - a tube surgically placed into a persons stomach to deliver nutrition) daily. 7/18/17 - Repeat PT/INR ([MEDICATION NAME] time/internation normalized ratio - laboratory tests to monitor the effectiveness of anticoagulant medication for individuals at risk for blood clots) on Thursday (7/20/17). 7/23/17 - (Vitamin K) 5 mg via PEG STAT (immediately) for bleeding from vagina. Hold (anticoagulant medication). Repeat PT/INR on Monday (7/24/17). 7/23/17 - Hold (anticoagulant) until further notice, repeat PR/INR on Monday. Give STAT dose of Vitamin K. 7/23/17 - PT/INR STAT blood in stools. 7/23/17 - Transfer to ER for GI bleed. The Medication Administration Record [REDACTED]. On 7/17/17, there was no nurse's signature on the MAR indicated [REDACTED]. There was no flow sheet for July 2017. Progress notes for July 2017 were reviewed and did not document any PT/INR results for 7/17/17. A note written by Nurse F on 7/17/17 documented, .one time PT/INR .done by ccc (clinical care coordinator - manager) . On 8/8/17 at 2:30 P.M., Nurse F was interviewed regarding the process for monitoring PT/INR for residents on anticoagulants. Nurse F reported that the Licensed Practical Nurses (LPN) don't do the PT/INR tests and that they are completed by the managers. The PT/INR flow sheet for July 2017 was requested at that time. Further review for Resident #804's clinical record was conducted on 8/8/17 at 2:45 P.M. and revealed the following progress notes: On 7/22/17 at 2:57 P.M. it was documented that CNA (certified nursing assistant) reported to writer that resident had clots (blood) in her brief when he changed her .The clots were in the area of the vagina .(Physician C) notified .(anticoagulant medication) to be D/Ced (discontinued). Repeat PT/INR on Monday (7/24/17). Another progress note from 7/22/17 documented, Give Vitamin K 5 mg per MD order. On 7/23/17 at 10:14 A.M., it was documented Per the CNA resident has blood in her stools. Writer assessed stools. Observed stools to be burgandy in color. Call placed to doctor, left message. Awaiting call back. 7/23/17 at 12:35 P.M. it was documented that the doctor had not called back. On 7/23/17 at 3:30 P.M. it was documented that Resident #804 was transferred to the hospital. A progress note on 7/23/17 at 3:41 P.M. documented, PT - 96, INR = 8.0, had another small BM (bowel movement) with blood in it .able to reach (Physician C). Wants the resident send out to (hospital) for GI bleed . On 8/8/17 at 3:00 P.M., Unit Manager, Nurse D provided the PT/INR flow sheet for Resident #804 from July 2017. The flow sheet revealed the following: On 7/17/17, Nurse E documented Resident #804's INR was 7.4 (target INR was between 2 and 3). It was documented that the physician was notified and ordered to hold (until) 07/19. The section for Next Lab Date was left blank (physician's orders [REDACTED]. On 8/8/17 at 3:33 P.M., the afternoon nurse supervisor, Nurse E was interviewed regarding the PT/INR flow sheet for Resident #804 that documented an INR of 7.4 on 7/17/17. Nurse E was queried about the facility protocol for monitoring residents on anticoagulant medication. Nurse E stated, We check INRs weekly. Results are called into the doctor and documented in progress notes. When queried about Resident #804's INR on 7/17/17 and what was done, Nurse E stated, It (INR) was elevated. The doctor said to hold (anticoagulant) for three days due to the INR. Nurse E indicated there would be a physician's orders [REDACTED]. On 8/8/17 at 3:45 P.M., the Director of Nursing (DON) was interviewed. The DON was asked to explain the protocol for monitoring residents on anticoagulant medications. The DON reported that any abnormal INRs would be reported to the physician, an order written [REDACTED]. When queried about Resident #804 and the elevated INR (7.4) documented on 7/17/17 and how it was determined to restart anticoagulant medications on 7/20/17, the DON stated, It was put on the MAR indicated [REDACTED]. The DON was asked if Resident #804's PT/INR was rechecked on 7/20/17 according to the documented physician's orders [REDACTED]. The DON was asked if there was a physician's orders [REDACTED]. The MAR indicated [REDACTED]. When queried about what the risks were of restarting an anticoagulant medication if the PT/INR was above the target range, the DON did not offer a response. On 8/8/17 at 4:00 P.M., the DON provided hospital records for Resident #804. The hospital records were reviewed at that time and revealed the following: An Emergency Department (ED) Note dated 7/21/17 documented, .presents (to) the ED today from (facility name) due to elevated INR and rectal and vaginal bleeding. Per EMS patient had bloody stools yesterday as well as vaginal bleeding, she had an elevated INR of 8, she was given 1 dose of vitamin K per family member. Patient was here in April 2017 with an elevated INR and GI bleed as well. Progress notes at that time had recommended discontinuing (anticoagulant) however patient's daughter states she was on the phone with someone from the nursing home who states her (anticoagulant) was started when she got back to the nursing home. It was just discontinued yesterday .Patient presents with daughter via EMS due to elevated INR yesterday of 8 with bloody stool .I did perform a rectal exam which does show guaiac positive stool it is not grossly bloody .Patients basic labs show .hemoglobin 9.4, INR is elevated at 13.5, PT 160 .Pt was given vitamin K as well as fresh frozen plasma (blood transfusion) .Final impression: GI bleed, supratherapeutic INR .Final disposition: admission to inpatient . On 8/8/17 at 4:21 P.M., Resident #804's care plans were reviewed and revealed a care plan initiated on 10/21/13 and revised on 10/5/16 that documented, I am on anticoagulant therapy r/t (related to) [MEDICAL CONDITION] Fibrillation. Interventions were documented as follows: On 10/21/13 (revised 4/14/17), Labs as ordered. Report abnormal lab results to the MD and Monitor/document/report to MD PRN (as needed) s/sx (signs and symptoms) of anticoagulant complications. On 8/8/17 at 5:58 P.M., Physician C was interviewed via the telephone. Physician C was asked how it was determined if a resident was restarted on an anticoagulant after having an elevated INR. Physician C reported that it would be determined on a case by case basis and based on the laboratory values. Physician C was asked if he was contacted by the facility with a rechecked INR value on 7/20/17 or if an order was given to restart the anticoagulant medication at the same 2 mg dose. Physician C reported that he did not remember. When queried about the risks of administering anticoagnulant medication to a resident when the INR is elevated, Physician C stated, Bleeding. A policy regarding monitoring of PT/INR monitoring for residents on anticoagulants was requested from the DON. A policy was not received prior to completion of the survey.

Based on observation, interview and record review the facility failed to add assistive devices including anti tippers and lap belt to a resident's wheelchair to prevent the resident from falling for one Resident (#903) out of three residents reviewed for accidents out of a total sample of 3 residents, resulting in the resident falling from wheel chair and sustaining fracture of the neck, laceration of the scalp and laceration of the eyebrow that required emergency hospitalization . Findings include: On 9/8/2016 at 2:55 PM, Resident #903 was observed in bed and appeared asleep but opened his eyes when called by name. When queried, Resident #903 had garbled speech and was difficult to understand. A review of the clinical record on 9/8/2016 at 3:15 PM, was conducted and revealed that Resident #903 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #903 was readmitted into the facility on [DATE] after hospitalization on [DATE] due to a fall from the wheelchair, with additional [DIAGNOSES REDACTED]. The most recent significant change MDS (minimum data set) dated 9/7/2016, indicated that the resident had a BIM (brief interview for mental status) score of 7 and was moderately cognitively impaired. Per the MDS, Resident #903 was totally dependent on staff and required two person assistance for activities of daily living. On 9/8/2016 at 3: 25 PM, a review of the Incident Report that had been dated (8/11/2016), timed (18:45 PM) and prepared by Nurse 'B' was conducted. Nurse 'B' documented: Observed resident on floor in front of nurses station face down, upon turning resident over noted blood coming from right side of head. Pressure dressing applied, noted deep wound above right eye brow approximately 2 inches. Vital signs BP 157/99, 97.7 -67- 18, oxygen saturation on room air 96% BS=175. Alert and responding to questions. Complaining of headache. Resident stated when asked what happened I was leaning over. An interview was conducted with the Director of Nursing (DON) and Administrator on 9/8/16 at 5:00 PM. The DON and Administrator were queried regarding Resident #903's fall and the type of wheelchair that was being used when the Resident fell on [DATE]. The DON explained that Resident #903 had been evaluated for a new specialty wheelchair on 8/2/2016 by therapy and received the new specialty wheel chair on 8/11/2016. The DON stated: He received the chair from a Physical Therapist (PT) that works contingent on the afternoon shift. The DON indicated that the wheel chair was supposed to have had anti-tippers and anti-roll backs device applied by the facility's maintenance but this had not been done. The DON stated: The contingent Physical Therapist came in and identified a safe tilt and space wheelchair. She (referring to contingent PT) gave the resident the new chair without the anti- roll back device. He (referring to Resident #903) leaned forward and due to his weight, he ended up falling. The Administrator further indicated that there had not been any communication between the rehabilitation department, therapy department and the nursing department that the maintenance department needed to add the anti-roll back device to the wheelchair. On 9/8/2016 at 5:10 PM, DON and Administrator were asked to provide the policy and procedure regarding Assistive Devices and this information was not received by the end of abbreviated survey. A review of the Occupational Therapy Treatment Encounter Note(s) date of Service 8/2/2016 was conducted on 9/8/2016 at 5:12 PM. The Occupational Therapy Treatment Encounter Note(s) documented: Seating specialist consulted with OT (Occupational Therapy) for patient's w/c (wheel chair), recommended anti-thrust cushion and adjust the anti- rollback, Maintenance Assistant 'D' notified. Further review of the Occupational Therapy Treatment Encounter Note(s) date of Service 8/10/2016 documented: Identified a safe tilting angle for pt in his current w/c and marked for CGs to identify the angle for positioning pt when he is transported and sitting up in his w/c. As pt is at risk for falls without the tilt back feature. An interview with the Maintenance Assistant 'D' was conducted on 9/12/2016 at 11:30 AM. The Maintenance Assistant indicated that Resident # 903's new wheel chair was called a Tilt and Space. The Maintenance Assistant indicated that an order had been received for anti-roll back and anti- tippers for Resident #903's new wheel chair and stated: There were none available or we (referring to the facility) do not stock that type of device. The Maintenance Assistant indicated that Resident #903 was put in the new wheel chair without anti-roll back or anti- tippers. ( )

This citation refers to Intake Number (s) M#I 755 Based on observation, interview and record review, the Facility failed to ensure resident care was provided in a safe manner for one (#701) of three residents reviewed for falls/injuries of unknown origin, from a total sample of three, resulting in Resident #701 falling out of bed and sustaining a large hematoma on the forehead, bruising around the right eye and swelling on the face. Findings include: An incident was reported to the State Agency by the complainant on 8/29/16 that documented Resident #701 had bruising and swelling to both eyes and a two large knots on her forehead. On 8/31/16 at 2:46 p.m., a phone interview was conducted with the complainant. The complainant reported that the Resident was unable to turn or move without assistance and could not understand how she obtained the injury. She further stated that the Facility had no documentation as to when the Resident was injured or as to the cause of the injury when notified. On 8/31/16 at 4:00 p.m., Resident #701 was observed lying in bed. The Resident had bruising around both the right and left eyes and a large hematoma (approximately the size of a golf ball) on the forehead. Her cheeks on both sides appeared swollen. When asked how she sustained her injury, Resident #701 made a grunting noise. When asked if her head hurt, the Resident made a grunting sound. On 9/1/16 at 9:00 a.m , Resident #701's clinical record was reviewed and revealed the following: Resident #701 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 7/18/16 documented that Resident #701 had severely impaired cognition and required total physical dependence on two staff members for assistance with transfers (via Hoyer lift) and bed mobility. Resident #801's Nurse notes were reviewed and documented the following: 8/30/16: 9:58 a.m. called to room by CENA (certified nurse aide) observed Resident with bruises on forehead and around right eye. Swelling noted in some areas. All responsible parties made aware of bruising and swelling. On 8/31/16 at 4:20 p.m., the Administrator was asked to provided documentation pertaining to the Resident's injury. The Administrator stated, We are in the process of investigating. We reported the incident to the State and local authorities. I will give you the information I have. I did some interviews with the CNA's and nurses who worked on 8/29/16 and 8/30/16 and nobody seems to have an answer. We did interview the Resident's roommate who stated, she heard a fall and they got her up off the floor fast. We suspended CNA A and CNA B pending the investigation because they worked with the Resident. A hand written interview statement by CNA B (undated) written by the Administrator was provided and revealed the following, When asked he did his last change on her between 4:00 and 5:00 a.m Nothing unusual, no fall. Didn't have to pick her up off the floor. On 9/1/16 at 8:45 p.m., an interview was conducted with the Administrator regarding the incident. The Administrator stated, I got a call from CNA B he wants to come in and talk to me. I told him to come in tomorrow. On 9/1/16 at 9:17 a.m. a phone interview was conducted with CNA B regarding Resident #701's injury. When queried as to how the injury occurred, CNA B stated, I worked on the Sunday night midnight shift (8/29/16). I was assigned to Resident #701. I went into the room around 5:45 a.m. to provide care and change her brief. When I opened her brief, I noticed that she had made a bowel movement. I rolled her on her side and realized that I did not have the proper towels to clean her up. I left her on her side and ran into the bathroom so that I could wet a washcloth so that I could clean her. I heard a noise and when I left the bathroom, I saw that she was on the floor. I saw CNA C who was in the hall and asked her to come and help me lift the Resident into bed. CNA C was able to help me get her into bed. We lifted her under her arms and legs. I told Nurse D what happened and she said no no don't tell me that. I believe she did assess the Resident after that. When further queried as to whether Resident #701 should have been left on her side alone while providing care, CNA B stated, No, I should not have left her alone. On 9/1/16 at 12:23 p.m., a phone interview was conducted with CNA C regarding the incident pertaining to Resident #701. CNA C stated, I worked on Sunday - midnight shift. I heard CNA B yelling from the Resident's room that he needed help putting the Resident in bed. I am on light duty so I could only lift her legs, but we were able to put her in bed. CNA B told me that Resident rolled out of bed and we told Nurse D. On 9/1/16 at 12:30 p.m., an interview was conducted with the Director of Nursing (DON) regarding the incident and the conversations with CNA B and CNA C. The DON was queried as to the Facility's policy pertaining to ADL (activities of daily living) care and reporting falls. The DON stated, She should not have been left alone by CNA B. I can't believe that Nurse D new about the incident and did not report it. It does not seem like something she would do. I don't even think she was assigned to the Resident that evening. I will have to continue investigating. On 9/1/16 at 1:24 p.m., a phone interview was conducted with Nurse D regarding the incident and injury sustained by Resident #701. Nurse D stated, I worked on Sunday night- the midnight shift (8/29/16). CNA B and C did tell me that the Resident fell . I didn't see her on the floor. She was already in bed and seemed ok. I took her vitals. I did not work the next day and did not report it to anyone. I should have, but again she seemed fine. It has been bothering me the past few days that I did not say anything. On 9/1/16 at 12:40 p.m., the Facility Policy titled FALL REDUCTION PROGRAM (revised 10/29/14) was reviewed and documented, in part, the following: PURPOSE: To provide a safe environment for residents, modify risk factors and reduce risk of fall related injury. PROCEDURE: 3. If fall occurs, follow steps 3.1 to 3.4.7 3.1 Complete the following (charge nurse): · Physical assessment of resident · Immediate interventions as identified by physical assessment · Incident/Unusual Occurrence Form - · Pain Assessment · Neurological Assessment Flow Sheet 3.4.4.: Complete/review fall Assessment ( )

Based on observation, interview, and record review, the facility failed to provide range of motion services to restore a prior level of function for one (#504) of six sampled residents reviewed for range of motion, from a total sample of 24, resulting in the development of an avoidable contracture. Findings include: On 1/7/14 at 10:30 a.m., Resident #504 was observed lying in bed, with a splint on her right elbow. A clinical record review was conducted on 1/8/14 at 3:00 p.m. Review of an "Occupational Therapy Evaluation and Plan of Treatment" for Resident #504, dated 12/18/13, noted: Reason for Referral: Pt (patient) referred to OT (Occupational Therapy) for decrease in level of function and possible right elbow contracture. RUE (right upper extremity) ROM (Range of Motion): Impaired Recommendation: Recommend right shoulder splint to increase elbow extension and prevent further contracture. On 1/10/14 at 10:00 a.m., Occupational Therapist (OT) "F" confirmed that the splint worn by Resident #504 on 1/7/14 was the splint recommended in the Plan of Treatment dated 12/18/13. Further record review on 1/8/14 at 3:00 p.m. revealed that Resident #504 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set, dated dated [DATE], Resident #504 had severely impaired cognition, and had no impairment in range of motion (ROM) to the upper extremities. According to an Initial Occupational Therapy Assessment for Resident #504, with an onset date of 7/29/12, the section for "Underlying Impairments" noted that Resident #504 had ROM deficits at bilateral shoulders and right hand/fingers, but did not note any impairment in the resident's right elbow. Review of a Radiology Report for Resident #504, dated 1/28/13, noted that the resident had sustained a "moderately displaced acute [MEDICAL CONDITION] humeral diaphysis" (the upper arm near the shoulder) of the right arm. On 2/19/13, a "Restorative Referral" was made for Resident #504, requesting "passive ROM (PROM) to the left upper extremity (LUE)" only. Review of the restorative notes for Resident #504 revealed that the resident received ROM to the LUE only, in March 2013, and April 2013. During an interview on 1/10/14 at 10:00 a.m., Occupational Therapist (OT) "F" confirmed that restorative therapy had been provided to Resident #504's left side only, due to the fractured humerus on the resident's right arm. A physician's orders [REDACTED]." An Orthopedic Physician's consultation report for Resident #504, dated 7/18/13, noted: "Healed fracture right humerus. No brace needed." There was no evidence that after this consultation report dated 7/18/13 that the facility assessed Resident #504's right upper extremity and provided services to restore her prior function. Further review of the restorative notes for Resident #504 revealed that the resident had received passive ROM to the LUE only, in August 2013, and September 2013. During an interview on 1/10/14 at 9:30 a.m., certified nurse assistant (CNA) "A" confirmed that up until recently, Resident #504 had worn a sling on her right arm at all times, and that ROM had been provided to Resident #504's left arm only. On 9/13/13, a "Nursing Maintenance Referral Form" was completed for Resident #504, which noted: "ROM passive". The referral did not specify what area of the body or which side of the body to provide the passive ROM. Review of the "Resident Care Guide" for Resident #504, revised 10/25/13, noted: "Restorative Interventions/Programs: PROM to LUE's". The Care Guide did not address any restorative services for Resident #504's right upper extremity. An ADL (activities of daily living)/Self Care/Mobility care plan for Resident #504, reviewed 11/26/13, noted: "Do PROM while providing my ADL care." On 1/10/14 at 9:30 a.m., when CNA "A" was queried regarding the specific ROM exercises to provide to a resident, CNA "A" stated that she would refer to the "Resident Care Guide" for specific instructions. The Care Guide for Resident #504 was reviewed with CNA "A". CNA "A" stated that because the care guide only specified ROM to the LUE, she would "not touch the right side." Review of a 10/25/13 physician's orders [REDACTED]." On 1/10/14 at 9:45 a.m., Nurse "B" stated that he had noticed in December 2013 that the Resident (#504) had decreased ROM to the right arm. Nurse "B" stated that he had updated Resident #504's Care Guide to reflect button up shirts only, because Resident #504 was having difficulty straightening her right arm. On 12/18/13, a physician's orders [REDACTED]." A 12/23/13 "Occupational Therapy Treatment Note" for Resident #504 noted: "Bilateral Upper Extremity PROM with end range stretch all planes-no active ROM noted-right elbow with a flexion contracture at 45 degrees." This note indicated that Resident #504 was unable to straighten her arm. On 1/10/14 at 10:00 a.m., Occupational Therapist (OT) "F" was queried regarding the newly acquired right elbow contracture for Resident #504. OT "F" stated that on her initial evaluation on 12/18/13, Resident #504 had limited ROM to the right elbow, and that the elbow was contracted at 90 degrees. OT "F" further stated that with treatment, Resident #504 currently had a 45 degree flexion contracture to the right elbow. OT "F" stated that even though Resident #504 had been wearing a right shoulder sling from 6/2013 to 10/2013, nursing staff "should have been ranging her right hand and elbow." OT "F" further stated, "We (therapy) should have been notified when the sling was discontinued in October (2013), so that we (therapy) could have picked her up." During an interview on 1/10/13 at 11:45 a.m., the Director of Nursing (DON) was queried regarding the lack of ROM services for Resident #504's right elbow, and the subsequent development of a flexion contracture to the right elbow. The DON stated, "We would rely on therapy to let us know what type of ROM we (staff) can do on the resident." No further explanation was provided. Review of the facility's policy, "Range of Motion", dated July 1, 2008, noted: "Establish range of motion plan individualized for the resident." ( )

This citation pertains to intake #'s MI 506 Based on interview and record review the facility failed to: 1) assess, monitor, and document skin condition change in one (#501) of three sampled residents reviewed for impaired skin integrity, from a total sample of 7 residents and 2) provide immediate medical evaluation and treatment for [REDACTED]. Findings include: On [DATE] at 5:20 p.m., review of clinical records for Resident #501 revealed that Resident #501 was a [AGE] year old male who was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) Assessment, Resident #505 required extensive assistance from staff for activities of daily living including bed mobility, transfers and wound care. The MDS assessment did not indicate that Resident #501 had any current or previous pressure ulcers. Further review of the clinical record revealed an initial skin assessment dated [DATE] which did not indicate any open areas on the resident's skin. The skin assessment also did not indicate that Resident #501 had a prior history of pressure ulcers. According to the Weekly Hydration and Skin Assessment for the month of [DATE], it appeared that a skin assessment was done one time only during the month, on [DATE]. The form revealed Resident #501 refused a shower 3 times on [DATE] . However, according to Unit Manager 'F', Resident #501 still should have received a skin assessment on that date. There were no additional skin assessment documented for Resident #501 during July. There was no Braden Scale Assessment in the medical record for Resident #501. The Medical Records Coordinator 'M' reported that it was not done. On [DATE] at 5:30 p.m. review of nurses notes revealed the following: A nurse's note on [DATE] 10:30 p.m., "CENA (Certified Nurse Aide) informed writer of skin breakdown on resident (#501), assessed...reddened and discoloration beneath the buttocks area noted and applied sensicare..." There were no additional nurses' notes concerning the resident's skin until a note written on [DATE] at 12 noon, documented "Had a meeting with the sister of the resident (#501) together with the wound nurse. Explained to the resident's sister that the physician had put on hold the discharge order of the resident due to the open area that the resident has on his buttocks..." A nurse's note on [DATE] (no time), "Resident complained not being checked on by CENA..." On [DATE], a telephone interview was conducted with with Family Member 'H' who explained that Resident #501 expired. Family Member 'H' further explained that she had concerns about the severity of the wounds that (Resident #501) acquired in the facility."He never had a problem with skin breakdown and he would complain to me that the staff at the nursing home did not assist him with cleaning him after he had bowel movements." According to the clinical record Resident #501 experienced diarrhea as a result of his [MEDICAL CONDITION]'s disease. On [DATE] at 12:45 p.m. review of the CNA's ADL (activites of daily living) documentation revealed the frequency size and the consistency of Resident #501's bowel movements (BM). According to the documentation, Resident #501 had more than one BM on the following dates: ,[DATE], ,[DATE]. ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], [DATE], ,[DATE] and [DATE]. When comparing those dates listed above, with the Treatment record the TAR revealed that Treatment was only provided one time on those dates, however, the order was written for treatment to be provided daily and prn (as needed). Therefore, when the dressings were soiled, a new treatment change should have been provided. Review of undated Resident Care Guide revealed that showers were to be provided to Resident #501 on Mondays and Thursdays. However, the shower sheets provided by the facility only indicated one shower day per week. There was nothing documented on the care guide related to Resident #501's assistance needs with regard to repositioning in bed, and documentation regarding Bowel elimination indicated that Resident #501 was continent. However, interviews with nursing staff revealed that Resident #501 required extensive assistance with repositioning and hygiene, and he was incontinent. According to treatment nurse 'P' "he didn't have any skin breakdown when he first came in the facility. He was able to reposition himself, but over time he required more extensive assistance." It was unclear why the care guide was not updated to reflect the change in the resident's condition. Review of physician orders [REDACTED]. Review of doctors progress notes on [DATE] at 3:00 p.m. revealed: On [DATE] there was no documentation related to Resident 501's wounds. However, the wounds were identified by the nurse on [DATE]. It was unclear why the doctor was not informed of the wounds. On [DATE] the physician noted "Bilateral Ischial Ulcers with gangrenous eschars s/p (status [REDACTED]. A new physician's orders [REDACTED]." A new pressure area had been discovered on Resident #501's ankle. On [DATE] at 3:30 p.m., an interview was conducted with the Director of Nursing (DON) 'B' who could not explain why Resident #501's skin was not consistently assessed prior to his acquiring the wounds, or why the physician was not informed of the wounds until [DATE]. The DON also explained that the treatment nurse who provided care for Resident #501 no longer worked at the facility. On [DATE] at 1:30 p.m. review of Skin/Pressure care plan on admission (initiated [DATE]) revealed "my skin will remain intact and I will not have skin breakdown. The careplan was updated with the following: On [DATE], "remind/assist me in my repositioning or shifting my weight and positioning." On [DATE], "noted black discoloration on sacral-coccyx and bilateral buttocks peeled off bearing area open...Given low air loss mattress." On [DATE] at approximately 1:50 p.m. review of the "wound assessment detailed report" dated [DATE] revealed a photograph of a large unstageable wound on the right buttock 7 cm x 5.2 cm x unknown depth. The wound contained slough and necrotic tissue. The wound assessment report dated [DATE] revealed a photograph of the wound which increased in size at 8 cm x 6 cm x 4.2 cm. The wound was still unstageable. Resident #501 also had large unstageable wounds on his left buttocks and on his sacral area. It was unclear how the resident's skin was documented as being reddened, discoloration on [DATE] but a few days later there were three unstageable necrotic wounds. A telephone interview was conducted with the former wound treatment nurse 'O' on [DATE] at 2:30 p.m.who explained that she had to write up a nurse (LPN 'Q') for not correctly documenting a pressure wound when it was first discovered on Sunday [DATE] but LPN 'Q' failed to initiate treatment for [REDACTED]. she would send a copy of the write up to the surveyor. On [DATE], According to the DON 'B', a nurse did receive a write-up, but she (DON) could not find it. On [DATE], copies of the write up were recieved. Treatment nurse 'O' explained in writing that on Sunday [DATE] Nurse 'Q' was notified by the CNA assigned to Resident #501 that "there's something going on with the resident's (#501) skin. She (LPN 'Q') went and checked and told the CNA to apply the cream. She (LPN 'Q') left that night without writing an order to initiate treatment, with no documentation in (Resident #501's) chart and without documenting in the 24 hour report. The next day, Monday [DATE], the afternoon nurse slid a note under my (Treatment nurse 'O') door to let me know that I need to check the skin of the resident (#501). On Tuesday [DATE] when I came to work, I did go straight to the room and checked and initiated treatment. I'm (Treatment nurse 'O') not sure what day that the unit manager (F) of the first floor called this nurse (Q) to come back so she can document and write the treatment order..." LPN 'Q' received more than one write up related to wound treatments: According to the "Employee Warning Notice Job Performance" written on [DATE], LPN Q failed to perform jub duties satisfactorily and according to established job description. Failed to do assigned treatment to ,[DATE] that was scheduled on ,[DATE] (afternoon shift)...Make sure you check treatment book to see what treatment is assigned to your shift," and on [DATE], "Failed to initiate treatment to resident that develooped skin breakdown (#501) by writing an order and failure to communicate in writing on the 24 hour report or endorsing it to the oncoming shift. - Check treatment book for the facility protocol on what treatment should be ordered if observed skin breakdown to any resident. Also make sure to communicate to coworkers..."

THIS CITATION PERTAINS TO INTAKES # MI 269, MI 660 & MI 856 BASED ON OBSERVATIONS, INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO ENSURE THAT 3 OF 5 RESIDENTS REVIEWED FOR FALLS (#101, #102 & #103), FROM A TOTAL SAMPLE OF 6, RECEIVED ADEQUATE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS, RESULTING IN INJURY. FINDINGS: RESIDENT #101 ACCORDING TO THE FACE SHEET DATED 8/10/2011, RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 8/04/2011. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #101 HAD IMPAIRED DECISION MAKING WITH SHORT TERM MEMORY LOSS. SHE NEEDED HUMAN ASSISTANCE TO BALANCE AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH BATHING, PERSONAL HYGIENE, DRESSING, TRANSFERS AND AMBULATION. ACCORDING TO THE "STATEMENT OF COMPETENCY" FORM, DATED 8/11/2011, RESIDENT #101 SUFFERED FROM PARKINSON'S DEMENTIA AND WAS "INCOMPETENT TO MAKE HER OWN MEDICAL DECISIONS." AN UNDATED "RESIDENT CARE GUIDE" NOTED THAT RESIDENT #101 HAD A RIGHT LEG BRACE AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST HER WITH ALL TRANSFERS AND AMBULATION. A SAFETY CARE PLAN DATED 8/12/2011, NOTED THAT RESIDENT #101 HAD WEAKNESS AND LIMITED MOBILITY. ACCORDING TO THIS CARE PLAN, RESIDENT #101 CONTINUED TO REQUIRE MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL TRANSFERS AND AMBULATION TO "REMAIN SAFE AND FREE FROM FALLS." A SECOND CARE PLAN, DATED 8/12/2012, DOCUMENTED THAT RESIDENT #101 HAD OCCASIONAL EPISODES OF INCONTINENCE AND REQUIRED STAFF ASSISTANCE TO TOILET. OCCUPATIONAL THERAPY DISCHARGE NOTES DATED 9/2011, NOTED THAT RESIDENT #101 REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSISTANCE HER WITH ALL TRANSFERS. ON 1/20/2012 AN OCCUPATIONAL THERAPIST DOCUMENTED, "CNA (CERTIFIED NURSING ASSISTANT) REPORTED RESIDENT (#101) PERFORMS TRANSFERS, DRESSING, GROOMING, AND TOILETING WITHOUT ASSISTANCE." AGAIN, THE THERAPIST SPECIFIED RESIDENT #101 WAS NOT SAFE TO DO THESE TASKS ALONE AND REQUIRED STAFF ASSISTANCE WITH ALL TRANSFERS. PHYSICAL THERAPY DISCHARGE NOTES DATED 1/03/2012 DOCUMENTED THAT RESIDENT #101 REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE HER WITH ASSISTANCE WHEN SHE WALKED. RESTORATIVE NURSING NOTES DATED 3/31/2012 REVEALED RESIDENT #101 WAS "TO GET HER AMBULATION EXERCISES WITH THE USE OF (A) ROLLING WALKER, GAIT BELT AND RESTORATIVE STAFF." NURSING NOTES DATED 4/04/2012 AT 5:00 A.M. REVEALED RESIDENT #101 fell WHILE ALONE IN HER BATHROOM. DURING AN INTERVIEW ON 5/23/2012 AT 10:45 A.M. CNA #1 SAID DESPITE THE ESTABLISHED SAFETY CARE PLAN, INCONTINENCE CARE PLAN AND MULTIPLE PROFESSIONAL ASSESSMENTS, RESIDENT #101 DID NOT REQUIRE STAFF TO ASSIST HER WITH HYGIENE, DRESSING, TRANSFERS OR AMBULATION. CNA #1 SAID, RESIDENT #101 DID ALL OF THESE THINGS INDEPENDENTLY, "ALL THE TIME," BEFORE SHE fell on [DATE]. THE "UNUSUAL OCCURRENCE" REPORT, DATED 4/04/2012 AT 5:00 A.M., DOCUMENTED THAT RESIDENT #101 HAD NO STAFF ASSISTANCE AS SHE ATTEMPTED TO SELF-TRANSFER FROM HER WHEELCHAIR TO THE TOILET AND SHE fell on THE WET BATHROOM FLOOR. RESIDENT #101 THEN COMPLAINED OF NEW ONSET LEFT GREAT TOE PAIN. PHYSICIAN ORDERS [REDACTED]. RESIDENT #101'S LEFT FOOT X-RAYS TAKEN 4/04/2012 REVEALED A "NON-DISPLACED FRACTURE" OF THE LEFT FOOT ("DISTAL DIAPHYSIS OF SECOND AND THIRD METATARSAL BONES..."). A PHYSICIAN'S PROGRESS NOTE DATED 4/05/2012, DOCUMENTED THAT RESIDENT #101 REQUIRED A NEW PLAN OF CARE AFTER SHE "fell DOWN YESTERDAY AND FRACTURED HER LEFT 2ND AND 3RD METATARSALS." THE SAFETY CARE PLAN WAS UPDATED ON 4/05/2012 AND REQUIRED STAFF TO IMPLEMENT A BED AND WHEELCHAIR SENSOR ALARM. DURING THE SAME INTERVIEW ON 5/23/2012 AT 10:45 A.M., CNA #1 SAID AFTER RESIDENT #101 fell on [DATE], STAFF PROVIDED HER WITH A BED AND WHEELCHAIR SENSOR ALARM. CNA #1 THEN SAID "BUT THEY (THE ALARMS) DON'T WORK" BECAUSE RESIDENT #101 HAD THE ABILITY TO SHUT THEM OFF INDEPENDENTLY BEFORE SELF-TRANSFERRING. CNA #1 SAID THE BED AND WHEELCHAIR ALARMS WERE TURNED BACK ON WHEN STAFF FINDS THEM OFF, BUT NO OTHER INTERVENTIONS WERE IMPLEMENTED TO MAINTAIN THE SAFETY OF RESIDENT #101. AT 1:30 P.M. CNA #1 RETURNED TO THE SURVEYOR AND SAID, "YOU JUST MISSED HER. SHE JUST GOT ONTO THE TOILET BY HERSELF." CNA #1 SAID SHE DID NOT HEAR THE WHEELCHAIR ALARM WHEN RESIDENT #101 TRANSFERRED BECAUSE IT WAS NOT TURNED ON. ON 5/23/2012 AT 2:15 P.M. RESIDENT #101 WAS OBSERVED UP IN A WHEELCHAIR NEXT TO HER BED, UNSUPERVISED. THE WHEELCHAIR SENSOR ALARM WAS IN THE "OFF" POSITION LEAVING HER AT RISK FOR FUTURE FALLS WITH INJURY. RESIDENT #102 ACCORDING TO THE FACE SHEET DATED 5/21/2012, RESIDENT #102 WAS AN [AGE] year OLD MALE WHO LIVED AT THE FACILITY SINCE 8/13/2009. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #102 HAD SEVERELY IMPAIRED DECISION MAKING, DISORGANIZED THINKING WITH BOTH LONG AND SHORT TERM MEMORY LOSS. RESIDENT #102 COULD NOT BALANCE WITHOUT HUMAN ASSISTANCE. HE DID NOT WALK, HAD RECENT FALLS AND REQUIRED MINIMALLY TWO STAFF MEMBERS TO ASSIST WITH ALL TRANSFERS. A SAFETY CARE PLAN DATED 7/12/2011 NOTED THAT RESIDENT #102 WAS AT RISK FOR FALLS AND REQUIRED STAFF TO PROVIDE HIM WITH PROPER FOOTWEAR AT ALL TIMES. ON 8/02/2011, STAFF UPDATED THIS CARE PLAN AND RESIDENT #102 WAS REQUIRED TO WEAR NON-SKID SOCKS WHILE IN BED. ON 2/06/2012 STAFF AGAIN UPDATED THIS SAFETY CARE PLAN AND DOCUMENTED THE NEED FOR STAFF TO "EVALUATE (FOR) PROPER FOOTWEAR." A REHAB SERVICE SCREENING FORM, DATED 2/06/2012 AND 3/18/2012, REQUIRED THERAPY TO EVALUATE RESIDENT #103 FOR A RECENT FALL WITH FUNCTIONAL CHANGES IDENTIFIED IN HIS AMBULATION AND BALANCE. PHYSICAL THERAPY NOTES DATED 3/20/2012 DOCUMENTED THAT RESIDENT #102 WAS AT RISK FOR FALLS WITH IMPAIRED SAFETY AWARENESS AND DECREASED KNEE STABILITY. THE PHYSICAL THERAPIST DETERMINED THAT RESIDENT #102 REQUIRED HUMAN ASSISTANCE TO BALANCE WHEN HE STOOD AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL TRANSFERS AND AMBULATION. OCCUPATIONAL THERAPY NOTES DATED 3/20/2012 DOCUMENTED THAT RESIDENT #102 WAS AT RISK FOR FALLS AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST HIM WITH ALL TRANSFERS. AN UNUSUAL OCCURRENCE REPORT DATED 3/24/2012 AT 12:10 A.M. REVEALED RESIDENT #102 WAS ALONE WHEN STAFF FOUND HIM LYING ON THE BATHROOM FLOOR. THIS DOCUMENT REVEALED RESIDENT #102 HAD NO APPROPRIATE FOOTWEAR IN PLACE BEFORE THE FALL, AND ALTHOUGH A BED ALARM WAS IN PLACE, STAFF FAILED TO DOCUMENT ITS OPERATION. DURING AN INTERVIEW ON 5/25/2012 AT 2:00 P.M. THE ADMINISTRATOR AND DIRECTOR OF NURSING REVIEWED RESIDENT #102'S MEDICAL RECORD AND SAID STAFF FAILED TO FOLLOW THE SAFETY CARE PLAN FOR RESIDENT #102 ON 3/24/2012, WHICH REQUIRED HIM TO WEAR APPROPRIATE NON -SKID FOOTWEAR. BOTH AGREED THAT RESIDENT #102'S BED ALARM WAS INEFFECTIVE EVEN IF IT SOUNDED, AS RESIDENT #102 MADE IT OUT OF HIS BED, ACROSS THE ROOM INTO THE BATHROOM AND fell WITHOUT ANY STAFF ASSISTANCE. THE ADMINISTRATOR AND DIRECTOR OF NURSING FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE OF INCREASED SUPERVISION OR ASSISTIVE SAFETY DEVICES IMPLEMENTED AFTER HE GOT OUT OF BED AND fell , TO KEEP RESIDENT #102 SAFE IN THE FUTURE. NURSING NOTES DATED 3/31/2012, 4/05/2012 AND 4/19/2012 DOCUMENTED CONSISTENT SELF-TRANSFER AND AMBULATION ATTEMPTS MADE WITH AN UNSTEADY GAIT BY RESIDENT #102. DESPITE THESE PROFESSIONAL ASSESSMENTS, STAFF FAILED TO IMPLEMENT ANY DOCUMENTED INCREASE IN SUPERVISION OR ASSISTIVE SAFETY DEVICES TO KEEP RESIDENT #102 SAFE. AN UNUSUAL OCCURRENCE REPORT DATED 4/20/2012 AT 3:05 A.M. REVEALED RESIDENT #102 AGAIN SELF-TRANSFERRED FROM BED AND fell TO THE FLOOR. THE PHYSICIANS PROGRESS NOTE DATED 4/20/2012 REVEALED RESIDENT #102 WAS ASSESSED AFTER THE FALL AND TRANSFER TO A LOCAL AREA HOSPITAL FOR A HEAD INJURY WITH BRUISING, "...MENTAL STATUS CHANGES AND EPISTAXIS (A NOSEBLEED)..." ONCE AT THE LOCAL AREA hospital on [DATE], RESIDENT #102 WAS diagnosed with [REDACTED]. RESIDENT #105 ACCORDING TO THE FACE SHEET DATED 5/03/2015 RESIDENT #105 WAS A [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 4/14/2012. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE] RESIDENT #105 HAD COGNITIVE IMPAIRMENTS WITH LONG TERM MEMORY LOSS. A FALL ADMISSION CARE PLAN DATED 4/14/2012 IDENTIFIED RESIDENT #105 AT RISK FOR FALLS. TO PREVENT INJURY AND MINIMIZE HER FALL RISK STAFF WERE TO APPLY ALARMS TO HER BED AND WHEELCHAIR. ADMISSION NURSING NOTES DATED 4/14/2012 DOCUMENTED THAT RESIDENT #104 had a history of [REDACTED]. PHYSICAL THERAPY NOTES DATED 4/09/2012 DOCUMENTED THAT RESIDENT #105 HAD IMPAIRED SAFETY AWARENESS, WAS AT RISK FOR FALLS AND REQUIRED STAFF ASSISTANCE WITH ALL BED MOBILITY AND TRANSFERS. OCCUPATIONAL THERAPY NOTES DATED 4/09/2012 DOCUMENTED THAT RESIDENT #105 WAS A FALL RISK AND COULD NOT BALANCE WHEN STOOD. IT WAS DETERMINED RESIDENT #105 REQUIRED STAFF ASSISTANCE WITH ALL TRANSFERS. A "PM&R (PHYSICAL MEDICINE AND REHABILITATION) PROGRESS NOTE," DATED 4/25/2012 DOCUMENTED THAT RESIDENT #105 DID NOT WALK, DID NOT BALANCE WHEN STOOD AND REQUIRED STAFF TO ASSIST HER WITH ALL TRANSFERS. NURSING NOTES DATED 4/15/2012, 4/16/2012, 4/20/2012 AND 4/23/2012 REVEALED RESIDENT #105 ATTEMPTED FREQUENT SELF-TRANSFERS FROM HER WHEELCHAIR. DESPITE THESE PERSISTENT BEHAVIORS STAFF FAILED TO MODIFY THE CARE PLAN, IMPLEMENT ANY INCREASED SUPERVISION OR ADDITIONAL ASSISTIVE DEVICES NECESSARY TO ENSURE THE FUTURE SAFETY OF RESIDENT #105. ACCORDING TO STAFF STATEMENTS DATED 5/03/2012, CNA (CERTIFIED NURSING ASSISTANT) #3 FOUND RESIDENT #105 STANDING ALONE IN HER BEDROOM ON 4/28/2012 JUST BEFORE 4:45 A.M. CNA #3 SAID THESE BEHAVIORS DEMONSTRATED AN IMMEDIATE FALL RISK. TO MAXIMIZE THE SAFETY OF RESIDENT #105 SHE WAS PLACED IN A WHEELCHAIR AND TAKEN TO CNA #1 FOR INCREASED SUPERVISION. AN UNUSUAL OCCURRENCE REPORT DATED 4/28/2012 AT 5:45 A.M. REVEALED RESIDENT #105 WAS UNSUPERVISED WHEN STAFF "OBSERVED (HER) ON (THE) FLOOR" IN THE COMMON AREA NEAR THE NURSES' STATION. NURSING NOTES DATED 4/28/2012 AT 7:00 A.M. REVEALED RESIDENT #105 DEVELOPED RIGHT HIP AND KNEE PAIN AFTER THE FALL. RESIDENT #105 WAS TRANSFERRED TO A LOCAL hospital on [DATE] WHERE SHE WAS diagnosed with [REDACTED]. DURING AN INTERVIEW ON 5/23/2012 AT 1:20 P.M. THE DIRECTOR OF NURSING SAID RESIDENT #105 DEMONSTRATED BEHAVIORS THROUGHOUT THE NIGHT THAT SUGGESTED INCREASED SUPERVISION WAS NECESSARY. THE DIRECTOR OF NURSING SAID THAT CNA #1 "SHOULD HAVE PROVIDED A HIGHER LEVEL OF SUPERVISION" FOR RESIDENT #105 AND NEVER LEFT HER ALONE IN THE COMMON AREA. THE FACILITY SUMMARY FOR THE FIVE DAY REPORT SUBMITTED BY THE ADMINISTRATOR DATED 5/04/2012, NOTED THAT CNA #1 "DID NOT FOLLOW THE CARE GUIDE AND LEFT A FALL RISK RESIDENT UNATTENDED."

THIS CITATION PERTAINS TO INTAKE MI 561 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO OPERATIONALIZE AND IMPLEMENT POLICIES AND PROCEDURES FOR SCREENING 25 EMPLOYEES FOR STATUTORILY-MANDATED CRIMINAL BACKGROUND CHECKS AND/OR FINGERPRINT SCANS. FURTHERMORE, THE FACILITY FAILED TO ACQUIRE PROFESSIONAL NURSING LICENSURE VERIFICATION AND NURSE'S AIDE CERTIFICATION VERIFICATION FOR 2 NURSING EMPLOYEES. THE FACILITY'S FAILURE TO CONDUCT STATUTORILY-MANDATED CRIMINAL BACKGROUND CHECKS FOR 25 EMPLOYEES AND ACQUIRE VERIFICATION OF A PROFESSIONAL NURSING LICENSE AND/OR NURSING CERTIFICATION FOR 2 NURSING EMPLOYEES RESULTED IN IMMEDIATE JEOPARDY, PLACING A TOTAL CENSUS OF 124 RESIDENTS AT HIGH RISK FOR SERIOUS HARM. FINDINGS INCLUDE: ON 3/20/12 AT 10:00 A.M., AN INTERVIEW WITH THE NURSING HOME ADMINISTRATOR REVEALED THAT, "TWO NURSING EMPLOYEES HAD RECENTLY BEEN TERMINATED," WHEN IT WAS ESTABLISHED ON 3/01/12, THAT NEITHER EMPLOYEE HAD THE REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATION IN NURSING. THE ADMINISTRATOR REPORTED THAT EMPLOYEE "A" WAS HIRED AS AN LPN/RN (LICENSED PRACTICAL NURSE/REGISTERED NURSE) ON 12/20/11. REVIEW OF THE PERSONNEL FILE FOR EMPLOYEE "A" VERIFIED THAT SHE WAS HIRED AS AN "LPN/RN" (LICENSED PRACTICAL NURSE/REGISTERED NURSE) AND STARTED EMPLOYMENT EFFECTIVE 12/20/11. THE PERSONNEL FILE INDICATED THAT EMPLOYEE "A" WAS IN ORIENTATION BEGINNING 12/26/11 THROUGH 1/30/12. A REVIEW OF A NURSING ASSIGNMENT RECORD FOR EMPLOYEE "A" REVEALED THAT SHE WORKED INDEPENDENTLY IN THE POSITION OF A LPN/RN (LICENSED PRACTICAL NURSE/REGISTERED NURSE) BEGINNING ON 1/31/12 THROUGH 3/1/12, AND WAS ASSIGNED A MAXIMUM OF 52 RESIDENTS ON HER UNIT AND SHIFT. ON 3/22/11 AT 11:00 A.M., AN INTERVIEW WITH THE DIRECTOR OF NURSING VERIFIED THE ASSIGNMENT RESPONSIBILITIES FOR EMPLOYEE "A" DURING THE PERIOD OF 1/31/12 THROUGH 3/1/12. THE DIRECTOR OF NURSING STATED THAT EMPLOYEE "A" HAD ALTERNATED WORKING ON BOTH THE AFTERNOON AND MIDNIGHT SHIFTS WHILE EMPLOYED AT THE FACILITY. DURING THE INTERVIEW, THE ADMINISTRATOR FURTHER REPORTED THAT AN EMPLOYEE KNOWN AS EMPLOYEE "B" WAS HIRED AS A CNA (CERTIFIED NURSING ASSISTANT) ON 11/09/11. A REVIEW OF THE PERSONNEL FILE FOR EMPLOYEE "B" VERIFIED THAT SHE WAS HIRED ON 11/09/11 AND WAS IN ORIENTATION ON 11/14/11 AND 11/15/11. A REVIEW OF A NURSING ASSIGNMENT RECORD FOR EMPLOYEE "B" REVEALED THAT SHE WORKED INDEPENDENTLY IN THE POSITION OF CNA (CERTIFIED NURSING ASSISTANT) BEGINNING ON 11/21/11 THROUGH 2/29/12, ON VARIOUS UNITS AT THE FACILITY. DURING THE ABBREVIATED SURVEY, THE SURVEYOR INITIATED MULTIPLE PHONE CONTACTS TO INTERVIEW EMPLOYEE "B", BUT WAS UNSUCCESSFUL IN ESTABLISHING CONTACT. THE ADMINISTRATOR FURTHER STATED THAT ON 2/29/12, SHE WAS NOTIFIED BY THE FACILITY SOCIAL WORKER THAT EMPLOYEE "B" MAY NOT HAVE THE REQUIRED CERTIFICATION AS A NURSING ASSISTANT. THE ADMINISTRATOR STATED THAT ON 2/29/22, SHE CHECKED WITH THE CNA REGISTRY AND WAS UNABLE TO ESTABLISH THAT EMPLOYEE "B" WAS LISTED AS HAVING CERTIFICATION AS A CERTIFIED NURSING ASSISTANT. THE ADMINISTRATOR STATED THAT EMPLOYEE "B" WAS INITIALLY SUSPENDED ON 3/1/12. THE ADMINISTRATOR FURTHER EXPLAINED THAT EMPLOYEE "B" COULD NOT PROVIDE ANY EVIDENCE OF CERTIFICATION AS A CERTIFIED NURSING ASSISTANT AND WAS TERMINATED ON MARCH 7, 2012. THE ADMINISTRATOR FURTHER REPORTED THAT ON 2/29/12, SHE REQUESTED THAT THE DIRECTOR OF HUMAN RESOURCES AUDIT ALL NURSING EMPLOYEE FILES FOR VERIFICATION OF PROCESSIONAL LICENSE AND/OR CERTIFICATION. THE ADMINISTRATOR STATED THAT ON 3/1/12, SHE WAS INFORMED BY THE DIRECTOR OF HUMAN RESOURCES OF THE AUDIT RESULTS AND THERE WAS NO EVIDENCE OF A PROFESSIONAL NURSING LICENSE IN THE PERSONNEL FILE FOR EMPLOYEE "A". ON 3/20/12, AT 2:00 P.M., AN INTERVIEW WITH THE DIRECTOR OF HUMAN RESOURCES VERIFIED THAT SHE CONDUCTED AN AUDIT OF ALL NURSING EMPLOYEE FILES AND ESTABLISHED THAT THERE WAS NO EVIDENCE OF A PROFESSIONAL NURSING LICENSE FOR EMPLOYEE "A" AND NO EVIDENCE OF CERTIFICATION AS A CERTIFIED NURSING ASSISTANT FOR EMPLOYEE "B". THE DIRECTOR OF HUMAN RESOURCES FURTHER REPORTED THAT EMPLOYEE "A" WAS HIRED AS AN "LPN/RN SINCE SHE "WAS A NEW NURSE GRADUATE." THE DIRECTOR OF HUMAN RESOURCES FURTHER STATED THAT, "SHE (EMPLOYEE "A") TOLD ME SHE WAS WAITING FOR A LETTER OF AUTHORIZATION IN ORDER TO TAKE HER NURSING BOARD (EXAMINATION)." THE DIRECTOR OF HUMAN RESOURCES STATED THAT SHE FAILED TO FOLLOW UP WITH EMPLOYEE "A" REGARDING OBTAINING A COPY OF HER PROFESSIONAL NURSING LICENSE. THE DIRECTOR OF HUMAN RESOURCES FURTHER REPORTED THAT AFTER SHE AUDITED THE PERSONNEL FILE FOR EMPLOYEE "B" ON 2/29/12, THERE WAS NO EVIDENCE THAT THE CNA REGISTRY HAD BEEN CONTACTED TO VERIFY CERTIFICATION OR THAT A COPY OF CURRENT CERTIFICATION WAS MAINTAINED IN THE EMPLOYEE'S PERSONNEL FILE. THE DIRECTOR OF HUMAN RESOURCES FURTHER STATED THAT ALTHOUGH EMPLOYEE "B" DID NOT HAVE CERTIFICATION AS A CERTIFIED NURSING ASSISTANT, THERE WAS EVIDENCE IN THE PERSONNEL FILE THAT EMPLOYEE "B" COMPLETED A "MEDICAL ASSISTANT" PROGRAM. A REVIEW OF THE PERSONNEL FILE FOR EMPLOYEE "B" REVEALED A XEROXED COPY OF A "MEDICAL ASSISTANT" DIPLOMA FROM A CAREER INSTITUTE, DATED 12/07/2010. A COPY OF THIS DOCUMENT WAS VERIFIED BY THE SURVEYOR IN THE PERSONNEL FILE FOR EMPLOYEE "B". ON 3/20/12, AT 2:00 P.M., THE SURVEYOR REVIEWED THE PERSONNEL FILES FOR BOTH EMPLOYEE "A" AND EMPLOYEE "B" AND COULD NOT FIND EVIDENCE THAT STATUTORILY-MANDATED FINGERPRINT BACKGROUND CHECKS HAD BEEN CONDUCTED ON EITHER EMPLOYEE. ON 3/20/12, AT 2:15 P.M., DURING AN INTERVIEW WITH BOTH THE ADMINISTRATOR AND DIRECTOR OF HUMAN RESOURCES, IT WAS VERIFIED THAT THE FACILITY HAD FAILED TO CONDUCT STATUTORILY-MANDATED FINGERPRINT BACKGROUND CHECKS ON EITHER EMPLOYEE "A" OR EMPLOYEE "B". ON 3/20/11, AT 2:30 P.M., THE SURVEYOR REQUESTED THAT A FACILITY WIDE AUDIT BE CONDUCTED TO VERIFY THAT ALL EMPLOYEES HAD EVIDENCE IN THEIR INDIVIDUAL PERSONNEL FILES FOR STATUTORILY-MANDATED CRIMINAL BACKGROUND CHECKS AND FINGERPRINT SCANS. ON 3/21/12, AT 10:00 A.M., THE ADMINISTRATOR REPORTED TO THE SURVEYOR THAT AN AUDIT OF 160 EMPLOYEE FILES FOR EVIDENCE OF CRIMINAL BACKGROUND CHECKS AND FINGERPRINT SCANS REVEALED THE FOLLOWING RESULTS: ? 8 EMPLOYEES DID NOT HAVE STATUTORILY-MANDATED CRIMINAL BACKGROUND CHECKS SUCH AS ICHAT (INTERNET CRIMINAL HISTORY ACCESS TOOL) VERIFICATION AS OF 3/20/12. ? ? 15 EMPLOYEES DID NOT HAVE STATUTORILY-MANDATED ELECTRONIC FINGERPRINT SCANS AS OF 3/20/12. ? ? 2 EMPLOYEES HAD NEITHER AN ICHAT VERIFICATION BACKGROUND CHECK NOR A FINGERPRINT SCAN BACKGROUND CHECK AS OF 3/20/12. ? ? ON 3/21/12 THROUGH 3/23/12, AN AUDIT OF 168 EMPLOYEE PERSONNEL FILES WAS CONDUCTED BY THE SURVEYOR TO DETERMINE THE EXTENT OF THE FACILITY'S FAILURE TO CONDUCT STATUTORILY-MANDATED CRIMINAL BACKGROUND CHECKS AND FINGERPRINT SCANS ON ALL CURRENT FULL AND PART TIME EMPLOYEES. THE SURVEYOR AUDIT REVEALED THE FOLLOWING RESULTS: ? ? 7 EMPLOYEES DID NOT HAVE STATUTORILY-MANDATED CRIMINAL BACKGROUND CHECKS SUCH AS ICHAT VERIFICATION AS OF 3/20/12; AND 2 OF THE 7 EMPLOYEES CONTINUED TO NOT HAVE STATUTORILY-MANDATED CRIMINAL BACKGROUND CHECKS CONDUCTED AS OF 3/23/11, AT 12:00 NOON. ? ? 22 EMPLOYEES DID NOT HAVE STATUTORILY-MANDATED ELECTRONIC FINGERPRINT SCANS AS OF 3/20/12; AND 9 OF THE 22 EMPLOYEES CONTINUED TO NOT HAVE STATUTORILY-MANDATED FINGERPRINT SCANS AS OF 3/23/12, AT 12:00 NOON. ? ? 11 EMPLOYEES DID NOT HAVE OIG (OFFICE OF THE INSPECTOR GENERAL) BACKGROUND CHECKS FOR MEDICARE/MEDICAID EXCLUSION. REVIEW OF THE FACILITY'S "HIRING POLICY", DATED 1/1/2009 AND "EMPLOYEE RECORDS POLICY" DATED 7/08/09, INDICATED THE FOLLOWING EMPLOYMENT CRITERIA: 1. PRIOR TO HIRING, CONTRACTING WITH, OR GRANTING CLINICAL PRIVILEGES TO AN INDIVIDUAL WHO WILL BE PROVIDING DIRECT SERVICES TO RESIDENTS, THE FACILITY WILL CONDUCT A THOROUGH INVESTIGATION INTO THE APPLICANT'S PAST HISTORY. THIS CHECK WILL INCLUDE: CRIMINAL BACKGROUND CHECKS; NURSE AIDE REGISTRY CHECK/LICENSING AUTHORITY (ALL LICENSED POSITIONS); OFFENDER TRACKING INFORMATION SYSTEM (OTIS); MEDICARE/MEDICAID EXCLUSION LIST (OIG); AND BUSINESS REFERENCES. 2. IF THESE BACKGROUND CHECKS REVEAL NO CONVICTIONS OR FINDINGS, THEN THE INDIVIDUAL MAY BE HIRED ON A CONTINGENT BASIS PENDING THE FINDINGS OF THE FINGERPRINT BACKGROUND CHECK. THE FACILITY WILL CONDUCT A CRIMINAL BACKGROUND CHECK USING APPLICANT FINGERPRINTS, ON APPLICANTS PROVIDING DIRECT SERVICES TO RESIDENTS, AFTER A CONDITIONAL OFFER OF EMPLOYMENT HAS BEEN MADE. INDIVIDUALS MUST SIGN A STATEMENT ATTESTING THAT THEY HAVE NOT BEEN CONVICTED OF ONE OF THE CRIMES LISTED ABOVE. 3. THE FACILITY WILL NOT HIRE OR INDEPENDENTLY CONTRACT WITH, OR GRANT CLINICAL PRIVILEGES TO ANY INDIVIDUAL WITH A CRIMINAL HISTORY IN THE FOLLOWING AREAS: ANY FELONY CONVICTION OR CONVICTED OF A MISDEMEANOR WITHIN THE TEN (10) YEARS IMMEDIATELY PRECEDING THE DATE OF APPLICATION FOR EMPLOYMENT. 4. DOCUMENTS TO BE INCLUDED IN THE EMPLOYEE'S PERSONNEL FILE MUST INCLUDE THE FOLLOWING ITEMS: OIG CHECK UPON HIRE AND ANNUAL; NURSE AIDE REGISTRY CHECK UPON HIRE AND ANNUAL; COPY OF APPROPRIATE LICENSE/CERTIFICATION FOR NURSES AND CNAS; CRIMINAL BACKGROUND CHECK; REFERENCE CHECKS. THE POLICY INDICATED THAT IT IS THE RESPONSIBILITY OF THE HUMAN RESOURCE MANAGER TO MAINTAIN EMPLOYMENT RECORDS ON EACH EMPLOYEE. IN ADDITION TO THE FACILITY'S FAILURE TO SECURE EVIDENCE OF A PROFESSIONAL NURSING LICENSE FOR EMPLOYEE "A", AND ALSO MAINTAIN A COPY OF THE EMPLOYEE'S NURSING LICENSE IN THE PERSONNEL FILE IN ACCORDANCE WITH THEIR EMPLOYMENT POLICIES, THE SURVEYOR DISCOVERED THAT EMPLOYEE "A" DID NOT MEET ELIGIBILITY FOR EMPLOYMENT AT THE FACILITY BASED ON THE RESULTS OF AN ICHAT (INTERNET CRIMINAL HISTORY ACCESS TOOL) CONDUCTED BY THE FACILITY PERSONNEL DEPARTMENT. A COPY OF THE ICHAT (INTERNET CRIMINAL HISTORY ACCESS TOOL) SEARCH RESULTS, DATED 12/14/11, INDICATED ON 1/11/05, EMPLOYEE "A" WAS CONVICTED OF A MISDEMEANOR FOR "BREAKING AND ENTERING-ILLEGAL ENTRY WITHOUT OWNER'S PERMISSION." ON 3/21/12/ AT 1:00 P.M., THE SURVEYOR ASKED THE ADMINISTRATOR IF SHE WAS KNOWLEDGEABLE ABOUT THE ICHAT SEARCH RESULTS FINDINGS FOR EMPLOYEE "A". THE ADMINISTRATOR STATED THAT SHE WAS UNAWARE OF THE ICHAT SEARCH FINDINGS AND STATED THAT THE FACILITY SHOULD NOT HAVE HIRED EMPLOYEE "A" BASED ON THE ICHAT SEARCH FINDINGS. FURTHERMORE, THERE WAS EVIDENCE IN THE PERSONNEL FILE FOR EMPLOYEE "A" THAT SHE (EMPLOYEE "A") HAD SIGNED AND DATED A FACILITY FORM ENTITLED, "CRIMINAL BACKGROUND AFFIDAVIT," IN WHICH SHE HAD DENIED HAVING EITHER FELONY OR MISDEMEANOR CONVICTIONS IN THE LAST [AGE] years. ON 3/21/12 AT 2:45 P.M., A PHONE INTERVIEW WITH EMPLOYEE "A" REVEALED THAT SHE WAS OFFERED EMPLOYMENT AT THE FACILITY AS A "NEW GRADUATE NURSE," AND BEGAN EMPLOYMENT ON 12/20/12. EMPLOYEE "A" STATED THAT SHE HAD "ATTENDED NURSING SCHOOL OUT OF STATE" AND "COMPLETED A BACHELOR OF SCIENCE DEGREE IN NURSING IN AUGUST 2011." EMPLOYEE "A" FURTHER STATED THAT SHE RELOCATED BACK TO MICHIGAN IN NOVEMBER 2011. EMPLOYEE "A" STATED THAT SHE HAD NOT TAKEN HER NURSING BOARD EXAM AND WAS NOT LICENSED TO PRACTICE NURSING IN MICHIGAN OR ANY OTHER STATE. EMPLOYEE "A" STATED THAT SHE WAS WAITING FOR HER "LETTER OF AUTHORIZATION TO SIT FOR THE NURSING BOARD EXAM." WHEN ASKED IF SHE HAD A TEMPORARY NURSING LICENSE SHE REPLIED, "NO." WHEN ASKED IF SHE WAS LICENSED IN MICHIGAN AS AN LPN (LICENSED PRACTICAL NURSE) OR RN (REGISTERED NURSE) SHE REPLIED, "NO. I AM A NEW GRADUATE NURSE." ON 3/26/12, AT 11:00 A.M., REVIEW OF THE CLINICAL RECORD FOR SAMPLED RESIDENT #107, REVEALED IN THE "NURSE'S NOTES", DATED 12/26/11 AT 11:00 P.M. AND 12/27/11 AT 11:00 P.M., DOCUMENTATION COMPLETED BY EMPLOYEE "A". EACH OF THESE TWO DATED ENTRIES REVEALED THAT EMPLOYEE "A" SIGNED THE CREDENTIAL "LPN" AFTER HER SIGNATURE. REVIEW OF THE NURSE ASSIGNMENT RECORD FOR 12/26/11 AND 12/27/11, VERIFIED THAT EMPLOYEE "A" WAS ASSIGNED TO AS THE CHARGE NURSE ON THE UNIT WHERE RESIDENT #107 HAD RESIDED. THE ADMINISTRATOR WAS NOTIFIED ON 3/23/12 AT 12:00 NOON, OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 11/9/2011, WHEN THE FACILITY FAILED TO OPERATIONALIZE ITS HIRING POLICY TO SCREEN EMPLOYEES FOR PROFESSIONAL CERTIFICATIONS AND TO SCREEN EMPLOYEES FOR A HISTORY OF CRIMINAL BEHAVIOR AND CONDUCT STATUTORILY-MANDATED CRIMINAL BACKGROUND CHECKS AND/OR FINGERPRINT BACKGROUND CHECKS FOR 27 EMPLOYEES INCLUDING EMPLOYEE "A" (HIRED 12/20/2011) AND EMPLOYEE "B" (HIRED 11/9/2011) WHICH PLACED A TOTAL CENSUS OF 124 RESIDENTS AT HIGH RISK FOR SERIOUS HARM. AN ACCEPTABLE PLAN OF CORRECTION TO REMOVE THE (IJ) IMMEDIATE JEOPARDY WAS RECEIVED ON 3/26/12, PRIOR TO THE DEPARTURE OF THE SURVEYORS FROM THE FACILITY ON 3/26/12. INTERVENTIONS TO REMOVE THE (IJ) IMMEDIATE JEOPARDY THAT WERE VERIFIED BY THE SURVEYOR INCLUDED: 1. ALL 160 FULL-TIME AND PART-TIME CURRENT EMPLOYEES, 14 CONTRACTED THERAPY STAFF AND 8 PHYSICIANS WERE SCREENED ON MARCH 23, 2012 FOR CERTIFICATION VERIFICATION; PROFESSIONAL CURRENT LICENSE VERIFICATION; CRIMINAL BACKGROUND CHECK (ICHAT); FINGERPRINTING; OFFENDER TRACKING INFORMATION (OTIS) AND THE OFFICE OF INSPECTION GENERAL (OIG) CHECKS ON ALL EMPLOYEES. 2. ALL 160 FULL AND PART TIME EMPLOYEES HAVE EVIDENCE OF ICHAT VERIFICATION IN THE EMPLOYEE'S PERSONNEL FILE AS OF 3/23/12. 3. AS OF 3/23/12; TWO (2) EMPLOYEES, ONE CNA (CERTIFIED NURSING ASSISTANT) AND ONE (1) DIETARY STAFF WERE TERMINATED AS THEY WERE NOT ELIGIBLE TO WORK IN LTC AS A RESULT OF ICHAT RESULTS. THE ICHAT RESULTS PROHIBITED THESE 2 EMPLOYEES FROM WORKING IN A LONG TERM CARE (LTC) SETTING. 4. AS ON 3/23/12, TEN (10) EMPLOYEES WERE IDENTIFIED AS LACKING FINGERPRINT CHECKS. 8 OF THE 10 EMPLOYEES WERE SENT FOR FINGERPRINTING. 2 OF THE 10 EMPLOYEES WERE TERMINATED FOR FAILURE TO SHOW UP FOR FINGERPRINTING ON 3/25/12. THE 8 EMPLOYEES WERE TAKEN OFF THE SCHEDULE UNTIL DEEMED ELIGIBLE BY FINGERPRINTING RESULTS. OF THE 8 EMPLOYEES, 4 ARE CNAS; 2 ARE LICENSED NURSES; 1 IS A DIETARY AIDE; AND 1 IS A LAUNDRY AIDE. 5. ON 3/23/12, THE HUMAN RESOURCE DIRECTOR WAS discharged FROM EMPLOYMENT. 6. ON 3/22/12, AN INTERIM HUMAN RESOURCE DIRECTOR HAD BEEN APPOINTED. THE INTERIM DIRECTOR WAS EDUCATED ON 3/22/12, BY THE HUMAN RESOURCE DIRECTOR CONSULTANT ON THE EMPLOYMENT APPLICATION PROCESS; INTERVIEWING; REFERENCE CHECKS; CRIMINAL BACKGROUND CHECKS; OTIS; OIG; FINGERPRINTING; NURSE AIDE REGISTRY CHECKS; LICENSING AUTHORITY CHECKS; PHYSICALS; AND DRUG SCREENING. 7. A "NEW HIRE CHECKLIST" FORM WILL BE COMPLETED ON EACH NEW HIRE PRIOR TO STARTING EMPLOYMENT AS OF 3/23/12. THE ITEMS ON THIS CHECKLIST WILL BE VERIFIED AS BEING COMPLETE AND CHECKED BY A SECOND DEPARTMENT HEAD. ALL DEPARTMENT HEADS WILL BE IN-SERVICED ON THE HIRING PROCESS AS OF 3/23/12. AN EXTERNAL AUDITOR WILL CONDUCT MONTHLY AUDITS FOR 3 MONTHS THEN QUARTERLY THEREAFTER TO ENSURE THE HIRING PROCESS IS BEING FOLLOWED AND THE FACILITY IS IN COMPLIANCE. THE AUDITS WILL BE REPORTED TO THE QA COMMITTEE MONTHLY FOR THREE MONTHS AND QUARTERLY THEREAFTER. 8. THE IJ REMOVAL DATE WAS 3/23/12. ON 3/26/12, AT 3:30 P.M., THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE INTERVENTIONS LISTED ABOVE TO REMOVE THE (IJ) IMMEDIATE JEOPARDY. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON 3/23/12, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY BECAUSE THE FACILITY WAS AWAITING THE FINGERPRINT RESULTS FOR 8 EMPLOYEES WHO HAD BEEN TAKEN OFF THE SCHEDULE AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. , , AND, .

THIS CITATION PERTAINS TO INTAKE: MI 499. BASED ON OBSERVATION, INTERVIES, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION TO PREVENT ACCIDENTS IN 1 (#103) OF 3 SAMPLED RESIDENTS , FROM A TOTAL SAMPLE OF 3 RESIDENTS, RESULTING IN RESIDENT #103 FALLING AND SUSTAINING A BRUISE TO THE FOREHEAD AND A FRACTURE TO THE RIGHT HUMERAL HEAD/ACROMION PROCESS (SHOULDER) WHILE SHE WAS LEFT UNATTENDED IN THE BATHROOM. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S INCIDENT REPORT DATED 12/2/11, ON 12/1/11 AT APPROXIMATELY 2:30 P.M., RESIDENT #103 WAS OBSERVED TO BE ON THE FLOOR IN THE BATHROOM WITH A HEMATOMA (BRUISED, SWELLING) TO THE RIGHT SIDE OF THE FOREHEAD. RESIDENT #103 WAS TRANSPORTED TO THE emergency room FOR ADDITIONAL EVALUATION AND TREATMENT. RESIDENT #103 RETURNED to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ON 1/13/12 AT 11:30 A.M., RESIDENT #103 WAS OBSERVED TO BE SEATED IN HER WHEELCHAIR WITH SLING TO HER RIGHT ARM AND FOAM BOOTS TO BILATERAL FEET. RESIDENT #103 WAS INTERVIEWED IN REGARDS TO THE FALL AND SAID THE NURSE LEFT HER ALONE IN THE BATHROOM AND SHE fell . RESIDENT #103 SAID THE NURSE WAS SUPPOSE TO WAIT OUTSIDE THE DOOR, BUT DID NOT, SHE JUST LEFT HER. RESIDENT #103 BEGAN TO GET VERY UPSET ABOUT BEING LEFT ALONE IN THE BATHROOM AND REQUESTED MONETARY COMPENSATION. A MEDICAL RECORD REVIEW REVEALED THAT RESIDENT #103 WAS A [AGE] year OLD FEMALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE], IDENTIFIED RESIDENT #103 AS BEING TOTALLY DEPENDENT ON STAFF FOR TRANSFERS, REQUIRING A 2 PERSONS FOR ASSISTANCE. THE FALL ASSESSMENT IDENTIFIED RESIDENT #103 AS BEING 'AT RISK' FOR FALLS. THE PHYSICAL THERAPY PROGRESS NOTES FROM 11/11 - 11/24/11 INDICATED THAT RESIDENT #103 HAD DIFFICULTY DEMONSTRATING BALANCE WHILE SITTING AND REQUIRED FREQUENT VERBAL CUES AND ASSISTANT. DURING AN INTERVIEW WITH CERTIFIED NURSING ASSISTANT (CNA) #3 ON 1/13/12 AT 12:05 P.M., SHE SAID SHE LEFT RESIDENT #103 UNATTENDED IN THE BATHROOM BECAUSE SHE WAS ASSISTING ANOTHER RESIDENT. CNA #3 SAID WHEN SHE RETURNED TO RESIDENT #103'S ROOM SHE HEARD HER (#103) CALLING OUT FOR HELP. CNA #3 ASSISTED THE RESIDENT BACK TO HER WHEELCHAIR AND CALLED FOR THE NURSE. CNA #3 SAID SHE KNEW SHE WAS NOT SUPPOSE TO LEAVE RESIDENT #103 UNATTENDED IN THE BATHROOM, BUT HAD 2 RESIDENTS THAT NEEDED HER HELP AT THE SAME TIME. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) #1 ON 1/13/12 AT 1:00 P.M., SHE SAID THE FACILITY'S POLICY IS NOT LEAVE A RESIDENT UNATTENDED IN THE BATHROOM. DON #1 SAID THAT CNA #3 IN NO LONGER EMPLOYED AT THE FACILITY. ( )

THIS CITATION PERTAINS TO INTAKE MI 882. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS IN 1 (#101) OF 4 SAMPLED RESIDENTS, FROM A TOTAL SAMPLE OF 4 RESIDENTS, WHEN RESIDENT #101, WHO REQUIRED THE ASSISTANCE OF TWO PERSONS FOR TRANSFERS, GOT HER RIGHT FOOT CAUGHT IN HER WHEELCHAIR WHEN SHE WAS TRANSFERRED BY ONE STAFF MEMBER, AND SUSTAINED A NONDISPLACED INCOMPLETE FRACTURE OF THE LATERAL MALLEOLUS (ANKLE). FINDINGS INCLUDE: REVIEW OF RESIDENT #101'S MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HER MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT SHE WAS COGNITIVELY INTACT WITH NO MEMORY PROBLEMS, AND REQUIRED MAXIMUM ASSISTANCE OF TWO PERSONS FOR TRANSFERS. FACILITY NURSES NOTES FOR RESIDENT #101 DATED 11/5/11 AT 8:30 PM DOCUMENTED THAT THE DOCTOR WAS NOTIFIED BECAUSE RESIDENT #101 WAS COMPLAINING OF EXCRUCIATING PAIN TO HER RIGHT LEG BETWEEN KNEE AND ANKLE AND THAT RESIDENT #101 STATED SHE ALMOST fell "YESTERDAY" DURING A TRANSFER WHEN HER LEG GOT CAUGHT UP IN HER WHEELCHAIR. NURSES NOTES FOR 11/5/11 ALSO DOCUMENTED THAT RESIDENT #101'S RIGHT SHIN LOOKED BRUISED AND RIGHT ANKLE APPEARED SWOLLEN, AND A STAT (AS SOON AS POSSIBLE) X-RAY WAS ORDERED. FACILITY NURSE'S NOTES DATED 11/5/11 AT 11:20 PM DOCUMENTED THAT RESIDENT #101'S X-RAY FOR THE RIGHT LOWER LEG AND ANKLE WERE NEGATIVE FOR FRACTURE. NO FURTHER NURSE'S NOTES WERE FOUND IN RESIDENT #101'S RECORD UNTIL 11/11/11. THERE WAS NO PAIN ASSESSMENT FOUND FOR RESIDENT #101 AFTER 11/5/11. physician progress notes [REDACTED].#101 HAD ONGOING RIGHT ANKLE PAIN AND THAT RESIDENT #101 HAD REPORT ON 11/5/11 THAT ON 11/4/11 HER LEG GOT CAUGHT IN THE WHEELCHAIR AS SHE WAS TRYING TO TRANSFER TO THE BED. THE PROGRESS NOTES DOCUMENTED RIGHT ANKLE SWELLING LATERALLY WITH LOCAL TENDERNESS OVER LATERAL COLLATERAL LIGAMENT AND PAIN ON INVERSION OF FOOT, AND MRI (MAGNETIC IMAGING STUDY OF THE ANKLE) TO BE ORDERED OF THE RIGHT ANKLE. MRI RESULTS OF THE RIGHT ANKLE DATED 11/15/11 DOCUMENTED A NONDISPLACED INCOMPLETE FRACTURE OF THE LATERAL MALLEOLUS (ANKLE) WHICH MAY BE SUBACUTE IN NATURE. REVIEW OF THE FALLS CARE PLAN FOR RESIDENT #101 IDENTIFIED HER TO BE AT RISK FOR FALLS RELATED TO LIMITED MOBILITY AND WEAKNESS, WITH INTERVENTIONS LISTED INCLUDE REMINDING RESIDENT #101 TO REMAIN CALM DURING TRANSFERS AND THAT RESIDENT #101 IS A TWO (2) PERSON ASSIST FOR TRANSFERS. RESIDENT CARE GUIDE FOR RESIDENT #101 DOCUMENTED THAT RESIDENT #101 REQUIRED TWO PERSON ASSIST FOR TRANSFERS. FACILITY UNUSUAL OCCURRENCE REPORT DATED 11/4/11 AT 6:00 PM DOCUMENTED THAT RESIDENT #101 STATED SHE ALMOST fell YESTERDAY DURING A TRANSFER FROM WHEELCHAIR TO BED WHEN HER RIGHT LEG GOT CAUGHT UP IN THE WHEELCHAIR. IN AN INTERVIEW ON 11/29/11 AT 10:35 AM, RESIDENT #101 WAS LYING IN HER BED IN HER ROOM, WATCHING TELEVISION, AND WAS OBSERVED TO HAVE HER RIGHT LEG PROPPED UP ON PILLOWS WITH AN ORTHOPEDIC BOOT ON. RESIDENT #101 WAS IDENTIFIED BY THE SURVEYOR TO BE ALERT AND ORIENTED TO PERSON, PLACE AND TIME BY THE SURVEYOR AT THE TIME OF THE INTERVIEW. RESIDENT #101 STATED SHE REMEMBERED WHEN SHE HURT HER ANKLE. RESIDENT #101 STATED SHE HAD JUST GOTTEN BACK FROM DIALYSIS AND SHE WAS ALWAYS TIRED WHEN SHE RETURNED FROM DIALYSIS. RESIDENT #101 STATED THE GIRL GRABBED HER AROUND THE WAIST TO HELP HER TO BED, AND HER FOOT (RESIDENT #101'S FOOT) GOT CAUGHT NEAR THE FOOT PEDAL OF THE WHEELCHAIR. RESIDENT #101 STATED SHE ALMOST fell , BUT THE GIRL PUT HER ON THE EDGE OF THE BED. RESIDENT #101 STATED THE GIRL DID NOT HAVE A BELT ON HER (RESIDENT #101) WHEN SHE TRANSFERRED HER. RESIDENT #101 STATED IT HURT IN HER ANKLE WHEN IT HAPPENED BUT WHEN SHE GOT INTO BED IT DIDN'T HURT ANYMORE, UNTIL THE NEXT DAY. RESIDENT #101 STATED THE NEXT DAY, HER ANKLE AND LEG WERE ALL SWELLED UP, SO IT HURT REAL BAD, AND IT HAS HURT EVER SINCE. IN AN INTERVIEW ON 11/29/11 AT 2:10 PM, CNA #7 STATED SHE REMEMBERED WHEN RESIDENT #101'S FOOT GOT CAUGHT IN THE WHEELCHAIR. CNA #7 STATED RESIDENT #101 HAD JUST COME BACK FROM DIALYSIS, SO SHE (CNA #7) WENT IN TO PUT HER (RESIDENT #101) TO BED. CNA #7 STATED RESIDENT #101'S RIGHT FOOT GOT CAUGHT ON THE FOOT PEDAL ON THE WHEELCHAIR, AND THE RESIDENT STATED THAT HER FOOT WAS CAUGHT. CNA #7 STATED THAT SHE FINISHED TRANSFERRING RESIDENT #101, CLEANED HER UP, AND RESIDENT #101 NEVER MENTIONED IT AGAIN FOR THE REST OF THE NIGHT. CNA #7 STATED SHE TRANSFERRED RESIDENT #101 BY HERSELF AND DID NOT USE A GAIT BELT. WHEN ASKED BY THE SURVEYOR HOW MAY STAFF MEMBERS WERE NEEDED TO ASSISTS RESIDENT #101 WITH A TRANSFER, CNA #7 STATED, "SHE IS A TWO PERSON TRANSFER". FACILITY EMPLOYEE WARNING NOTICE - JOB PERFORMANCE FORM FOR CNA #7 DATED 11/9/11 DOCUMENTED THAT CNA #7 RECEIVED VERBAL WRITTEN COACHING FOR QUALITY OF CARE/PERFORMANCE AS A TYPE OF OFFENSE. UNDER DESCRIPTION OF INFRACTION THE FOLLOWING IS DOCUMENTED: ON 11/4/11 DID NOT FOLLOW CARE GUIDE WHEN PROVIDING CARE TO RESIDENT (#101 LISTED). PROVIDED ASSIST OF ONE FOR TRANSFER WHEELCHAIR TO BED CAUSING AN INJURY TO HER RIGHT ANKLE. RESIDENT CARE GUIDE STATES ASSIST OF TWO. #

THIS CITATION PERTAINS TO INTAKES MI 471; MI 537; MI 604; AND MI 634. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO PREVENT INCIDENTS OF RESIDENT TO RESIDENT PHYSICAL ABUSE THAT RESULTED IN INJURIES FOR 2 OF 7 SAMPLED RESIDENTS (#505 AND #506). IN SEPARATE INCIDENTS RESIDENT #505 SUSTAINED FACIAL BRUISING AFTER BEING PUNCHED IN THE FACE, AND RESIDENT #506 SUSTAINED A BREAK IN THE SKIN WHEN HE WAS BITTEN ON HIS RIGHT FOREARM. FURTHERMORE, THE FACILITY FAILED TO PREVENT INCIDENTS OF SEXUAL ABUSE FOR 3 OF 7 SAMPLED RESIDENTS (#502; #503; AND #504) THAT POTENTIALLY COULD RESULT IN DISEASE EXPOSURE. FINDINGS: ON 5/04/11, AT 10:00 A.M., A TOUR OF THE FACILITY'S SECOND FLOOR REVEALED A SECURED UNIT REFERRED BY STAFF AS THE "SERENITY UNIT." OBSERVATION REVEALED THAT A KEY CODE WAS REQUIRED FOR ENTRY OR EXIT ON THE UNIT. ON 5/04/11, AT 11:00 A.M., INTERVIEW WITH THE ADMINISTRATOR AND THE DIRECTOR OF NURSING REVEALED THAT RESIDENTS WITH SEVERELY IMPAIRED COGNITIVE ABILITIES OCCUPIED ROOMS ON THE SERENITY UNIT. REVIEW OF THE FACILITY ROSTER OR CMS 802 FORM INDICATED THAT RESIDENTS #503, #504, #505, AND #506 RESIDED ON THE SERENITY UNIT. RESIDENT #502 WHO NO LONGER RESIDED AT THE FACILITY ALSO OCCUPIED A ROOM ON THE SERENITY UNIT AS REPORTED BY THE DIRECTOR OF NURSES AND ADMINISTRATOR. REVIEW OF A "FACILITY INVESTIGATION REPORT" DATED 4/22/11, INDICATED THAT ON 4/12/11, AT APPROXIMATELY 3:40 P.M., RESIDENTS #505 AND #506 WERE IN THE TELEVISION ROOM ON THE SERENITY UNIT WHEN RESIDENT #505 BIT RESIDENT #506 ON HIS RIGHT FOREARM THAT RESULTED IN A BREAK IN THE SKIN. THE REPORT INDICATED THAT THE SERENITY UNIT SOCIAL WORKER AND A CERTIFIED NURSING ASSISTANT, KNOWN AS EMPLOYEE "A" WITNESSED THE INCIDENT. ON 5/06/11, AT 8:50 A.M., INTERVIEW WITH THE SERENITY UNIT SOCIAL WORKER REVEALED THAT RESIDENT #505 HAD A BEHAVIORAL PROBLEM THAT INCLUDED BITING BOTH PEERS AND STAFF. THE SOCIAL WORKER STATED THAT "SOMETIME IN 2010, SHE (RESIDENT #505) HAD AN ALTERCATION WITH A FEMALE RESIDENT ON THE SERENITY UNIT AND BIT THAT RESIDENT ON HER ARM." THE SOCIAL WORKER ALSO STATED THAT RESIDENT #505 HAD ONCE BITTEN A CERTIFIED NURSING ASSISTANT (CNA) ON THE ARM. REVIEW OF A FACILITY INCIDENT REPORT DATED 2/05/10, REVEALED THAT RESIDENT #505 WAS INVOLVED IN AN ALTERCATION ON THE SERENITY UNIT WITH ANOTHER FEMALE RESIDENT AND BIT HER ON THE LEFT ARM. THE INCIDENT REPORT INDICATED THAT THE PHYSICIAN WAS IMMEDIATELY NOTIFIED. THE RESIDENT'S BITE WAS CLEANSED AND TREATED WITH ANTIBIOTIC OINTMENT AND A COLD COMPRESS WAS APPLIED. THERE WAS NO INDICATION THAT THE RESIDENT'S SKIN HAD BEEN BROKEN. ON 5/06/11, AT 11:30 A.M., INTERVIEW WITH EMPLOYEE "A" REVEALED THAT RESIDENT #505 BIT HER ON THE ARM. EMPLOYEE "A" STATED, "LAST YEAR, SHE (RESIDENT #505) BIT ME ON THE ARM AND BROKE THE SKIN." EMPLOYEE "A" WAS UNABLE TO RECALL THE EXACT DATE OF THE INCIDENT BUT REPORTED IT WAS "SOMETIME LAST YEAR OR IN 2010." EMPLOYEE "A" STATED THAT THE BITE REQUIRED TREATMENT AT AN EMPLOYEE HEALTH CLINIC. ON 5/06/11, AT 12:30 P.M., INTERVIEW WITH THE ADMINISTRATOR VERIFIED THAT THE INCIDENT OCCURRED AND EMPLOYEE "A" REQUIRED MEDICAL treatment for [REDACTED]. REVIEW OF THE CLINICAL RECORD FOR RESIDENT #505 REVEALED IN THE physician progress notes [REDACTED]. ON 5/05/11, AT 11:00 A.M., INTERVIEW WAS ATTEMPTED WITH RESIDENT #505, HOWEVER HER RESPONSES WERE NONSENSICAL AND IRRELEVANT. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT THE RESIDENT HAD BOTH SHORT AND LONG TERM MEMORY IMPAIRMENT WITH DISORGANIZED THINKING. REVIEW OF THE COMPREHENSIVE CARE PLAN DATED 3/01/11, INDICATED THAT THE RESIDENT HAD BEHAVIORAL PROBLEMS THAT INCLUDED AGITATION AND PARANOID THINKING. INTERVENTIONS TO ADDRESS THIS PROBLEM BEHAVIOR INCLUDED INCREASED MONITORING AND SUPERVISION. A BEHAVIOR TRACKING FORM INDICATED THAT BITING, GRABBING, AND HITTING STAFF AND PEERS WERE BEHAVIORAL PROBLEMS FOR RESIDENT #505. REVIEW OF THE CLINICAL RECORD FOR RESIDENT #505 INDICATED IN THE "NURSE'S NOTES" DATED 4/12/11, AT 5:00 P.M., "PASSED BY RESIDENT (#506) AND SHE GRABBED HIS RIGHT ARM AND BIT HIM, BREAKING SKIN CAUSING MODERATE AMOUNT BLEEDING. PHYSICIAN NOTIFIED." REVIEW OF THE CLINICAL RECORD FOR RESIDENT #506 REVEALED ON THE ADMISSION FACE SHEET [DIAGNOSES REDACTED]. INTERVIEW WAS ATTEMPTED WITH RESIDENT #506, HOWEVER HIS RESPONSES WERE NONSENSICAL AND IRRELEVANT. REVIEW OF THE "NURSE'S NOTES" DATED 4/12/11, AT 5:00 P.M., INDICATED "BITTEN ON RIGHT ARM BY (RESIDENT #505) 4/3 CM (CENTIMETER) AREA. MODERATE AMOUNT OF BLEEDING. AREA CLEANSED AND DRESSING APPLIED. TETANUS SHOT TO BE GIVEN IF NOT RECEIVED IN LAST TEN YEARS. TYLENOL GIVEN FOR COMFORT. STAFF TO MONITOR." REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. THE PHYSICIAN HAD ALSO ORDERED FOR THE RESIDENT TO RECEIVE A TETANUS SHOT WHEN IT WAS ESTABLISHED THAT HE REQUIRED ONE AS DOCUMENTED IN THE NURSE'S NOTES ON 4/15/11. ON 5/6/11, AT 9:30 A.M., OBSERVATION REVEALED THAT RESIDENT #506 HAD A HEALED AREA ON HIS RIGHT FOREARM WHICH WAS WHERE HE WAS BITTEN BY RESIDENT #505 ON 4/12/11. AT THE TIME OF THIS OBSERVATION IT WAS REPORTED BY LICENSED NURSING STAFF THAT ONLY MONITORING OF THE WOUND SITE WAS REQUIRED WITHOUT ANY NEED FOR FURTHER TREATMENT. THERE WAS EVIDENCE THAT RESIDENT #505 had a history of [REDACTED]. STAFF FAILED TO PROVIDE RESIDENT #505 WITH THE REQUIRED MONITORING AND SUPERVISION WHICH WERE INTERVENTIONS OUTLINED IN THE RESIDENT'S PLAN OF CARE. FAILURE TO PROVIDE THE NECESSARY SUPERVISION RESULTED IN AN AVOIDABLE INCIDENT OF PHYSICAL ABUSE AND INJURY TO RESIDENT #506. REVIEW OF A "FACILITY INVESTIGATION REPORT" DATED 4/29/11, INDICATED THAT ON 4/25/11 AT APPROXIMATELY 4:50 P.M., RESIDENTS #505 AND #507 WERE IN THE TELEVISION ROOM ON THE SERENITY UNIT WHEN RESIDENT #507 PUNCHED RESIDENT #505 IN HER CHEST AND FACE THAT RESULTED IN SWELLING AND BRUISING AROUND HER LEFT CHEEK AND BELOW HER LEFT EYE. THE REPORT INDICATED THAT FACILITY STAFF WAS UNABLE TO RESPOND QUICKLY ENOUGH TO PREVENT THE INCIDENT. THE INCIDENT WAS WITNESSED BY A CERTIFIED NURSING ASSISTANT, KNOWN AS EMPLOYEE "B". THE REPORT INDICATED THAT THE RESIDENT'S FACIAL INJURY REQUIRED PHYSICIAN INTERVENTION THAT INCLUDED AN ICE PACK. THE REPORT FURTHER INDICATED THAT THE PHYSICIAN ORDERED BOTH CHEST AND FACIAL X-RAYS. REVIEW OF THE "NURSE'S NOTES" DATED 4/25/11, AT 5:00 P.M., INDICATED THAT THERE WAS NO EVIDENCE OF REDNESS OR COMPLAINTS OF PAIN OR DISCOMFORT IN THE CHEST AREA. REVIEW OF THE X-RAY REPORTS DATED 4/25/11, REVEALED NEGATIVE RESULTS. ON 5/05/11, AT 3:00 P.M., INTERVIEW WITH EMPLOYEE "B" REVEALED THAT SHE WITNESSED THE INCIDENT BETWEEN RESIDENT #505 AND #507. EMPLOYEE "B" STATED THAT PRIOR TO THE INCIDENT RESIDENT #507 WAS OBSERVED PACING UP AND DOWN THE CORRIDORS ON THE SERENITY UNIT AND BECOMING VERBALLY AGGRESSIVE. EMPLOYEE "B" STATED THAT SHE HEARD RESIDENT #507 TELL RESIDENT #505 TO "SHUT UP" BECAUSE SHE WAS TAKING LOUDLY. EMPLOYEE "B" STATED THAT RESIDENT #507 APPROACHED RESIDENT #505 AND STARTED PUNCHING HER IN THE FACE AND CHEST. EMPLOYEE "B" REPORTED "THERE WAS A LOT OF CONFUSION GOING ON THE UNIT. WE HAD ANOTHER INCIDENT BETWEEN TWO OTHER RESIDENTS WHO WERE FOUND IN BED TOGETHER. THERE WAS A LOT OF NOISE AND I THINK IT SET HIM (#507) OFF." REVIEW OF THE CLINICAL RECORD FOR RESIDENT #507 REVEALED ON THE ADMISSION FACE SHEET [DIAGNOSES REDACTED]. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT THE RESIDENT HAD BOTH SHORT AND LONG TERM MEMORY IMPAIRMENT WITH DISORGANIZED THINKING. REVIEW OF THE COMPREHENSIVE CARE PLAN DATED 3/01/11, INDICATED THAT THE RESIDENT HAD BEHAVIORAL PROBLEMS THAT INCLUDED WANDERING, FRUSTRATION WITH PEERS, AND SUSPICIOUS THOUGHTS. INTERVENTIONS TO ADDRESS THIS PROBLEM BEHAVIOR INCLUDED INCREASED MONITORING AND SUPERVISION. A BEHAVIOR TRACKING FORM INDICATED THAT VERBAL AGGRESSION, UNPROVOKED COMBATIVENESS, AND WANDERING BEHAVIORAL PROBLEMS FOR RESIDENT #507. REVIEW OF THE CLINICAL RECORD FOR RESIDENT #505 REVEALED A PRIMARY [DIAGNOSES REDACTED].M., INTERVIEW WAS ATTEMPTED WITH RESIDENT #505, HOWEVER HER RESPONSES WERE NONSENSICAL AND IRRELEVANT. OBSERVATION REVEALED A SMALL BRUISED AREA BELOW THE LEFT EYE. NURSING STAFF REPORTED THAT THERE WAS NO FURTHER TREATMENT REQUIRED TO THE RESIDENT'S FACIAL AREA. FURTHER REVIEW OF THE CLINICAL RECORD FOR RESIDENT #505 INDICATED IN THE "SOCIAL SERVICE PROGRESS NOTES" DATED 4/26/11, "TODAY FAMILY MEMBER OF (RESIDENT #505) MET WITH ADMINISTRATOR AND SOCIAL WORKER AND DIRECTOR OF NURSING REGARDING INCIDENT ON 4/25/11. FAMILY MEMBER STATED THAT SHE IS CONCERNED ABOUT RESIDENT'S SAFETY AND BEING MONITORED ON THE UNIT." THERE WAS EVIDENCE THAT RESIDENT #507 had a history of [REDACTED]. STAFF FAILED TO PROVIDE RESIDENT #507 WITH THE REQUIRED MONITORING AND SUPERVISION THAT WERE INTERVENTIONS OUTLINED IN THE PLAN OF CARE. FAILURE TO PROVIDE THE NECESSARY SUPERVISION RESULTED IN AN AVOIDABLE INCIDENT OF PHYSICAL ABUSE AND INJURY TO RESIDENT #505. REVIEW OF A "FACILITY INVESTIGATION" REPORT DATED 4/22/11, REVEALED THAT ON 4/17/11, AT APPROXIMATELY 3:40 P.M., RESIDENTS #502 AND #504 WHO BOTH RESIDED ON THE SERENITY UNIT WERE FOUND TOGETHER LAYING IN BED. THE REPORT INDICATED THAT RESIDENT #502 WAS FOUND WITHOUT UNDERGARMENTS AND HER SKIRT LIFTED AT THE WAIST. RESIDENT #504 REPORTEDLY WAS WEARING ONLY A "PULL UP" BRIEF. THE INCIDENT WAS WITNESSED BY EMPLOYEES "C" AND "D" WHO WERE NURSING PERSONNEL ON THE AFTERNOON SHIFT ON THE SERENITY UNIT. ON 5/5/11, AT 12:30 P.M., INTERVIEW WITH EMPLOYEE "C" REVEALED THAT AT APPROXIMATELY 3:40 P.M., ON 4/17/11, SHE WAS MAKING ROUNDS ON THE SERENITY UNIT AND COULD NOT LOCATE RESIDENT #502 WHO SHE OBSERVED EARLIER IN THE TELEVISION ROOM WITH RESIDENT #504. EMPLOYEE "C" STATED THAT SHE OBSERVED THE DOOR CLOSED TO THE ROOM OCCUPIED BY RESIDENT #504. EMPLOYEE "C" STATED THAT WHEN SHE OPENED THE DOOR SHE OBSERVED RESIDENTS #502 AND #504 LAYING IN HIS BED. EMPLOYEE "C" STATED THAT RESIDENT #502 HAD HER SKIRT PULLED UP AT HER WAIST AND WAS NOT WEARING ANY UNDERGARMENTS. EMPLOYEE "C" STATED THAT RESIDENT #504 WAS WEARING ONLY A "PULL-UP BRIEF." EMPLOYEE "C" STATED THAT AFTER THE RESIDENTS WERE SEPARATED SHE NOTIFIED THE PHYSICIAN WHO GAVE ORDERS FOR RESIDENT #502 TO BE TRANSFERRED TO AN AREA HOSPITAL emergency room FOR A PELVIC EVALUATION. REVIEW OF THE "HOSPITAL emergency room PHYSICIAN REPORT" DATED 4/17/11, INDICATED THAT THERE WAS NO SIGN OF VAGINAL TRAUMA. THE RESIDENT WAS TRANSFERRED BACK TO THE NURSING HOME SUBSEQUENT TO THE emergency room TREATMENT. REVIEW OF CLINICAL RECORD FOR RESIDENT #504 REVEALED ON THE ADMISSION FACE SHEET THAT HE HAD [DIAGNOSES REDACTED]. ON 5/5/11 AT 1:00 P.M., INTERVIEW WAS ATTEMPTED WITH RESIDENT #504, HOWEVER HIS RESPONSES WERE NONSENSICAL IN CONTEXT. THERE WAS NO EVIDENCE IN THE RESIDENT'S CLINICAL RECORD THAT HE HAD EXHIBITED SEXUALLY INAPPROPRIATE BEHAVIOR. REVIEW OF THE CLOSED CLINICAL RECORD FOR RESIDENT #502 REVEALED THAT SHE HAD [DIAGNOSES REDACTED]. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT THE RESIDENT HAD BOTH SHORT AND LONG TERM MEMORY IMPAIRMENT WITH DISORGANIZED THINKING. THE RESIDENT HAD COURT APPOINTED GUARDIANSHIP WITH HER DAUGHTERS DESIGNATED AS CO-GUARDIANS. REVIEW OF THE "NURSE'S NOTES" DATED 4/4/11, AT 2:30 P.M., INDICATED "REDIRECTED SEVERAL TIMES TO STAY AWAY FROM MALE RESIDENTS. RESIDENT INITIATING HOLDING OF HANDS, KISSING, AND OCCASIONAL SHARING OF FOOD ITEMS. SOCIAL WORKER AWARE OF DAUGHTER WISHES TO KEEP HER APART FROM MALE RESIDENTS." ON 5/05/11, AT 1:00 P.M., INTERVIEW WITH THE SOCIAL WORKER REVEALED THAT THE GUARDIANS FOR RESIDENT #502 HAD REPORTED TO HER THAT IT WAS "OUT OF THE RESIDENT'S (#502) CHARACTER TO HOLD HANDS AND KISS OTHER MALES." THE SOCIAL WORKER STATED THAT THE GUARDIANS HAD REQUESTED FOR STAFF TO SEPARATE THE RESIDENT FROM HOLDING HANDS WITH MALE RESIDENTS. REVIEW OF A "FACILITY INVESTIGATION REPORT" DATED 4/25/11, INDICATED THAT AT APPROXIMATELY 4:00 P.M., RESIDENT #502 WAS OBSERVED WITH HER HAND INSIDE THE PANTS OF RESIDENT #503, AND SHE ATTEMPTED TO TOUCH HIS GENITALIA. THE INCIDENT WAS WITNESSED BY EMPLOYEE "D". THE REPORT INDICATED THAT WHEN STAFF ATTEMPTED REDIRECT RESIDENT #502 SHE BECAME HOSTILE AND EXHIBITED INCREASED CONFRONTATIONAL BEHAVIOR WITH RESIDENTS AND STAFF. RESIDENT #502 WAS TRANSFERRED BY PETITION FOR INVOLUNTARY PSYCHIATRIC hospitalization on [DATE]. ON 5/5/11, AT 1:30 P.M., INTERVIEW WITH EMPLOYEE "D" REVEALED THAT ON 4/25/11, AT APPROXIMATELY 2:00 P.M., SHE OBSERVED RESIDENTS #502 AND #503 WALKING ON SERENITY UNIT HOLDING HANDS. EMPLOYEE "D" STATED THAT SHE OBSERVED RESIDENT #502 PUT HER HAND INSIDE THE PANTS OF RESIDENT #503 IN AN ATTEMPT TO TOUCH HIS PENIS. EMPLOYEE "A" STATED THAT WHEN SHE ATTEMPTED TO SEPARATE THE RESIDENTS SHE ENCOUNTERED RESISTANCE FROM RESIDENT #502. EMPLOYEE "D" STATED THAT SHE ALERTED OTHER NURSING STAFF OF HER OBSERVATION. EMPLOYEE "D" STATED THAT AT APPROXIMATELY 4:00 P.M., SHE OBSERVED RESIDENTS #502 AND #503 ENTER THE SHOWER ROOM ON SERENITY UNIT. EMPLOYEE "D" STATED THAT WHEN SHE ENTERED THE SHOWER ROOM SHE OBSERVED RESIDENT #503 WITH HIS PENIS EXPOSED. EMPLOYEE "D" STATED THAT WHEN SHE ATTEMPTED TO REDIRECT RESIDENT #502 OUT OF THE SHOWER ROOM SHE BECAME VERBALLY AND PHYSICALLY AGGRESSIVE. EMPLOYEE "D" STATED THAT "SHE (RESIDENT #502) WAS JERKING HIM (RESIDENT #503) BY HIS ARM AND WOULDN'T LET HIM OUT OF THE SHOWER ROOM." EMPLOYEE "D" STATED THAT SHE ALERTED THE CHARGE NURSE AND RESIDENT #502 WAS TRANSFERRED TO THE HOSPITAL FOR PSYCHIATRIC EVALUATION. REVIEW OF THE CLINICAL RECORD FOR RESIDENT #503 REVEALED ON THE ADMISSION FACE SHEET THAT HE HAD [DIAGNOSES REDACTED]. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT HE HAD BOTH SHORT AND LONG TERM MEMORY LOSS WITH DISORGANIZED THINKING. ON 5/5/11 AT 10:30 A.M., INTERVIEW WAS ATTEMPTED WITH RESIDENT #503, HOWEVER HIS RESPONSES WERE NONSENSICAL IN CONTEXT. THERE WAS NO EVIDENCE IN THE RESIDENT'S CLINICAL RECORD THAT HE HAD EXHIBITED SEXUALLY INAPPROPRIATE BEHAVIOR. THERE WAS EVIDENCE THAT RESIDENT #502 HAD EXHIBITED BEHAVIORS THAT HER LEGAL GUARDIANS HAD REQUESTED BE MONITORED TO PREVENT ANY INCIDENTS OF POTENTIAL ABUSE. STAFF FAILED TO PROVIDE RESIDENT #502 WITH THE REQUIRED MONITORING AND SUPERVISION IN RECOGNITION OF THIS BEHAVIORAL PROBLEM THAT RESULTED IN AVOIDABLE INCIDENTS OF SEXUAL ABUSE INVOLVING RESIDENTS #503 AND #504. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT ASSISTIVE DEVICES WERE ACCESSIBLE FOR ONE OF TWO RESIDENTS IDENTIFIED WITH FALLS (#321) OUT OF A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN A FALL WITH ASSOCIATED INJURY. FINDINGS INCLUDE: A REVIEW OF THE ADMISSION FACE SHEET, ON 11/9/10 AT 11:25 A.M., REVEALED THAT RESIDENT #321 WAS admitted TO THE FACILITY IN MARCH 2005. A PHYSICIAN PHYSICAL FORM, DATED 4/1/10, INDICATED THAT THE RESIDENT HAD MULTIPLE DIAGNOSES, THAT INCLUDED PERIPHERAL VASCULAR DISEASE, ATRIAL FIBRILLATION, CONGESTIVE HEART FAILURE, HYPERTENSION, POLYMYALGIA RHEUMATICA (A SYNDROME THAT IS ASSOCIATED WITH PAIN IN THE NECK, SHOULDERS AND HIPS) AND OSTEOPOROSIS. THE MINIMUM DATA SET (MDS), WITH AN ASSESSMENT REFERENCE DATE OF 9/20/10, REVEALED THAT RESIDENT #321 DID NOT AMBULATE (WALK), REQUIRED TOTAL ASSISTANCE WITH TRANSFERS, DRESSING AND HYGIENE, WAS INCONTINENT AND HAD A PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBE (A TUBE INSERTED INTO THE STOMACH THROUGH A SMALL INCISION IN THE ABDOMEN FOR USE OF LONG-TERM NUTRITION) . THE MDS ALSO NOTED THAT THE RESIDENT HAD EXPERIENCED FALLS IN THE PAST 180 DAYS. ON THE AFTERNOON OF 11/9/10, THE RESIDENT'S "UNUSUAL OCCURRENCE "REPORTS WERE REQUESTED. A REVIEW OF THE "UNUSUAL OCCURRENCE " REPORT, WRITTEN ON 3/29/10 AT 5:40 P.M., INDICATED THAT RESIDENT #321 WAS "OBSERVED ON FLOOR ...IN RESIDENT'S ROOM" ON 3/29/10. THE REPORT DESCRIBED THE EXTENT OF THE RESIDENT'S INJURY AT THE TIME OF THE OBSERVATION AS "RT (RIGHT) LEG CONTRACTURED ... .... PT (PATIENT) CRYING OUT WITH TOUCH OF LEG ... ...TRANSFER PT. TO (NAME OF HOSPITAL) emergency room FOR EVALUATION." THE REPORT NOTED THAT THE RESIDENT'S ROOM MATE WAS THE ONLY WITNESS TO THE FALL. NURSING NOTES, DATED 3/31/10, REVEALED THAT THE RESIDENT WAS readmitted TO THE FACILITY WITH A "R (RIGHT) LEG IMMOBILIZER ....IN PLACE" DUE TO A "DX (DIAGNOSIS): FX (FRACTURE) R (RIGHT) FEMUR(THIGH BONE)." AN UNDATED "AFFIDAVIT FOR UNUSUAL OCCURRENCE", WRITTEN BY A STAFF NURSE, INDICATED THAT SHE (THE WRITER OF THE AFFIDAVIT) WAS "NOTIFIED BY RESIDENT (UNNAMED) THAT PT (PATIENT) HAD GOTTEN UP FROM W/C (WHEELCHAIR) UNASSISTED-WITHOUT CALLING FOR ASSISTANCE." FURTHER REVIEW OF THE "UNUSUAL OCCURRENCE" REPORT REVEALED THAT THE ONLY SAFETY/ASSISTIVE DEVICES NOTED AT THE TIME OF THE FALL WERE A LOW BED AND BED BOLSTERS. OTHER ITEMS, SUCH AS, "CALL LIGHT WITHIN REACH", "WHEELCHAIR LOCKED" AND "ALARM SOUNDING" HAD NOT BEEN CHECKED OFF AS IN PLACE AT THE TIME OF THE FALL. THE REPORT ALSO INDICATED THAT THE RESIDENT WAS "REMINDED EVERY DAY WRITER WORKS TO REQUEST ASSISTANCE WITH TRANSFERS." A REVIEW OF THE RESIDENT'S NURSING CARE PLAN FOR FALLS, DATED 10/23/09, IDENTIFIED THE FALL RISK PROBLEM FROM THE RESIDENT'S PERSPECTIVE AS "I HAVE LIMITED MOBILITY. I AM WEAK AND I TIRE EASILY. I RECENTLY RECEIVED AN INJURY TO MY SHOULDER. I DON'T WANT TO FALL AND HURT MYSELF ANYMORE." INTERVENTIONS LISTED ON THE CARE PLAN INCLUDED: ANTICIPATE MY NEEDS AND INTERVENE AS NEEDED, MAKE SURE MY BRAKES ARE ON AND FUNCTIONING PROPERLY ON MY BED AND WHEELCHAIR DURING TRANSFERS, CHECK ON ME FREQUENTLY THROUGHOUT THE DAY, AND KEEP MY CALL LIGHT WITHIN MY REACH WHEN I AM IN MY ROOM." A FALL RISK ASSESSMENT, DATED 1/18/10, IDENTIFIED THE RESIDENT'S FALL RISK AS "22" (SCORES BETWEEN 20-29 ARE CONSIDERED A MODERATE RISK FOR FALLS). THE FALL RISK ASSESSMENT ALSO NOTED THAT WHEN A RESIDENT'S TOTAL SCORE IS 10 OR MORE, INTERVENTIONS SHOULD PROMPTLY BE PUT IN PLACE. ON 11/10/10 AT 9:00 A.M., THE RESIDENT'S ROOM MATE, WHO WAS ALERT AND ORIENTED, WAS INTERVIEWED REGARDING RESIDENT #321'S FALL ON 3/29/10. ADMINISTRATOR "I" WAS PRESENT DURING THE INTERVIEW. THE RESIDENT'S ROOMMATE STATED THAT SHE REMEMBERED THE RESIDENT FALLING FROM HER WHEELCHAIR IN MARCH. SHE INDICATED THAT THE RESIDENT WAS SITTING IN HER WHEELCHAIR IN THEIR ROOM AND WAS ATTEMPTING TO STAND UP. SHE SAID THAT SHE TOLD HER ROOMMATE TO SIT BACK DOWN AND SHE DID. HOWEVER, SHE INDICATED THAT THE RESIDENT DIDN'T LISTEN TO HER, AND STOOD UP AGAIN, AND fell . WHEN QUESTIONED FURTHER ABOUT THE LOCATION OF THE RESIDENT'S CALL LIGHT, SHE INDICATED THAT IT WAS ON THE FLOOR AND NOT WITHIN REACH OF THE RESIDENT. RESIDENT #321 WAS ALSO INTERVIEWED ON 11/10/10 AT 9:05 A.M., BUT WAS UNABLE TO RECALL THE FALL OR ANY DETAILS RELATED TO THE FALL. THERE WAS NO INFORMATION IN THE RESIDENT'S MEDICAL RECORD TO INDICATE THAT OTHER SAFETY DEVICES WERE ATTEMPTED FOR A RESIDENT, THAT ACCORDING TO THE "UNUSUAL OCCURRENCE" REPORT ON 3/29/10, HAD TO BE REMINDED "EVERY DAY" TO "REQUEST ASSISTANCE WITH TRANSFERS." THERE WAS NO INFORMATION TO INDICATE HOW THE RESIDENT WOULD BE ABLE TO CALL FOR ASSISTANCE WITHOUT ACCESS TO HER CALL LIGHT. ( ) DURING A GROUP INTERVIEW, ON 11/8/10 AT 2:00 P.M., NINE OUT OF 12 RESIDENTS COMPLAINED ABOUT CALL LIGHTS NOT BEING ACCESSIBLE. THEY STATED THAT THE CNA'S THROW THEIR CALL LIGHTS BEHIND THEIR BED. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF A PRESSURE ULCER FOR ONE OF FIVE SAMPLED RESIDENTS IDENTIFIED WITH PRESSURE ULCERS (#308 ) OUT OF A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN THE DEVELOPMENT OF FACILITY ACQUIRED PRESSURE ULCER. FINDINGS INCLUDE: ACCORDING TO A REVIEW OF THE ADMISSION FACE SHEET ON 11/7/10 AT 2:00 P.M., RESIDENT #308 WAS admitted TO THE FACILITY IN JANUARY 2009 WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS), WITH AN ASSESSMENT REFERENCE DATE OF 9/30/10, REVEALED THAT RESIDENT #308 DID NOT AMBULATE (WALK) AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS, DRESSING AND HYGIENE. THE MDS ALSO INDICATED THAT ON THE DATE OF THE ASSESSMENT THE RESIDENT WAS IDENTIFIED AS HAVING A STAGE ONE PRESSURE ULCER (INTACT SKIN WITH NON-BLANCHABLE REDNESS). A REVIEW OF THE LICENSED NURSE WEEKLY HYDRATION AND SKIN ASSESSMENT SHEETS REVEALED THAT THE RESIDENT WAS IDENTIFIED WITH A "REDDENED" AREA ON THE LEFT BUTTOCKS ON 10/6/10. HOWEVER, NURSING NOTES, DATED 10/6/10, IDENTIFIED THE RESIDENT AS HAVING AN "OPEN AREA IN CREASE AND TO LEFT SIDE OF BUTTOCKS." A PHYSICIAN ORDER [REDACTED]. ACCORDING TO A REVIEW OF THE FACILITY WOUND PROTOCOL, DATED 6/4/10, STAGE TWO PRESSURE ULCERS (PARTIAL THICKNESS LOSS OF DERMIS PRESENTING AS A SHALLOW OPEN ULCER) SHOULD BE CLEANSED WITH SAFCLENS AND [MEDICATION NAME] APPLIED. THERE WAS NO DOCUMENTATION THAT THEIR POLICY WAS FOLLOWED WHEN THE "OPEN AREA" WAS FIRST IDENTIFIED ON 10/6/10. THE WEEKLY HYDRATION AND SKIN ASSESSMENTS, DATED 10/9/10 AND 10/13/10, CONTINUED TO DESCRIBE THE SKIN ON THE RESIDENTS BUTTOCKS AS "REDDENED". YET NURSING NOTES, DATED 10/10/10, IDENTIFIED A "NEW OPEN AREA ON THE RESIDENT'S COCCYX" THAT WAS "PAINFUL TO TOUCH....SKIN SURROUNDING THE WOUND AREA APPEARS FRAGILE." NO CHANGES WERE MADE TO THE RESIDENTS WOUND CARE TREATMENT UNTIL 10/13/10 WHEN AN ORDER WAS WRITTEN TO "CLEANSE THE OPEN AREA ON THE SACRUM WITH SAFCLENS (WOUND CLEANSER) AND APPLY [MEDICATION NAME] ( AN OPAQUE DRESSING USED TO PROTECT WOUNDS FROM CONTAMINATION) EVERY 3-5 DAYS AND AS NEEDED". THERE WAS NO FURTHER DOCUMENTATION ON THE STATUS OF THE RESIDENT'S "OPEN AREAS" UNTIL 10/18/10. A REVIEW OF THE physician progress notes [REDACTED]. TREATMENT WAS CHANGED TO "SANTYL (AN ENZYMATIC OINTMENT USED TO REMOVE NECROTIC TISSUE FROM WOUNDS) Q (EVERY) DAY." WEEKLY PRESSURE ULCER WOUND DOCUMENTATION WAS NOT INITIATED UNTIL 10/22/10, TWO WEEKS AFTER THE "OPEN AREAS" WERE IDENTIFIED. THE PRESSURE ULCER WAS NOW DESCRIBED AS UNSTAGEABLE (FULL THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE ULCER IS COVERED BY SLOUGH - DEAD TISSUE - AND/OR ESCHAR - A HARD CRUST OR SCAB) MEASURING 10 CENTIMETERS BY 7 CENTIMETERS. ON 10/26/10 THE physician progress notes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