Every finding on record at Lakeside Manor Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure resident safety during van transportation, resulting in a laceration (cut) to the head, fractured ankle, and increased anxiety when being transported for one resident (R6) out of two reviewed for accidents. Findings include:A review of R6's Electronic Medical Record (EMR) revealed they were admitted to the facility 7/15/2023 with diagnoses of depression, generalized anxiety disorder, and cardiomyopathy (heart disease). Review of R6's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.On 08/04/2026 at 11:06 AM, an interview was conducted with R6. R6 indicated they had a fractured ankle and cut to their head as a result of tipping backward in a wheelchair and being thrown from the chair striking their head and lower leg in the facility transport van. R6 explained they were being taken out for an appointment and revealed the transport driver set them up in their wheelchair in the van in a reclined position, and when the van slowed down to a stop, they were thrown from the chair across the van, causing them to hit their head and break a bone in their foot.A review of nursing notes in R6's EMR revealed a note dated 3/30/2026 at 9:15 AM documenting that R6 left the facility at 7:50 AM that morning for a urology appointment, and later the driver called to report R6 had fallen in the transport van and the resident was taken to the hospital by emergency medical services (EMS). A review of R6's hospital after visit summary dated 3/30/2026 revealed diagnoses of laceration of scalp and nondisplaced fracture of medial malleolus. (bone on the inside of the leg close to ankle joint) and included instructions to have staples (used to repair scalp laceration) removed in 7-10 days. Review of a nursing note dated 3/30/2026 at 1:40 PM, documented R6 had 2 staples placed for the laceration to the back of their head and a right ankle fracture.A review of R6's care plan revealed a focus area initiated 01/28/2026 of, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) activity intolerance, hemiplegia (one-sided paralysis), impaired balance, limited mobility, with an intervention initiated 01/28/2026 of Transfer-The resident requires mechanical lift total 2 person staff assistance for transfers. An additional focus area in R6's care plan initiated 01/28/2026 included The resident is at risk for falls r/t mobility deficits and limitations, with an intervention initiated 2/24/2026 for a high back wheelchair.On 08/05/2026 at 1:49 PM, an additional interview was conducted with R6 and was asked to recount the incident in the transport van. R6 said they were strapped into their wheelchair with a seatbelt and positioned in a way where they felt like their whole weight was leaning backward, almost like they were lying down. R6 explained when the van stopped, their wheelchair tipped backwards, and they flew out of it, and slid across the floor and hit their head on the chair in the van. They recalled seeing their legs go straight up into the air and then come back down causing the impact injury to their foot (ankle). R6 went on to say they will never feel safe in a car again.On 08/05/2026 at 2:23 PM, the Director of Nursing (DON) was asked to explain their findings from the investigative report surrounding the incident which occurred on 3/30/26. The DON stated they helped oversee the internal investigation of this incident, and to their knowledge, it was determined R6 was traveling in the facility van to an appointment, and when the driver stopped R6's wheelchair tilted backwards causing R6 to slide out and hit their head. The DON did not confirm whether the resident was in a high back wheelchair at the time of the incident. A review of the investigative report signed by the DON on 3/30/2026 identified a root cause for the incident as Resident was not secured properly in wheelchair.On 08/05/2026 at 2:33 PM, an interview was conducted with the Facilities Director (FD) who said upon inspecting the safety equipment of the van after the incident they found one seatbelt was locked up and wouldn't retract correctly. The FD also stated they ordered and installed a replacement seatbelt. Upon request, a receipt for the order of the new seatbelt was provided and revealed an order transaction date of 05/08/2026 (39 days after the incident with R6).On 08/06/2026 at 10:02 AM, an interview was conducted with the facility van driver, Driver K who confirmed they were the one who secured the resident and was driving the van during the incident with R6. Driver K recounted the incident from that day and said they slowed down the van while going downhill, R6, who was strapped into their wheelchair, facing the rear of the van, fell backwards towards the front of the van. The driver further explained R6 is top heavy, and they were reclined back somewhat and not sitting straight up in their wheelchair when strapped in, with their legs in an outstretched position. Driver K did not confirm if R6 was in a high back wheelchair or if the described position was the proper way to transport a resident. Driver K said they did see R6's head was bleeding after they fell out of their wheelchair.A review of a social services note dated 3/31/2026 documented R6 is now nervous about being up in a wheelchair after their injury in the transport van and noted R6 expressed they felt trauma from the experience.A review of the active physician's order with a revision date of 4/2/2026 revealed an order for Alprazolam (generic name for Xanax, an anti-anxiety medication) 0.25 milligrams (mg) oral tablet to be given before appointments. Further review of R6's active physician orders revealed R6 had an order for Xarelto 20mg once daily (medication which reduces the ability for blood to clot increasing the risk of bleeding from physical trauma).Review of a nursing note dated 4/6/2026 documented, R6 requested Xanax to be available for an appointment on 4/7/2026 to ensure they felt safe to travel in the facility van.A facility policy dated 4/1/2026 (the day after the incident) revealed it is the policy of the facility that All residents transported in facility-operated vehicles. shall be secured in a manner that ensures their safety.at all times

This citation pertains to Intake 3002913. Based on interview and record review, the facility failed to ensure the responsible party (RP) was informed of a change in skin condition for one resident (R53) of one reviewed for a change in condition. Findings include: A review of a concern called into the State Agency revealed concerns regarding the alteration of the skin and a failure to properly assess, treat, communicate, and disclose critical aspects of R53's health.A progress note dated 04/04/26 documented R53's transfer to the hospital for urine retention and groin pain.An re-admission summary by Licensed Practical Nurse (LPN) O dated 04/13/2026 at 18:21 (6:21 PM) revealed: Patient (R53) arrived via EMS (emergency medical system) at approximately 18:10 (6:10 PM). Brief assessment completed .Peri care provided and soiled linens removed and replaced with clean linens. Patient resting comfortably in bed, call light within reach, and bed placed in low position for safety. admission process ongoing; will endorse to oncoming shift for continuation of care. A review of the admission skin assessment dated [DATE] at 19:40 (7:40 PM) documented a skin tear to the coccyx (tailbone area). A corresponding note which documented notification of the RP of the skin tear was not found. A Skilled Evaluation dated 04/13/26 at 23:01 (11:00 PM) also documented the skin tear to the coccyx. The line education/notification was left blank. A review of a noted authored by LPN N dated 05/27/2026 at 19:42 PM, documented, .Skin warm & dry, skin color WNL (within normal limits) and turgor (ability to return back to normal) is normal. Resident does not have an external device. No new skin issues identified. Skin Issues: Skin Issue: #001: Skin issue has not been evaluated. Location: Coccyx. Laterality/Orientation: Middle. Issue type: Skin tear. Type 1: No skin loss. Wound was present on admission. It is unknown how long the wound has been present . A corresponding note which documented notification of the RP of the skin tear was not found. A progress note dated 06/13/26 documented a discharge to the hospital for respiratory concerns and R53 had not returned.On 08/06/26 at 12:08 PM, the Director of Nursing (DON) reported they recalled the RP wanting to transfer R53 to another facility but did not recall any other concerns or any wounds. At this time, notification of the RP related to skin tear was requested and an email dated 04/07/26 (prior to hospital discharge) was provided indicating the daughter (for R53) asked about a deep tissue injury (DTI-closed pressure injury-deep purple or maroon in color) and any documentation of any care provided. The facility response did not address the DTI, but indicated changes in condition can occur rapidly and staff responded to the changes (urinary retention and groin pain) which sent R53 to the hospital. A review of the electronic medical record (EMR) revealed R53 was originally admitted into the facility 08/05/25. R53's diagnoses included Stroke and Paralysis of the left side, Prostate and Throat Cancer and Heart Disease. A final/resolved care plan documented The resident has potential/ impairment to skin integrity (related to) r/t fragile skin. Date Initiated: 01/27/2026. Revision on: 06/08/2026. Resolved: Wound Management. Date Initiated: 04/13/2026. Revision on: 06/08/2026.A review of the Medication and Treatment Administration Records (MAR's and TAR's) from 04/3/26 to 06/13/26 documented treatments to the sacrum (buttocks).The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score and that R53 was dependent on staff for lower body dressing, bed mobility, personal hygiene and transfer.

Based on observation, interview, and record review, the facility failed to develop a care plan with targeted goals and interventions for use of an upper extremity brace for one resident (R43) of two reviewed for care plans. Findings include:R43 On 08/04/2026 at 8:47 AM, R43 was observed lying in bed. Their right upper extremity was observed as contracted (muscle shortening) and a brace was observed sitting to the right of the resident on their nightstand. R43 was asked if they wear their brace and explained they sometimes wear it, but it hurts when they do. A review of R43's medical record revealed they were admitted into the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction (stroke), Major Depressive Disorder, and Hyperlipidemia (high cholesterol). Further review revealed the resident moderately cognitively impaired and was dependent on staff for bathing, dressing and transfers. Further review of the medical record revealed the following active physician's order dated 2/3/26, Elbow splint (brace) RT (right) UE (upper extremity), to be worn up to 6 hours or as tolerated daily. Every dayshift. On 08/06/2026 at 10:39 AM, Certified Nursing Assistant (CNA) A who also provides restorative services was asked about R43 and the application of their brace. CNA A said they attempt to apply the splint to the resident daily and explained at times they may refuse because it causes them discomfort. A review of R43's medical record did not reveal a care plan for restorative services for R43's brace. On 08/06/2026 at 1:23 PM, the Director of Nursing (DON) and Unit Manager B were asked about R43's missing care plan. Upon review of the resident's medical record, Unit Manager B noted it was not there but was sure it had been created in the previously used electronic medical record. At that time, R43's restorative care plan was requested. On 08/06/2026 at 2:00 PM, Unit Manager B said the care plan was not located in the previously used electronic medical record and acknowledged the need for one. A review of the facility's, Comprehensive Care Plans policy revealed the following, .6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed

Based on interview and record review, the facility failed to revise a care plan with an appropriate intervention following a fall for one resident (R45), of one reviewed for care plan revision. Findings include:On 08/05/2026 at 8:36 AM, an interview was conducted with R45 in their room. They were asked if they have sustained any falls in the facility to which they said they slipped out of their wheelchair after becoming dizzy. A review of R45's medical record revealed they were admitted into the facility on [DATE] with diagnoses which included Dementia, Acquired Absence of Left Leg above Knee, and Polyneuropathy (neurological condition). Further review revealed the resident was cognitively intact and required extensive assistance for activities of daily living. Further review of the medical record revealed a progress note dated 6/8/2026 at 12:09pm . Resident was been (being) transferred to the chair by two CNA (certified nursing assistants) use (using) the [mechanical lift] when resident slipper (slipped) out of the chair and landing (landed) on the floor. Resident did not hit [their] head. A full assessment was done no injury present. Resident c/o (complaint of) of back pain. NP (nurse practitioner) was notified and new order for an x-ray. Resident was place back in the bed with call light in reach. On 08/06/2026 at 10:05 AM, a phone interview was completed with CNA E (one of the two CNA's who transferred R45 into the chair) who indicated they and another CNA transferred the resident into their chair via a [mechanical lift] and reported once they got R45 in the chair, the resident needed to be slid up as they weren't sitting all the way up. CNA E explained they and the other CNA attempted to pull R45 up without success and went to locate additional assistance, however, the resident slid from the chair onto the floor. A review of R45's care plan revealed the following fall care plan and intervention following R45's fall, Focus: The resident is High risk for falls r/t (related to) Left AKA (above knee amputation), cognitive deficits. Hx (history) of falls .Date Initiated: 01/28/2026. Revision on: 03/13/2026 .Interventions: The resident needs activities that minimize the potential for falls while providing diversion and distraction. Date Initiated: 06/08/2026. Revision on: 06/15/2026. On 08/06/2026 at 1:23 PM, the Director of Nursing (DON) and Unit Manager B were asked about R45's post fall care plan revision and the appropriateness of the intervention of The resident needs activities that minimize the potential for falls while providing diversion and distraction as the fall was not related to activities. The DON did not provide an explanation, and Unit Manager B stated, I see what you mean. A review of the facility's, Care Plan Revisions Upon Status Change policy was reviewed but did not address appropriate and meaningful interventions.

This citation pertains to Intake 3002913. Based on observation, interview, and record review, the facility failed to ensure dependent residents were repositioned timely for two residents (R10 and R7) of two reviewed for professional standards of practice with positioning. Findings include: R10On 08/04/2026 at 10:54 AM, R10 was in bed with the head of the bed raised at around 30-45 degrees. A low air loss mattress was set on the alternating setting. A pillow was partially visible at the right side of the torso. R10 opened their eyes when queried but did not respond. At 11:30 AM, a family member reported via a phone conversation that R10 was less communicative and more confused during and since their recent trip to the hospital. The family member also reported R10 did not move much on their own.On 8/04/2026 at 11:45 AM, Certified Nursing Assistant (CNA's) C and CNA D were observed to provide care to R10. Pink colored (name of non-adherent type) dressings were observed on both heels. The CNAs noted some redness to the skin of the buttocks and lower back (sacral) area. Heel boots were not in place at this time as R10 was returned to a position more on their back but turned slightly onto the right side facing the door. A pillow under the lower legs. A pillow was not placed under the right arm. The head of the bed was up around 30-45 degrees. The CNAs reported R10 had just returned from the hospital the day before and was more dependent in care now than before the recent hospitalization. On 08/04/2026 at 12:33 PM, R10 was in bed, laying more on their back but remained facing toward the right side. The legs were flexed up toward the abdomen and off the pillow. At 1:33 PM, R10 was observed in the same position as before. R10's head was tilted back and the mouth was open. At 4:21 PM, R10 was observed in a similar position as before, with the legs flexed toward the abdomen a little more and off the pillow. On 08/05/2026 at 8:27 AM, 9:36 AM, 10:10 AM, and 11:03 AM, R10 was in bed, on their right side with the head of the bed raised around 30-45 degrees. The legs were flexed toward the abdomen. At 12:39 PM, R10 was more on their back but remained faced toward the right side, with the head of the bed up around 30-45 degrees.On 08/05/2026 at 1:16 PM, staff were in the room and completed wound care. At 2:04 PM, R10 was on their right side, with the head of the bed up 30-45 degrees. At 3:59 PM and 4:56 PM, R10's position was unchanged. On 08/05/2026 at 1:41 PM, CNA G reported R10 was dependent on staff for all care and had a history of an open area on the buttocks. On 08/06/2026 at 4:13 AM, CNA I and RN J were in with R10 to provide incontinence and wound care. At 4:35 AM, R10 was observed in bed on their right side with the head of the bed up around 30-45 degrees. The legs were flexed and were not elevated on a pillow or device, and the protective heel boots were not on. A pair of regular foam heel boots and two pair of pressure relieving ankle foot orthotic (PRAFO) boots were on the chairs at the foot of the bed. A review of a current physician's orders documented the heel boots were to be on twelve hours and off twelve hours. On 08/06/2026 at 5:54 AM, 6:48 AM and 8:13 AM, R10 continued in bed as before. A review of the available electronic medical record (EMR) revealed, R10 was admitted into the facility on [DATE] and readmitted on [DATE]. Diagnoses included Dementia, Left Sided Paralysis, Arthritis, Muscle Wasting and Malnutrition. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition and dependence on staff for all activities of daily living.A review of the active care plan for R10 revealed, .The resident has an Activities of Daily Living (ADL) self-care performance deficit r/t (related to) Activity Intolerance, Fatigue, Impaired balance, Limited Mobility. Date Initiated: 05/18/2026 . Bed mobility: The resident is totally dependent on staff for repositioning and turning in bed. Date Initiated: 05/18/2026. Revision on: 05/18/2026. The resident has potential for pressure ulcer development r/t Hx (history) of ulcers, Immobility, incontinence, and MASD (Moisture Associated Skin Damage). Date Initiated: 05/18/2026. Revision on: 08/04/2026. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements .frequent repositioning. Date Initiated: 05/18/2026. Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Date Initiated: 05/18/2026.R7On 08/04/2026 at 9:23 AM, R7 was observed on their back (supine) in bed with the head of the bed up 45-60 degrees. A low air loss (LAL) pressure reducing mattress was in place. R7 had protective heel boots on and legs elevated. At 1:29 PM, R7 continued supine in bed, the head of the bed up 45-60 degrees. at 2:28 PM, R7 continued in bed as before. On 08/04/2026 at 4:36 PM, R7 continued in bed as before and covered more fully with the bedspread. Drinks were on a tray table which was partially over the bed at the waist area. The head of the bed was up around 45-60 degrees with the lower legs elevated.On 08/05/2026 at 8:22 AM, R7 was observed supine in bed with the head of the bed up around 45-60 degrees for breakfast.On 08/05/2026 10:17 AM, R7 was observed supine in bed with the head of the bed up around 30-45 degrees. At 10:23 AM, CNA M entered the room, and an observation of incontinence care was completed. R7 was observed to have old wound areas to the buttocks and tailbone areas. R7 continued to leak urine.A review of the August 2026 Treatment Administration Record (TAR) revealed a pressure wound to the left upper buttock with an active treatment. On 08/05/26 at 10:36 AM, CNA M reported this was the first time they were getting to R7 (since the start of their shift at 7:00 AM). At completion of care CNA M returned R7 to a supine position and placed a wedge at both sides of the torso. The foam heels protectors were on with the legs elevated and the head of the bed around 30-45 degrees. At 10:46 AM, R7's position was remined unchanged.On 08/05/2026 at 1:00 PM, R7 was supine in bed with the head of the bed up around 45-60 degrees. At 2:17 PM, R7's position was unchanged. At 4:07 PM and 4:54 PM, R7 was positioned as before. A review of the electronic medical record for R7 revealed, R7 was admitted into the facility on [DATE]. R7's diagnoses included Dementia, Paraplegia, Bladder Dysfunction and Pressure Ulcer of Unspecified Site. A review of the Minimum Data Set (MDS) dated [DATE] documented impaired cognition with a 6/15 Brief Interview for Mental Status (BIMS) score; Impaired range of motion to both legs and dependence on staff for positioning in bed, dressing bathing and toileting.The active care plan documented, Impaired Physical Mobility. Date Initiated: 02/06/2026. The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility. (R7) is bedridden most of the time. Date Initiated: 01/27/2026. I have a self-care deficit r/t: Hx of paraplegia, multiple comorbidities and weakness Date Initiated: 01/28/2026. Bed mobility: x 2 assist. Date Initiated: 01/28/2026. Revision on: 02/02/2026 .On 08/06/26 at 12:08 PM, the Director of Nursing (DON) reported dependent residents should be repositioned at least every two hours and as needed. A review of the facility policy titled, Turning and Repositioning implemented 11/01/22 revealed, It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning . 1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. In this case, small shifts in repositioning will be employed. 2. Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning. 3. The facility has established routine turning and repositioning schedules consisting of every 2-4 hours, on the even hour. A maximum of thirty minutes before or after the scheduled time will be allotted for compliance with the schedule. 4. A routine turn schedule includes using both side-lying and back positions, alternating from the right, back, and left side. It also includes assisting the resident to stand, or making small shifts of position, if in chair. A resident's condition will determine whether or not a specialized turn schedule is warranted. 5. The frequency of turning and repositioning will be documented in the resident's plan of care, and will be determined by the resident's: a. Tissue tolerance b. Level of activity and mobility c. Skin condition d. Overall medical condition e. Treatment goals f. Type of pressure redistribution support surface in use (turning and positioning is still required on specialty surfaces, but frequency may be reduced) g. Comfort levels . Ensure that heels are floated off the surface of the bed with pillows or devices designed to do so. If using a heel protector, the heel must still be floated.

Based on observation, interview and record review, the facility failed to ensure an effective pain management plan was implemented for one resident (R10) of three reviewed for pain management. Findings include: On 08/04/2026 at 10:54 AM, R10 was in bed with the head of the bed raised at around 30-45 degrees, a non-English news program was on the TV. A low air loss mattress was set on the alternating setting. R10 opened their eyes when queried but did not respond. On 08/04/2026 at 11:30 AM, a family member reported via a phone conversation that R10 was less communicative and more confused during and since their recent trip to the hospital. The family member reported R10 did not move much on their own and only spoke one word or two during a recent hospital stay. It was further noted R10 would not use the call light.On 8/04/2026 at 11:45 AM, Certified Nursing Assistant (CNA) C and CNA D were observed to provide care to R10. R10 vocalized an ah sound three times in succession intermittently during care and turning of the resident. The vocalization increased in volume with touching and movement. The CNAs noted some redness to the skin of the buttocks and lower back (sacral) area. A pillow was under the lower legs. The CNAs reported R10 had just returned from the hospital the day before and was more dependent in care now than before the recent hospitalization. On 08/05/2026 at 9:59 AM, two CNA's and Registered Nurse (RN) F were observed with R10, and a heel dressing was completed. The RN reported R10 had a stage four (non-intact skin with exposed muscle tissue or bone) pressure ulcer to the left heel. R10 had a bowel movement, and the ah, ah sound was vocalized by the resident intermittently during clean up care. On 08/05/2026 at 10:10 AM, 11:03 AM, and 12:39 PM, R10 was in bed and faced toward the right side with their legs flexed up toward the abdomen, and the head of the bed up around 30-45 degrees. R10 made two faint unprovoked ah, ah sounds.On 08/05/2026 at 1:16 PM, staff were in the room, intermittent ah sounds were heard. At 1:25 PM, the wound care nurse practitioner (NP) told the CNA they wanted to look at the buttocks of R10 but first needed to be cleaned of a bowel movement. The aide entered to provided care and an oh, oh, oh was heard intermittently during care. The vocalization was steady and the pitch went up and down. These vocalizations were heard greater than 30 times during the care provided. At 1:36 PM, the sound converted to ow and was heard multiple times with longer and shorter intonations of this. On 08/05/2026 4:57 PM, RN F reported R10 makes the ah sound when just touched slightly and was unsure if it was actual pain each time the vocalization was heard. The nurse further reported staff had not reported any concerns about R10's pain to them. Upon review of the physician orders in the electronic medical record (EMR) R10 had been ordered acetaminophen (pain reliever) every six hours as needed. A review of the August 2026 Medication Administration Record (MAR) revealed no pain medication had been offered or provided to R10 from August 1st through 5th, 2026.On 08/05/2026 at 1:41 PM, CNA G reported R10's vocalizations were a response to pain. CNA G reported family were in most days and would assist with communication. On 8/6/26 (the day after the observations, the pain rating was documented in the Medication Administration Record (MAR) as a 5 (scale of 1 to 10. 1 being lowest and 10 being highest). A Vitals and Pain Only evaluation dated 08/06/26 at 11:49 AM, revealed a pain score of 4 on the numerical scale with nonverbal descriptors of pain documented (the numerical scale requires a verbal response from the resident).On 08/06/2026 at 4:13 AM, CNA I and RN J were in with R10 to provide incontinence and wound care. Vocalizations of ah, ah, ah could be heard through the door at various levels of volume and pitch.On 08/06/2026 at 4:30 AM, RN J reported R10's vocal expressions were a combination of movement and pain. RN J confirmed they had observed a change in the facial expression with their dressing change of R10's heel.On 08/06/2026 at 8:13 AM, during unit rounds, a couple of ah, ah sounds were heard. 08/06/2026 at 8:33 AM, Licensed Practical Nurse (LPN) L reported R10 does not speak a lot, and it was hard to say how much R10 understands. LPN L further confirmed R10 yells out during incontinence care, and feels the vocalizations are likely related to some discomfort with the care being provided.On 08/06/26 at 12:08 PM, the Director of Nursing (DON) reported pain assessments are done with administration of medications and are prompted by the electronic medical record (EMR). The DON further noted that nurses and CNAs are to monitor, report, and/or manage a resident's pain concerns and using appropriate pain scale as with pictures should be used (for non-verbal residents). A review of the EMR revealed, R10 was admitted into the facility on [DATE] and readmitted on [DATE]. Diagnoses included Dementia, Left Sided Paralysis, Arthritis, Muscle Wasting and Malnutrition.A review of the active care plan for R10 revealed, I do not speak in the dominant language of the facility. I am not vocalizing any words at this time. I am making eye contact and may start to vocalize again. I was making some responses in both English and (primary language) prior. Date Initiated: 05/12/2026. The resident has chronic pain (related to) r/t Diabetic neuropathy. Date Initiated: 04/22/2026. Revision on: 04/22/2026. Administer analgesia as per orders. Give 1/2 hour before treatments or care. Date Initiated: 05/18/2026. Revision on: 06/04/2026. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 04/22/2026. Monitor/record/report to Nurse any (sign/symptoms) s/sx of non-verbal pain: Changes in breathing, (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Date Initiated: 05/18/2026 .A review of the policy titled, Pain Management revised 03/05/25 revealed, Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain). c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences .

Based on observation, interview, and record review, the facility failed to date inhalers (for R22) after opening in one of three medication carts reviewed for medication storage and labeling. Findings include: On 8/5/2026 at 9:09 AM, the South Two medication cart was inspected with Licensed Practical Nurse (LPN) O. During the inspection two inhalers for R22 were observed to be opened with no name on the inhalers. On 08/05/2026 at 11:19 AM, a medication room check with LPN O was done. During the inspection two of three tuberculin vials were not dated when opened on the vial, the boxes were dated 7/20 and 7/16/26 respectively. LPN O indicated the resident's name should be on the inhalers, and medication vials should be dated when opened. On 08/06/2026 at 7:08 AM, during an interview with the Director of Nursing (DON) they confirmed inhalers to be dated after opening.

Based on observation, interview, and record review, the facility failed to timely implement a divided plate during meals for one resident (R43) of one reviewed for assistive eating equipment/utensils. Findings include:On 08/04/2026 at 8:47 AM, R43 was observed sitting up in bed with their meal tray in front of them. Further observation of the meal tray revealed curved built-up utensils. A review of R43's medical record revealed they were admitted into the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction (stroke), Major Depressive Disorder, and Hyperlipidemia (high cholesterol). Further review revealed the resident was moderately cognitively impaired and was dependent on staff for bathing, dressing and transfers.Further review of R43's medical record revealed the following active order dated, 8/3/26, Regular diet. Mechanical Soft (Ground or Soft) texture, Regular/Thin consistency, Divided plate placed on rubber-like material used to keep items from slipping for non-slippage while scooping and manipulation of left hand, curved, built-up utensils, scooping ability.On 08/05/2026 at 8:30 AM, R43 was sitting up in bed with their breakfast tray sitting in front of them. There was no divided plate or rubber-like material used for non-slippage. On 08/05/2026 12:29 PM, R43 was sitting up in bed with their lunch tray sitting in front of them. There was no divided plate or rubber-like material used for non-slippage. On 08/06/2026 at 8:19 AM, R43 was sitting up in bed with their breakfast tray sitting in front of them. There was no divided plate or rubber-like material used for non-slippage. R43 was asked if they had ever used a divided plate, and they stated, No.On 08/06/2026 at 12:33 PM, the Dietary Manager was asked about the observations of R43 not having their divided plate, and the timeliness of implementation once the order was placed. The Dietary Manager did not provide an explanation regarding the surveyor's observations; however, they did acknowledge the importance of the resident having it to assist with eating for the prevention of weight loss. A review of the facility's, Accommodation of Needs policy revealed the following, .4. Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well being to the extent possible .

Based on observation, interview and record review, the facility failed to appropriately store a nebulizer (medication to assist with breathing) mask for one resident (R47) of one reviewed for sanitary storage of nebulizer masks. Findings include:On 08/04/2026 at 8:44 AM, 11:51 AM, and 2:16 PM, R47 was observed lying in bed. A nebulizer mask was observed sitting on the resident's nightstand uncovered and lying on top of miscellaneous personal items of the resident. A review of R47's medical record revealed they were admitted into the facility on 9/25/25 with diagnoses of Chronic Obstructive Pulmonary Disease, Asthma, and Acute Respiratory Failure with Hypoxia. Further review revealed the resident was moderately cognitively impaired and required some assistance for activities of daily living (ADL's). Further review of the medical record revealed the following active orders dated 2/1/26: Albuterol Sulfate 2.5 mg (milligrams)/3 ML (milliliters) 0.083 % VIALNEB (vial nebulizer) 1 ml inhale orally three times a day for Asthma. Nebulizer: After each use, wipe nebulizer mask with a clean damp cloth. Rinse nebulizer chamber with warm tap water and allow to air dry, three times a day. On 08/05/2026 at 8:31 AM, 11:34 AM, and again at 12:29 PM, R47's nebulizer mask was observed sitting on the resident's nightstand uncovered. The mask was sitting on top of miscellaneous personal items of the resident. A review of the August (2026) Medication Administration Record (MAR) revealed the resident received the nebulizer medication as ordered, and the task of cleaning the mask had been signed out as completed on 8/4/26 and 8/5/26. On 08/06/2026 at 10:22 AM, the Infection Control Preventionist (ICP) was asked about the proper storage of nebulizer masks. The ICP explained that when a nebulizer mask is not in use it should be stored in a plastic bag, and it shouldn't be sitting out on a dresser.

Based on observation, interview, and record review, the facility failed to properly transfer one resident (901) of one reviewed for transfers. Findings include:A review of documentation submitted to the State Agency (SA) revealed the following, [R901] requires 2-person transfer assist and is unable to maintain [their] weight on [their] own. On 3/23/2026, 2 aides, Certified Nursing Assistants (CNA) A and CNA B transferred [R901] from [their] wheelchair to [their] bed by pulling on [their] arms .On 4/15/26 at 8:44 AM, an interview was completed with R901 regarding a manual transfer that occurred on 3/23/26, with the two CNAs. R901 explained they were transferred from the bed to the wheelchair with a mechanical lift, and when it was time for them to be transferred from the wheelchair to the bed, the CNAs (CNA A and CNA B) said to them that the sling had slipped too far up for it to be used, and they would have to manually transfer them (back into bed). R901 explained there was a CNA on each side of them when they lifted them out of the wheelchair resulting in them attempting to stand them on their feet causing pain which they told the CNAs. R901 explained they spoke to the Director of Nursing (DON) regarding the transfer, and she confirmed the CNAs should not have transferred them in that way. A review of R901's medical record revealed they were admitted into the facility on 9/4/25 with diagnoses which included Cerebral Infarction, Lymphedema, and Polyarthritis. Further review revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs).Further review of R901's physician orders revealed an active order dated 1/22/26: Transfers: (name of mechanical) lift w (with)/ 2 person assist.On 4/15/26 at 10:04 AM, an interview was completed with CNA A regarding the transfer of R901.They explained they were asked to assist the resident's assigned CNA (CNA B) with transferring the resident; however, the resident's mechanical lift sling had slipped too far up their back, and with the resident being a large resident, they were unable to reposition the sling and connect it to the lift. CNA A confirmed the decision was made to manually transfer the resident back to bed which they completed with CNA B.On 4/15/26 at 11:08 AM, CNA B was interviewed via phone about the transfer of R901. CNA B explained they were assigned to R901 on the date of the transfer. He reports he and another CNA (CNA A) transferred the resident from their bed to their wheelchair and once in the wheelchair, the resident had to be readjusted which resulted in the sling becoming out of position. When it was time for R901 to be transferred back into bed, they were unable to use the sling. CNA B explained they informed the resident of the manual transfer, and appeared to be ok with it, as they indicated it had been a while since they were able to place their feet on the floor. CNA B explained the resident was able to bear a bit of weight on their feet and were transferred into the bed. CNA B explained the resident did not complain about the transfer or indicate they were in any pain. On 4/15/26 at 12:52 PM, the DON was asked about the manual transfer of R901, and she explained the CNAs were supposed to follow the resident's plan of care. She further explained they should have gathered everyone together, and if they still were unable to transfer the resident per plan of care, they could have contacted 911. On 4/15/26 at 9:52 AM, a Transfer policy was requested from the facility, however, it was not received by the end of survey.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include:On 02/04/2026 at 9:45am-10:15am during the initial kitchen tour with Dietary Supervisor J, observed an opened bag of turkey dated 2/3 with a discard date of 2/10 and an opened bag of salami dated 2/3 with a discard date of 2/10, located in the walk-in refrigerator. During this observation, Dietary Supervisor J was asked how long they hold onto food and stated food is kept for 7 days.According to the facility's date marking policy, Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 F or less for a maximum of 7 days.According to the 2022 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 02/04/2026 at 9:45am-10:15am observed a dark brown residue on the interior walls of the ice machine located in the kitchen. During this observation, Dietary Supervisor J was asked how often the ice machine is cleaned and stated it's cleaned every month. On 02/04/2026 at 9:45am-10:15am observed utility sink with an attached hose to a chemical feeder downstream of an atmospheric vacuum breaker (AVB). According to the 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.On 02/04/2026 at 10:22am observed a strong odor coming from refrigerator with a black box of leftovers and a cup of yogurt that was warm to the touch, located in the cafe. During this observation, Housekeeping Supervisor C was asked how long the refrigerator has been off and stated the refrigerator has been off for several months. According to the 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5 C (41 F) or less.According to the 2022 Food Code, 4-301.11 Cooling, Heating, and Holding Capacities, Equipment for cooling and heating food, and holding cold and hot food, shall be sufficient in number and capacity to provide food temperatures as specified under Chapter 3.On 02/04/2026 at 10:29am observed yellow residue on the interior wall of the ice machine, located in the nourishment room. On 02/05/2026 at approximately 2:00pm during interview with Director of Facilities K on how often the ice machine is cleaned in the nourishment room, he stated it's cleaned and sanitized monthly. According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, interview, and record review, the facility failed to maintain the exterior trash refuse area in a sanitary manner. This deficient practice had the potential to affect all residents, staff and visitors. Findings include:On 2/4/26 at 10:45 AM, the exterior trash refuse area was observed. There were 2 dumpsters, and both doors on each dumpster were observed to be in the open position. Garbage was observed spilling onto the ground surface including several used disposable gloves. Also observed on the ground in the enclosure were 2 large empty boxes, a grill unit, a wood pallet. On 2/4/26 at 10:15 AM, prior to the observation of the garbage area, Dietary Manager J was queried about maintenance of the outside garbage area and stated that the responsibility was shared among Maintenance, Housekeeping, and Dietary for maintaining that area. Record review of the facility policy Disposal of Garbage and Refuse Policy dated 11/1/2022 indicates: Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

Based on observation, interview, and record review, the facility failed to put on and take off personal protection equipment for one (R5) of eight residents with an Enhanced Barrier Precaution (EBP) sign on room door and did not provide adequate Personal Protection Equipment (PPE) for four resident rooms with PPE equipment located in resident rooms; and failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings include: On 02/04/2026 at 10:29am observed filter to the ice machine dated 8/14/2023 as the installment date, located in the nourishment room. On 02/04/2026 at 11:01am observed an unused fountain pop machine wrapped in plastic and plumbed into the wall with an attached carbonator, located in the dining area. On 02/04/2026 at approximately 11:30am during interview with Dietary Supervisor J on the unused fountain pop machine in the dining area, she stated the fountain pop machine has been wrapped in plastic and unused for as long as she's been working there, and she's been working at the facility for about a year and four months. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow. On 02/04/2026 at 1:35pm during the environmental tour with Director of Facilities K, observed an out of order toilet removed from the water line and the water line to the toilet was left open to the environment, located in the shower room in the 200 hallways. During this same observation, there appeared to be an unused hydrotherapy tub with dirt accumulation at the bottom of the tub. During this observation, Director of Facilities K was asked if the tub was flushed, and he answered the tub is flushed monthly. According to the facility's policy on Legionella/OPPP Flushing and Disinfection of fixtures/equipment, Resident showers, faucets, toilets, or other plumbing fixtures that are not in regular use must be flushed for at least 1 minute weekly, toilets flush twice. Upon review of the flushing logs given by the facility at the time of survey, there was not a record of the hydrotherapy tub being flushed. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. On 02/04/2026 at approximately 2:00pm during interview with Director of Facilities K on how often the ice machine filter is changed in the nourishment room, he stated it should be changed out quarterly. On 02/04/2026 at 3:12pm during interview with the Administrator on the hydrotherapy tub located in the 200 hallways, she stated the hydrotherapy tub hasn't been used the entire time she's been there and no residents are care planned to use the tub. On 2/4/2026 at 10:53 AM, a review of rooms with EBP signs on the room door revealed that four rooms (119, 203, 218, 226) had no gowns or masks available. On 2/4/2026 at 12:30 PM a CNA was observed delivering a tray and then moving resident bedding around without gloves or a gown on. On 2/4/26 at 1:30 PM, R5, a resident on EBP, was observed receiving morning care from Certified Nursing Assistant (CNA) A who did not have a gown on. CNA A stated, They never wear a gown when getting this resident out of bed. Gowns and masks were not available in the EBP cart at the door of R5's resident. CNA A revealed the scheduler fills the containers in the morning. On 2/4/26 at 1:44 PM, a review of the rooms with EBP signs on the room door revealed that four rooms had no gowns or masks available. On 2/5/2026 at 10:00 AM, an interview with the Infection Control Practitioner (ICP) and Director of Nursing (DON) revealed supplies should be in containers inside room with gowns. ICP further revealed that masks are not in drawers at this time because there are no residents with transmission-based precautions. ICP further revealed a supply person fills the containers on the night shift and is assisted by the night supervisor. The ICP further revealed that all of the care providing staff know where to obtain PPE if a container needs restocking. On 2/5/26 at 12:57 PM, Scheduler E revealed they restock any gloves that are needed in the rooms, but does not check the PPE carts. Scheduler E further revealed that they are in charge of orders for Central Supply and when stock is needed in that area, they reorder. Scheduler E further revealed masks are on order but masks are also available at the nurses' desk and the DON has some in their office. A review of the policy titled, Personal Protective Equipment implemented on date 11/1/2022 under the heading PPE supply management revealed a. the Central Supply Clerk is responsible for ordering and maintaining adequate PPE supplies and stocking in appropriate facility locations to ensure access to staff who need them .c. The charge nurses hall check isolation supply carts twice per shift and replenish as needed. The policy also revealed, All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. In addition, the policy under Indications/considerations for PPE use: a. Gloves: i. Wear gloves when direct contact with .potentially contaminated surfaces or equipment is anticipated. b. Gowns: i. Wer gowns to protect arms, exposed body areas, and clothing from contamination with .other potentially infections material. A review of the policy titled, Enhanced Barrier Precautions revised on 2/26/25 under the heading Implentation of Enhanced Barrier Precautions revealed a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .4. High-contact resident activities include: Dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting

Based on observation, interview, and record review, the facility failed to apply heel boots for three residents (R2, R4, and R13) out of four reviewed for skin conditions. Findings include:R2On 2/4/2026 at 1:15 PM, R2 was observed lying in bed. R2's bed was observed in a low position and their head of bed elevated. R2's heels were noted to be on the mattress, and heel boots were observed in a chair across the room.A review of the medical record revealed R2 was admitted into the facility on [DATE] with the following medical diagnoses, Retention of Urine and Adjustment Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating R2 was unable to complete the assessment. R2 also required staff assistance with bed mobility and transfers.A review of the physician's orders revealed the following, Order: Apply soft heel protector boot when in bed, up to 12 hours a day. Status: Active.On 2/4/2026 at 10:21 AM and 11:467 AM, R2 was observed lying in bed. No heel boots were applied.On 2/5/2026 at 8:46 AM, 9:28 AM, and 1:32 PM, R2 was observed lying in bed. No heel boots were applied.On 2/6/2026 at 9:52 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that R2 does refuse to wear their heel boots. The DON reported the nurses should document when R2 refuses to wear heel boots.A review of the progress notes, treatment administration record (TAR) and care plan did not reveal any refusals for the application of R2's heel boots.R4On 2/4/2026 at 1:24PM, R4 was observed lying in bed. No heel boots were observed in the room.A review of the medical record revealed that R4 admitted into the facility on 1/21/2021 with the following medical diagnoses, Fracture of Left Femur and Dementia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R4 also required staff assistance with bed mobility and transfersA review of the physician's orders noted the following, Order: Resident to wear proactive heel boots while in bed up to 12 hours. Status: Active.On 2/5/2026 at 8:50 AM and 1:31 PM, R4 was observed lying in bed. No heel boots were applied.On 1/6/2026 at 9:57 AM, an interview was conducted with Unit Manager (UM) B. UM B reported R4 refuses to wear their boots and often kicks them off. UM B reported if R4 refuses application, or takes them off, then it should be documented.A review of the progress notes, treatment administration record (TAR) and care plan did not reveal any refusals for the application of R4's heel boots.On 2/6/2026 at 10:04 AM, R4 was observed lying in bed, no heel boots were applied.R13On 2/5/2026 at 8:59 AM, R13 was observed lying in bed. R13 was noted to have their oxygen cannula off and sitting next to them. Heel boots were observed to be in their wheelchair, and their heels on the mattress. R13 reported they took their O2 off, but no one offered to place heel boots in them. R13 reported they were unsure of the last time they had them on.A review of the medical record revealed R13 admitted into the facility on 5/3/2023 with the following medical diagnoses, Functional Quadriplegia and Chronic Venous Hypertension. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R13 also required staff assistance with bed mobility and transfers. A review of the physician's orders noted the following, Order: Apply soft heel protectors when in bed for up to 12 hours. Status: Active.On 2/5/2026 at 12:27 PM and 1:31 PM, R13 was observed lying in bed. No heel boots were applied.On 2/6/2026 at 10:05 AM, R13 was observed lying in bed. No heel boots were applied.A review of the progress notes, treatment administration record (TAR) and care plan did not reveal any refusals for the application of R13's heel boots.A review of a facility policy titled, Physician and medication orders did not address following physician orders.

Based on observation, interview, and record review, the facility failed to implement fall interventions for one resident (R4) out of three reviewed for falls. Findings include:On 2/4/2026 at 10:09 AM, R4 was observed lying in bed. R4's bed was observed to be in an elevated position with the head of bed elevated. R4 reported they had a fall in the facility before and broke their hip. A review of the medical record revealed that R4 admitted into the facility on 1/21/2021 with the following medical diagnoses, Fracture of Left Femur and Dementia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R4 also required staff assistance with bed mobility and transfersFurther review of the fall care plan revealed the following intervention, Floor mats next to bed.On 2/4/2026 at 12:05PM, R4 was observed lying in bed. No fall mats were observed next to the bed.On 2/5/2026 at 12:16 PM, R4 was observed lying in bed. No fall mats were observed next to the bed.On 2/6/2025 at 9:55 AM, an interview was conducted with the Director of Nursing (DON). The DON reported that the fall mats should be in place for R4. The DON reported they were unsure why they were not in place, but anyone that has had a major fall should have fall mats in place.On 2/6/2026 at 10:02 AM, R4 was observed lying in bed. No fall mats were observed next to the bed.A review of a facility policy titled, Fall Prevention Program noted the following, .8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. A. Interventions will be monitored for effectiveness. B. The plan of care will be revised as needed.

Based on observation, interview, and record review, the facility failed to revise a care plan to reflect accurate transfer status for one resident (R2) out of three reviewed for falls. Findings include:On 2/4/2026 at 1:15 PM, R2 was observed lying in bed. R2's bed was observed in a low position and their head of bed elevated.A review of the medical record revealed R2 admitted into the facility on [DATE] with the following medical diagnoses, Retention of Urine and Adjustment Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating R2 was unable to complete the assessment. R2 also required staff assistance with bed mobility and transfers.Further review of an incident and accident report dated 1/14/2026 noted the following, No injuries noted during fall.A review of R2's care plan noted the following intervention on the self-care deficit care plan, Transfer: One assist; pivot transfer.Further review of the fall care plan noted the following intervention, Transfer: Two person assist.On 2/5/2026 at 9:50 AM, Certified Nursing Assistant (CNA) L was asked how R2 transfers. CNA L reported that R2 used to be a one person assist and could help get to the chair. CNA L reported R2 does not get out of bed now, so they are unsure how they transfer.On 2/6/2026 at 1:15 PM, an interview was conducted with the Director of Nursing (DON). The DON reported that R2 was made a two-person assist for transfers, following their fall. The DON reported they will have to update the care plan to reflect their accurate transfer status. The DON reported R2 has refused to get out of bed lately, so they have not witnessed any recent transfers. A review of a facility policy titled, Fall Prevention Program noted the following, .8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. A. Interventions will be monitored for effectiveness. B. The plan of care will be revised as needed.

This pertains to intakes 2723857 and 2717388 Based on interviews and record review, the facility failed to provide adequate monitoring and supervision for two residents (R38 and R44) of two residents reviewed for monitoring and supervision.R38On 2/06/2026 at 10:30 AM, R38 was observed ambulating in the hallway. R38 could not recall alleged incident or the name of the facility. A review of R38's medical record revealed that they were admitted into the facility on 9/26/23 and readmitted on [DATE] with diagnoses that included Dementia; Hypertension and Failure to Thrive. A review of R38's Minimum Data Set assessment revealed that the resident was cognitively impaired and required assistance for Activities of Daily Living.R44On 2/06/2026 at 11:30 AM, R44 was observed sitting in a chair in his room with his oxygen nasal cannula on. R44 thought they were in an apartment and would be leaving soon. R44 could not recall alleged incident.A review of R44's medical record revealed that they were admitted into the facility on 8/20/25 with diagnoses that included Vascular with Agitation, Anxiety and Chronic Obstructive Pulmonary Disease. A review of R44's Minimum Data Set assessment revealed that the resident was cognitively impaired and required extensive assistance for Activities of Daily Living. A review of R44's physician orders state 2 liters of continuous oxygen via nasal canula.A review of the medical record revealed the following nursing progress note dated on 1/10/2026 at 4:30 AM resident (R38) and another resident (R44) spent most of the night talking in the hallway in front of room114, writer educated both residents on the importance to go to sleep, but both residents continued talking to each other on the hallway of the north side of the facility.Further review of the medical record revealed the following note dated 1/10/2026 at 6:40 AM, During morning rounds, the writer entered room [ROOM NUMBER] and observed R38 seated on the bed facing the doorway without clothing. The other resident R44 from room [ROOM NUMBER] was observed standing approximately four feet away from R38 and was not wearing a shirt. The residents were engaged in conversation. The writer immediately escorted R44 back to their room. The writer then returned to room [ROOM NUMBER] to assess R38 and inquired as to why they were unclothed; the resident stated they were preparing to go to bed.On 2/7/2025 at 8:50 AM, a phone call was made to Registered Nurse (RN) M who was the nurse on duty for the day of incident. RN M stated that they noticed the residents were outside of their room talking most of the night. When preparing to round, RN M noticed that R44 was not in their room. R44 is on 2 liters of continuous oxygen. RN M was asked why the residents were not redirected or taken to their rooms during the first encounter of noticing them at 4:30 AM in the hallway. RN M stated that they were both outside their rooms. RN M went to get a nursing assistant and then went to R38's room and found both residents in there. RN M was asked why they went get a nursing assistant and they stated that just in case they needed additional assistance with a resident. RN M indicated that R38 and R44 could be in the room indicating the door was closed.On 2/7/2026 at 9:15 AM Certified Nursing Assistant (CNA) N was interviewed by phone and asked about the alleged incident. CNA N explained that they were busy with a resident when RN M came to her and stated the need to go with them to R38's room. CNA N revealed that they finished providing care and then followed RN M to R38's room. CNA N stated that upon opening the door and entering R38's room both residents were there. R38 was observed with their bra on and brief pulled down to their ankles. R44 was observed with their shirt off standing near the bed. The nurse immediately took R44 back to their room to and then came to assess R38.On 2/7/2026 at 12:30 PM, the Nursing Home Administrator (NHA) was interviewed and reported their expectation is that staff would provide adequate supervision and monitoring for all residents.

Based on observation, interview, and record review, the facility failed to empty a catheter drainage bag for one resident (R2) out of one reviewed for indwelling catheters. Findings include:On 2/4/2026 at 10:21 AM, R2 was observed lying in bed. R2 was noted to have an indwelling catheter in place, and the drainage bag (bag connected to indwelling catheter that collects urine) was full.A review of the medical record revealed R2 admitted into the facility on [DATE] with the following medical diagnoses, Retention of Urine and Adjustment Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating R2 was unable to complete the assessment. R2 also required staff assistance with bed mobility and transfers.A review of the physician's orders revealed the following, Order: Change foley bag/tube/anchor as needed.On 2/4/2026 at 1:13 PM, R2 was observed lying in bed. The drainage bag was observed to be full.On 2/5/2026 at 8:45 AM and 9:28 AM, R2 was observed lying in bed. The drainage bag was observed to be full.On 2/5/2026 at 9:52 AM, R2 was observed lying in bed. The drainage bag was observed to be full. Licensed Practical Nurse (LPN) I was shown the drainage bag and stated that it was full and should have been emptied. LPN I reported the drainage bag should be emptied every two hours and as needed.On 2/5/2026 at 9:53 AM, an interview was conducted with Certified Nursing Assistant (CNA) L. CNA L stated they were unsure of the last time R2's drainage bag was emptied. CNA L reported they did not know if it was emptied on midnights and that they had not emptied it on their shift.On 2/6/2026 at 9:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the drainage bag should be emptied when the bag is half full and should be emptied no matter what at the end of a shift.A review of a policy titled Appropriate use of Indwelling Catheters noted the following, .Indwelling urinary catheters (urethral and suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible.

Based on observation, interview, and record review, the facility failed to provide assistive devices and utensils for eating for one resident (R4) out of two reviewed for limited range of motion. Findings include:A review of the medical record revealed that R4 admitted into the facility on 1/21/2021 with the following medical diagnoses, Fracture of Left Femur and Dementia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R4 also required staff assistance with bed mobility and transfers. Further review of R4's diet order revealed the following, Directions: Help with setting up meals, use padded foam utensils/divided plate w (with) guard.On 2/5/2026 at 12:15 PM, R4 was observed in their room with their lunch tray in front of them. R4 was noted to be on a pureed diet and had not eaten much. R4 stated they did not want anymore because their stomach was hurting.R4 was observed to have regular utensils and a regular plate.On 2/5/2026 at 12:24 PM, CNA O was shown the plate and utensils. CNA O stated that on the meal ticket it showed that R4 was supposed to have padded foam utensils, but the divided plate was not on there. CNA O reported that the utensils and plates come from the kitchen and they were unsure why R4 had a regular plate and utensils.On 2/6/2026 at 11:56 AM, an interview was conducted with Dietary Manager (DM) P. DM P reported they run out of padded utensils when the staff keep them in the rooms and don't put them back on the cart to be cleaned and reused. DM P reported the divided plate is not on the meal ticket which means they never received the order to update the ticket.On 2/6/2026 at 12:02 PM, an interview was conducted with the Director of Rehab (DOR). The DOR reported that R4 was on therapy and the order came from their department to increase R4s independence with eating.A review of a facility policy titled, Restorative Nursing Programs noted the following, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.

Based on observation, interview, and record review, the facility failed to maintain the exterior trash refuse area in a sanitary manner. This deficient practice had the potential to affect all residents, staff and visitors. Findings include:On 08/04/2025 at 9:00 AM, the exterior trash refuse area was observed. There were 2 dumpsters, and both doors on each dumpster were observed to be in the open position. There was a greasy liquid observed leaking from the bottom corner of one of the dumpsters. A large area of a greasy liquid was pooled on the concrete near the dumpsters. There was a strong garbage odor present in the area. On 08/04/2025 at 10:30 AM, Dietary Manager R was queried about the dumpster area, and stated that Maintenance was responsible for cleaning that area. The policy for maintaining the exterior trash refuse area was requested from the Administrator on 08/04/25 at 11:00 AM, but was not provided by the end of the survey.According to the 2022 FDA Food Code section 5-501.115 Maintaining Refuse Areas and Enclosures, A storage area and enclosure for refuse, recyclables, or returnables shall be maintained free of unnecessary items, as specified under S 6-501.114, and clean.

This citation pertains to Intake MI00145446. Based on interview and record review, the facility failed to protect one (R4) of three residents reviewed for abuse, from sexual abuse (grabbing their breast) by another resident (R45) . Findings include: A review of Intake MI00145446 revealed the following, Incident Summary: (R45) was observed reaching out trying to touch (R4) inappropriately. (R45) was observed by staff trying to touch (R4's) chest. Further review of the Intake revealed the following interventions: 1. R45 room was changed from 202A to 213A. 2. Checks are conducted on R45 hourly. 3. R45 is being followed by psych services. 4. Legal guardians was notified. 5. R45 was petitioned out for an psychological evaluation. Review of a facility investigation revealed an Incident where R45 inappropriately grabbing R4 breast on 6/11/24. A review of the following progress notes revealed the following: -On 6/6/24 a progress note written by LPN N revealed (R45) attempted to grab on residents' breast area several times today. Writer (LPN N) explained to resident that he can not touch residents. Staff had to redirect (R45) several times today. -Late entry: On 6/5/24, Director of Nursing (DON) observed R45 on 6/5/24 attempting to touch two female residents on two separate occasions. R45 was redirected by writer on both occasions and informed that behavior was not appropriate. The DON observed R45 attempting to touch the unit manager inappropriatly. -On 6/11/24, LPN N observed R45 grabbing R4's breast. R45 was immediated redirected. -On 6/11/24, The DON noted R45 had to be redirected more than five times from following specific female patients who R45 appears to seek out and approach. On 7/16/24 at 09:45 AM, in an interview with Licensed Practical Nurse (LPN) N, who witnessed the alleged incident, was asked what happened. LPN N said on 6/11/24, R45 was observed grabbing R4's breast. R45 was redirected by the nurse and taken to their room and Director of Nursing (DON) was notified. On 7/16/24 at 10:00 AM, in an interview with LPN O, was asked about the incident, LPN O revealed they did not see the incident, however was told by other staff what occurred. LPN O confirmed on that day, I had to redirect R45 several times from going into R4's room. Staff had to monitor R45's whereabouts for the rest of that day. A copy of the monitoring sheets for R45 was requested and one day of monitoring (6/11/24) was received. The DON was not able to provide any additional evidence of protective interventions for R4 from R45 who's room was directly across the hall. A progress note dated 6/14/24 from psychological services provider documented, R45 seen as priority for ongoing sexual behaviors . A nurses noted dated 6/20/24 documented, R45 going into R4's room and staff observed R45 trying to get into the bed with R4 and redirected R45 out of the room. The DON was not able to provide any additional evidence of protective interventions for R4 from R45 who's room was directly across the hall. A progress noted dated 6/26/24 documented, (R45) was petitioned out to the hospital due to resident's inappropriate behavior in regard to requesting sexual favors from staff and residents, grabbing staff and residents. It was decided by the facility to administrator to have resident petitioned out to the hospital for a psychiatric evaluation. R45 returned on 6/27/24 from the hospital. On 6/28/24 R45's room was changed from right across the hall from R4, to further down the hallway in room (17 days after sexual assault incident). A review of R4's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included, Hypertensive Heart Disease, and Dementia. A review of R4's Minimum Data Set (MDS) assessment revealed the resident had moderately impaired congnition and required extensive assistance for Activities of Daily Living. A review of R45's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included, Vascular Dementia, Hemiplegia and Hemiparesis. A review of R45's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Infterview for Mental Status (BIMS) assessment of 8 which indicated moderate cognitive impairment. On 07/16/24 at 10:00 AM, a phone interview occurred with Director of Nursing (DON). The DON was asked her expectations for protecting their residents regarding abuse and stated, Every resident has a right to be protected from harm and abuse. A review of the facility's Abuse, Neglect and Exploitation revealed the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse.

This citation pertains to Intakes: MI 936, MI 989, MI 009, MI 142, MI 425, and MI 451. Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement from the facility for one sampled Resident (R901), noted with severe cognitive impairment and known high risk elopement history resulting in, R901 exiting the facility through the North side door of the building unbeknownst to staff, located near a busy road, during the evening approximately one mile away by a non-facility staff member and after notification retrieved by the Director of Nursing (DON). This deficient practice resulted in an immediate jeopardy, with the likelihood of serious injury, harm, impairment, or death. Findings include: A review of Intake MI 451 revealed the following, Incident Summary. The DON was notified by a staff member that a man resembling [R901] was walking down the street. She continued to keep her eyes on the person until hearing back from the DON. The DON had just left the facility, so she called and asked the charge nurse to complete a head count. During the headcount, it was noted that [R901] was not in [their] room. The DON went to the location and was able to redirect the resident and brought [them] back to the facility On 8/16/22 at 10:46 AM, R901 was observed in their room coloring with a 1:1 patient sitter (Patient Sitter D) in the room. The resident was pleasantly confused at this time. The 1:1 sitter was asked if she had been working with the resident long and indicated that this was her first time working with the resident and they were not sure why they needed 1:1 supervision. A review of R901's medical record revealed that R901 was admitted into the facility on [DATE] with diagnoses that include, Dementia, [CONDITION(S)] and Hypertensive [CONDITION(S)]. A review of the Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 4/15 indicating severe cognitive impairment. Further review of R901's medical record revealed the resident was ambulatory, and review of the facility's care plan revealed the following: [R901] is at risk of wandering and elopement; [R901] has dx (diagnosis) of dementia with bx (behavioral) disturbance, is on psych ([CONDITION(S)]) med (medication) and is a new admission; has hx (history) of elopement from home and from another nursing facility. Approach date:12/29/2021: monitor when ambulating on the unit; keep near the nursing station. Approach date:12/29/2021Redirect resident if [they] wanders toward any exit doors . On 8/16/22 at 11:05 AM, The State Ombudsman was interviewed via phone about concerns regarding the facility, and explained that R901 had eloped from the facility, and someone from the nursing home saw [R901], put [them] in the car and brought [them] back. The State Ombudsman further stated, [R901] got a good way away. I guess the door was propped open because they were bringing supplies in . The State Ombudsman further explained that the facility wants to ship [R901] out to any other location and are desperate to get rid of them because they are one of the residents who got out, however their spouse does not want them sent 3 hours away. On 8/16/22 at 12:12 PM, a phone call was attempted to Licensed Practical Nurse E, assigned nurse the date of R901's elopement to no avail. Review of their written statement revealed the following, Resident was with writer throughout the day at the nurses' station. [R901] was relaxed and calm throughout shift. After dinner between 4:45pm to 5pm I notified the Southside nurse and nursing aide that I will be going on break soon to see family for Father's Day and get an extra set of clothes. Resident was last observed eating snacks at nurse's station before going on break. Upon coming back from break north side nursing aide stated that [R901] has not been seen. We then began to search each room, bathroom, and notified all staff to search for resident. After 10-20 minutes there was a call to south side nurses station that resident was observed outside facility, DON was notified of resident's location and was then picked up and brought back to facility. A review of Nurse E's Human Resources file revealed a document titled Discipline Record Form noting that (Nurse E) were terminated on 6/30/2022. The document also revealed the following, On 6/19/22, [Nurse E] left his unit and residents for an extended period of time. He didn't give report to his coworkers. Did not do his elopement sheets for a resident under his care. [Nurse E] neglected his duties as a charge nurse, clocked in at 7:07AM and he clocked out at 8:37PM. He was clocked in at work when he was gone for a long time. His leaving the unit for an extended period of time without caring for his elopement risk resident was detrimental to the welfare of all the residents in the unit and to his fell ow employees and the company as a whole. On 8/16/22 at 2:24 PM, the Nursing Home Administrator (NHA) was interviewed and asked about R901 eloping from the facility and explained that she was not involved in the investigation as she was not the NHA at that time, however, she did hear that R901 was outside of the building, an aide saw them, and the [DON] brought them back in the building. The NHA was asked if they knew how far the resident had gotten and explained that she did not. The NHA was asked if she knew when the incident had occurred, and she explained that she thought it may have occurred during the afternoon on a Saturday. On 8/16/22 at 2:36 PM, the DON was interviewed and asked about the elopement of R901 and explained that she was in the building the date of the elopement and was driving away from the facility when she received a phone call about R901 being outside of the facility. She explained that she saw R901 and the Certified Nursing Assistant (CNA F). The DON was asked where the two were located and stated, Out by the North Hall door. The DON further explained that she parked her car, and redirected the resident back inside. The DON was asked for the name of the CNA, and initially indicated that she did not remember. She was asked if the CNA was employed at the facility and stated that they were contingent. The DON then revealed CNA F was not employed by the agency, but a CNA with a Hospice agency. A review of the statement by the DON revealed the following, At 6:55 (pm) got a call from staff who thinks resident is walking out the building; staff wasn't sure who it was but looked familiar. Receptionist called Code Pink, Checked, and found [R901] was not in [their] room. Receptionist stated she has been calling the nurse, but he is not answering his phone. Apparently, he left the building for lunch. DON driving out from facility parking lot and saw [R901] standing outside with another staff. They were talking. DON got [R901] and redirected back to facility . On 8/17/22 at 2:51 PM, a phone interview was completed with CNA G regarding the elopement of R901. CNA G explained that she was the only CNA assigned to the unit along with Nurse E who left the unit to go on a break. She explained that she saw R901 sitting at the nurses' station eating dinner when she entered another resident's room to assist them with their [CONDITION(S)] bag. She reported that she was having a difficult time with emptying the [CONDITION(S)] bag and did not have any help. CNA G was asked the amount of time she was in the room, and stated, About 30 minutes. CNA G reports that when she exited the room, she heard that they were looking for R901. A review of CNA G's written statement revealed the following, .Last time I saw [R901] was a few minutes after taking dinner tray. After that I got real busy. Also, nobody heard any alarm . On 8/18/22 at 9:06 AM, a phone interview was completed with the hospice agency CNA, CNA F regarding R901 eloping from the facility. CNA F explained that she was driving home between 6-7 PM, when she recognized R901 as a resident from the facility she provides hospice services at walking down the street. CNA F was asked what street the resident was walking down and described a busy, high traffic street that is approximately 1 mile away from the facility. CNA F explained that R901 was walking in the street, and she followed them in her car. CAN F explained she kept an eye on R901 so no one would hit them, all while contacting the facility to notify them that she found one of their residents. CNA F explained that she eventually found a safe place to park her car to get to R901 and comfort them until the DON arrived. CNA F was asked R901's cognition at that time and explained that R901 appeared confused. On 8/18/22 at 9:43 AM, a phone interview was completed with Nurse H regarding the elopement of R901. Nurse H explained that she was working on the Southside unit of the facility when Nurse E came over to the unit where she and another nurse, Nurse K were working. Nurse E stated that he was going on his break and had left his keys in his jacket at the nurses' station. Nurse H explained that Nurse K acknowledged him and said, Ok. Nurse H explained that hours later, R901's assigned CNA asked them if they had seen R901, which she reported she had not, and they began to look for them. Nurse H explained that R901's nurse had been gone for extended period of time and arrived back to the facility at approximately 7:15 PM with their basketball uniform on. Nurse H was asked if they had heard an alarm going off and stated, No, but the alarm on the door on the Northside of the building has not been working for a few weeks. On 8/18/22 at 10:02 AM, a phone call was attempted to Nurse K to no avail however, a review of her undated, unsigned statement revealed the following: I was at the nursing station with [Nurse H] when [Nurse E] came and told us (me and Nurse H) he was stepping out to go home and will be back. The keys are in his jacket pocket. This was around 4:30 to 5:00 I wasn't sure. I didn't realize anything until the Code Pink was called that was when we checked everyone and observed [R901] wasn't there. I didn't see Nurse E in between that because I was busy with my assignment. I only saw him at shift change again. But he didn't tell me to watch [R901]. Nothing like that. A review of R901's statement revealed the following: Interviewer: Where were you going the other day? R901: I tried to go home because I heard my wife voice, I was going this way and that way because it was a big circle. Then someone said, 'hey I know you.' Interviewer: How did you get out? R901: Well, the door opens you just have to push it, the alarm will go off and they will have to reset it Interviewer: [R901] we want you safe and not to leave out. R901: I know I am sorry that I did that. I won't do it again. On 8/18/22 at 4:01 PM, an interview was completed with the Regional Director of Operations (RDO) who was serving as the Administrator the date of the elopement. She explained that she received a phone call and was told that the resident was outside on the street part of the facility campus, and that the DON was on her way home when she turned back around and escorted the resident back into the building. The RDO explained that they submitted the Facility Reported Incident, and the DON completed interviews with staff. A review of the facility's Elopements policy did not reflect monitoring and supervising residents at risk of elopement. The Administrator was notified of Immediate Jeopardy on 8/18/2022 at 12:16 PM and a plan of correction was requested to remove the immediacy that began on 6/19/2022. The facility provided the following removal plan. Immediate Jeopardy was removed on 8/19/2022 and validated by the team on 8/19/2022. Removal Plan: The following steps were implemented immediately as listed: - 6/19/22-Resident back in room and facility safely - 6/19/22-Full body assessment completed, no signs of swelling, redness, bruises, or cuts noted. Pain assessed- resident denies pain. ROM negative for pain. No adverse effects noted. - 6/19/22-hourly safety checks in place; one on one sitter with resident - 6/19/22---Elopement policy and Incidents and Accident Reporting Policy reviewed with nurses and certified nurse aides on the unit. Policy understood and verbal understanding confirmed. - 06/19/22-hourly Elopement checks and hourly exit door check audits in place - 6/21/22-Elopement Assessments for all residents completed - 06/23/22-Education for all Staff on Elopement Policy and Incidents and Accident Reporting Policy completed - 06/23/22-Elopement Drill completed - From 6/24/22 to current date-all new admits reviewed for elopement risks and zero triggers noted. Other residents found at risk (2) placed on 1 hour safety monitoring. A QA meeting was held with the IDT in attendance to review action steps and results to assure compliance. The facility alleges abatement on June 19, 2022. Although the immediacy was removed on 8/19/22, the facility remained out of compliance at pattern with actual harm that is not Immediate Jeopardy as sustained compliance could not be verified by the state agency.

This citation pertains in part to intake MI 847. Based on observation, interview, and record review, the facility failed to assess for removal of a urinary catheter following admission to the facility for one sampled Resident (R907) of three residents reviewed for catheters, resulting in a urinary tract infection ([CONDITION(S)]), pain, and resident frustration. Findings include: On 8/16/22 at 8:37 AM, during an initial tour of the facility, R907 was observed sitting in bed. The resident's Foley catheter drainage bag was observed to be lying flat on the floor. When queried regarding the catheter, R907 confirmed that she has an indwelling Foley urinary catheter and that she wishes it would get taken out. R907 was asked why she has the catheter to which she responded, I was having problems peeing .I wish they'd get rid of the catheter because it [CONDITION(S)]. On 8/16/22 at 9:30 AM, R907 remained in bed and the Foley/catheter drainage bag remained lying on the floor. R907 was calling out from her room asking for help to get up out of bed. Two unidentified staff members in maroon scrubs passed by the resident's room but did not acknowledge R907. A review of R907's Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicated that the resident was cognitively intact (BIMS of 13/15). Further review of the resident's record revealed that R907 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R907's (Facility's Corporate Name) Admission Nursing Comprehensive Evaluation (admission comprehensive evaluation) document, completed by Nurse I and dated 07/23/2022 at 12:16 AM under the Observations tab in the resident's electronic medical record (EMR) revealed an indwelling catheter evaluation that included the following: .-Does the resident have a terminal illness or sever (sic) impairment, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain? No -Does the resident have a Stage III IV pressure ulcer (full thickness skin loss) in an area affected by incontinence? No -Is there a documented Post Void Residual volumes in range over 200 cc? No -Inability to manage the retention/incontinence with intermittent catheterization? No -Persistent overflow incontinence, symptomatic infections, and/or renal dysfunction? No -Summary: All questions are checked no and there is no appropriate diagnosis. No additional information related to R907's catheter was found on the Admission assessment and no additional catheter assessments were found upon reviewing the resident's medical record. Further review of R907's medical record included two hospital documents from R907's admission, one titled, Printable Discharge Form, and the other titled, Patient Discharge Summary. Both documents indicated that R907 was discharged from the hospital after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's medical history on the Patient Discharge Form, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation supporting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R907's History and Physical completed by Physician (MD) J and dated 07/26/2022 revealed no indication for continuing R907's urinary catheter and did not make mention of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R907's CKD was addressed but did not indicate use of a catheter. MD J signed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R907's progress notes revealed: -08/01/2022 7:38 AM, resident c/o (complains of) pain when urgency to urinate. writer asked resident to notify nurse next time she feels pain if it persists. Foley bag had been emptied, writer was unable to see if there was any discoloration or odor to urine. Oncoming nurse made aware. -08/02/2022 10:30 AM, written by Nurse Practitioner (NP) C, .Following for [CONDITION(S)], dysuria and generalized pain .Also reports of burning on urination however much improved after [MEDICATION(S)]. No fever chills .GU ([CONDITION(S)]): Incontinent of bladder .ASSESSMENT/PLANS: .#Dysuria likely [CONDITION(S)] (urinary tract infection). UA CS (urinalysis, culture & sensitivity) .start [MEDICATION(S)] (used to relieve symptoms caused by irritation of the urinary tract such as pain, burning, and the feeling of needing to urinate urgently or frequently) 200 3 times daily x 2 days . A progress note from Physician (MD) B dated 08/03/2022 [Recorded as Late Entry on 08/08/2022 07:47 AM] was reviewed and revealed that the resident's name was spelled incorrectly, indicated there were no new concerns per nursing staff, and indicated that the resident was incontinent of bladder, under the [CONDITION(S)] assessment with no mention of a urinary catheter. The Assessment/Plans, section included the following: #[CONDITION(S)] #[CONDITION(S)] heart disease #History of [CONDITION(S)] #Constipation #DM (Diabetes mellitus) #GERD (Gastroesophageal reflux disease) #Essential hypertension #HLD ([CONDITION(S)]) #CKD (Chronic Kidney Disease) #Debility and muscle weakness +Continue current medical management +will Continue to follow labs +24/7 Coordinated care +Fall precaution +continue to maintain comfort +PT/OT (Physical Therapy/Occupational Therapy) +Skin integrity checks and precautions +monitor diet/ dietitian on consult +Social worker involved +DVT (blood clot) prophylaxis +GI (gastrointestinal) prophylaxis. Discussed this plan with nursing staff. Inform our team of any acute changes or complaints. -08/04/2022 11:40 AM, written by Nurse Practitioner (NP) C, .Following for positive urinalysis. No signs and symptoms of infection at this time, no lethargy weakness, fever chills, dysuria is resolved, denies any pain . 8/2: More than 100,000 CFU/mL E. coli .ASSESSMENT/PLANS: #Positive urinalysis. Awaiting urine sensitivity, will defer ABT (antibiotic therapy), no signs or symptoms of infection at this time . -08/04/2022 6:36 PM, NP reviewed recent UA results and ordered [MEDICATION(S)] (antibiotic) 100 mg Q12H (every 12 hours) x 7 days. R907's progress notes continued to mention the resident taking oral antibiotics to treat a [CONDITION(S)] but did not include further assessment for continuation of the urinary catheter. Continued review of R907's progress notes revealed: -08/17/2022 7:11 PM, Resident continues to yell out help, threatening to throw herself on the floor. Resident observed ambulating down hall with foley in hand, stated it came. I don't know what happened. 16 French foley reinserted. Med size BM (bowel movement) noted . -08/18/2022 6:49 AM, Resident is alert and able to make needs known. Requires a 1PA (one person assist) with transfers. Resident yelled all night for help .Resident also wanted to pull her foley out because she said it did not belong. Resident also educated about the importance of her foley . On 8/18/22 at 8:00 AM, R907 was observed lying in bed. The resident's Foley catheter drainage bag was observed lying on the floor. On 8/18/22 at 8:32 AM, R907 remained in bed and the Foley catheter drainage bag remained lying on the floor. R907's assigned nurse, Licensed Practical Nurse (LPN) L was interviewed and queried regarding R907's catheter. LPN L explained that she didn't think R907's catheter was re-assessed for use and was not sure why the resident came into the facility with it. When queried regarding R907's catheter getting pulled out the previous day, LPN L stated that she did not receive report of that incident. When queried regarding her knowledge of how R907 felt about her catheter, LPN L stated she wasn't sure and that R907 has behaviors. On 8/18/22 at 8:50 AM, the Minimum Data Set (MDS)/LPN M, who had initiated the care plan for R907's catheter, was interviewed. LPN M was asked where the information was located in R907's record to support the continuation of the urinary catheter after admission. LPN M indicated that she gathered information from the patient, patient's family, and hospital documentation but was unable to provide a specific document or information. On 8/18/22 at 10:04 AM, the Director of Nursing (DON) was asked to provide information regarding R907's catheter which included an assessment for need and if the facility had conducted any voiding trials. On 8/18/22 at 11:26 AM, the DON had not yet provided the requested information regarding R907's catheter. The Nursing Home Administrator (NHA) was asked for the following: Voiding trials/PVRs (post-void residuals) for [R907], or assessments indicating need for continuing indwelling urinary catheter. On 8/18/22 at 11:42 AM, the DON was interviewed and claimed that she spoke with NP C who stated the resident was supposed to have a catheter because of [CONDITION(S)] (this was not noted to be documented in any of NP C's progress notes). The DON stated there were no voiding trials conducted. The DON then reviewed R907's admission documentation including hospital records as well as called LPN M during the interview. The DON was not able to locate and/or show where the supporting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that LPN M was Looking for the discharge paperwork from the hospital .I think what they uploaded is not the whole packet. The DON was asked if the whole packet - i.e. all information necessary for R907's admission into the facility - should be uploaded and available in the resident's medical record to which she responded, Yes, it should be. On 8/18/22 at 2:37 PM, the DON emailed a copy of the 7/23/22 admission bladder assessment completed by Nurse I (dated 07/23/2022 and noted above) along with a form titled TENA/SCA Bladder Observation. This bladder observation assessment was filled out by hand, contradicted the electronic assessment completed by Nurse I, was dated 7/23/22 (date also handwritten), was not signed, and was not noted to be available in the resident's medical record during the survey. This form was only provided after multiple inquiries regarding R907's supporting catheter documentation. All other assessments for R907 were noted to have been completed electronically however this one was not. Final review of R907's progress notes revealed: -08/18/2022 07:01 PM, Resident observed having increased behaviors. Increased agitation and screaming throughout the day .[NP C] D/C'd (discontinued) indwelling foley catheter AND ordered to Straight cath Q6H (every 6 hours), if residual greater than 350 mL to contact NP . The facility provided two policies/procedures related to catheters, however upon review they were not noted to address assessing for removal/continuation of indwelling urinary catheters. A review of the facility's policy/procedure titled, Catheter Care, Urinary, revised 3/15/22, revealed, Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor .

Based on observation, interview, and record review, the facility was placed in Immediate Jeopardy (IJ) related to failing to ensure that medically complicated residents receiving enteral nutrition (tube feeding) and at risk for weight loss, dehydration, and aspiration (inhalation of foods/fluids into the lungs) were thoroughly assessed, evaluated, and monitored by a Registered Dietitian (RD) as well as provided care by competent staff to prevent complications, effecting six Residents (#15, #43, #46, #901, #902, #903) out of six Residents reviewed for enteral nutrition. This deficient practice resulted in: 1) Resident #902 receiving no enteral assessment or monitoring by an RD or other qualified health practitioner, was never weighed during his admission, did not have appropriate tube feeding orders or documentation of administration, and was found unresponsive with cause unknown and expired [DATE] while in transport to the Emergency Department.; 2) Resident #46 failed to receive a timely RD consult for tube feeding intolerance, did not have appropriate water flush orders or documentation of administration, started to exhibit signs of intolerance (emesis of coffee ground-like substance) post feeding, and was found unresponsive and expired the following day on [DATE]; 3) Resident #903's tube feeding and orders were not monitored by an RD and weights were not consistently taken which resulted in a significant weight loss of 25.4 pounds in two months; 4) Resident #15 was observed receiving the wrong tube feeding formula on [DATE] and [DATE] during the annual survey, with the potential for significant weight change and nutritional inadequacy; 5) Resident #43's bolus tube feeding administration was observed where staff used ice water to flush and dilute the tube feeding, resulting in discomfort and the potential for clogging and intolerance. The IJ began on [DATE], when the RD failed to assess and provide tube feeding order recommendations, the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . As of [DATE] the facility still had no RD providing nutritional care on a consistent basis to ensure Residents receiving tube feeding were being assessed, monitored for tolerance, weighed appropriately, and had correct tube feeding orders consistently to prevent significant weight loss, tube feeding intolerance, and malnutrition. The IJ notification was communicated verbally to the Administrator and Director of Nursing (DON) on [DATE] at 6:23 p.m. and was followed with an email copy with request for an abatement plan. The IJ was removed on [DATE] when the facility abatement plan was accepted. The deficient practice continued at a pattern level of potential for more than minimal harm until onsite review and confirmation of the completion of the full plan of correction. Findings include: Resident #902 A review of Resident #902's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] Minimum Data Set (MDS) assessment revealed he was Severely Impaired in cognition per staff assessment and received tube feeding to meet his nutritional needs. A review of Resident #902 weight log revealed he was never weighed during his admission. A review of Resident #902's record revealed no nutrition or dietary notes. Resident #902 was never seen by an RD or by a Certified Dietary Manager (CDM). The facility was asked to provide the November and [DATE] MAR and TAR. The facility only provided the [DATE] MAR/TAR that included [DATE]. These Administration records did not show that any tube feedings were documented as administered during his stay, as the orders were not translated to any of the administration records. A review of Resident #902's physician order dated [DATE] revealed . Glucerna 1.5 @ 50 hr 1800 total water 100ml/hr total 1115mL . This order was discontinued on [DATE] when Resident #902 was admitted to the hospital. This order was not clearly or correctly written, as the maximum tube feeding that could be administered at a rate of 50mL/hr in 24 hours would be 1200 mL, not 1800. A review of Resident #902's physician order dated [DATE] revealed, . Glucerna 1.5 @ mL water bolus @ 10mL/hr 1800 kcal 99g ppot. 1151mL . and was discontinued on [DATE]. This tube feeding order does not provide the rate per hour, the total mL of tube feeding to be dispensed. Further review revealed the flush order of 10mL per hour could never amount to 1151mL in a 24 hour period. Further review of Resident #902's physician orders revealed no other orders for tube feeding, or documentation as to what his tube feeding order was from [DATE] through [DATE] when he was found unresponsive. This suggests he did not receive any tube feeding during this time period as there was no physician order nor any record showing anything was administered. A review of Resident #902's progress notes revealed the following: [DATE] .(tube feeding) Formula infusing per orders . [DATE] . Pt (patient) displayed using accessory muscle and flushed face along with diaphoresis when checked vitals SPO2 was 80% . 911 called . A review of the [DATE] History & Physical from the hospital reveled, Chief complaint: [CONDITION(S)] On the day of ED (Emergency Department) admission, patient was noted to be hypoxic with noted [CONDITION(S)] prompting EMS (Emergency Medical Services) . Chest x-ray revealed right lower lobe pneumonia. admitted to the ICU (Intensive Care Unit) for severe [CONDITION(S)] management . Active Problem List: Severe [CONDITION(S)] likely source pneumonia . Severe protein calorie malnutrition . A review of the [DATE] Discharge Summary for Resident #902 revealed, . Severe protein calorie malnutrition. PEG tube in place. Nutrition consult .Will start trickle feeds. Monitor lytes (electrolytes) closely for refeeding syndrome . A review of the Plan of Care discharge document by Hospital RD NNN revealed, . evident muscle and body fat losses . TF started ,d+[DATE], trickle feedings. Pt has been tolerating Glucerna 1.5 at 15 mL/hr. Electrolytes have been replaced . Interventions: 1. Increase Glucerna 1.5 10ml q 4 hours to eventual goal rate of 50 ml/hr x 24 hr via PEG . will provide 1800 kcals, 99 grams protein, in 910 ml free water. 2. Flush 120 ml H20 via PEG . 3. Ongoing electrolyte monitoring as needed. 4. Weekly weight . Further review of Resident #902's progress notes after he readmitted to the facility on [DATE] revealed the following: [DATE] . Resident readmitted with a DX (diagnosis) of post [CONDITION(S)], post RT lower lobe pneumonia (suggestive of aspiration pneumonia), and chronic [CONDITION(S)] w/ (with) [CONDITION(S)] . [DATE] . Resident received peg tube feeding, during feeding machine malfunctioned. Writer called RD, and Acting D.O.N (Director of Nursing) no answer, awaiting return phone call for bolus order . [DATE] Resident is observed in bed with head elevated not breathing. Code Blue Initiated. 911 services notified and arrived after 10 minutes of CPR initiated. Will continue to monitor. [DATE] Resident is expired (deceased ) 1608 (at 4:08 p.m.) by (Hospital Doctor) . A review of Resident #902's Nutritional Status care plan initiated on [DATE] revealed, Resident has potential alteration in nutritional status R/T PMH (past medical history) of: malnutrition, [CONDITION(S)], tubefeeder . This care plan contained only 4 interventions, including [DATE] Obtain dietary consult and follow recommendations. There were no interventions regarding weighing the resident, monitoring for signs or symptoms of aspiration, or to keep the head of the bed elevated to prevent aspiration. On [DATE] at 11:23 a.m., a phone interview was conducted with NP Y who reported she was aware the facility had no full time RD or CDM. NP Y reported that she thought that the RD from another building was coming on a set schedule. When asked about resident #902's tube feeding issues, NP Y reported that she usually works with RD but could not remember this resident. When asked about what her expectations are if there are issues with tube feeding, NP Y reported the staff should call her. When asked if not having an RD available to address nutrition and tube feeding concerns impacts the care, NP Y stated, It does. NP Y also reported that residents should be weighed regularly. Resident #46 A review of Resident #46's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] MDS assessment revealed he scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition and relied on a feeding tube to meet his nutritional needs. A review of the nutritional assessments completed for Resident #46 dated [DATE], [DATE], and [DATE] revealed they were all completed by Certified Dietary Manager (CDM) UU. A review of the [DATE] Nutritional Assessment revealed Resident #46's estimated caloric needs were ,d+[DATE] kcals (calories) based on his current body weight. Resident #46 weighed 101 pounds with a Body Mass Index (BMI) of 17.33 (BMI < 18.5 is underweight). This assessment also revealed, No referrals necessary . Resident may benefit from planned weight gain program A review of Resident #46's weight log revealed that he was weighed only three times between his admission on [DATE] through his expiration on [DATE], and had significant weight loss. The weight log revealed: [DATE] 101 lbs (pounds) [DATE] 94.2 lbs (-6.8 pounds/ -6.7% weight loss x 1 month - Significant) [DATE] 91.4 lbs (-9.6 pounds/-9.5% weight loss x 2 months) A review of Resident #46's [DATE] Medication Administration Record (MAR) and Physician orders revealed: [DATE] Consult Dietitian r/t (related to) enteral tube feeding evaluation and loose stools. This was marked as completed on the MAR, but the review of the record revealed it was not completed. [DATE] RD consult re: (regarding) eval (evaluation) formula pt (patient) with diarrhea. This order did not translate to the MAR but review of the record revealed it was not completed. [DATE]-[DATE] diabetisource 1 can 250 cc (cubic centimeters) five times daily which would provide 1500 calories per day. The administration of this bolus (a single dose of tube feeding given all at once) order was documented as charted late 24 times. Late boluses of tube feeding can result in intolerance, high residuals, and refusal of subsequent scheduled boluses due to the patient still feeling too full. [DATE] - [DATE] ok to use Glucerna 1.2 for bolus 250cc five times a day which would provide 1500 calories per day. This order ran concurrently to the order for diabetisource, and staff documented on multiple days that they gave boluses of both tube feeding formulas. A physician's order dated [DATE] through [DATE] for 1550 cc QID (four times per day) water flushes Four times a day was not translated to the MAR or any other administration record provided, and therefore there was no documentation to show it was administered. Furthermore, this order of flushing 1550 cc four times per day would equal to 6,200 cc of free water or 209 fluid ounces in 24 hours. This would grossly exceed the 1377cc fluid needs estimation by CDM UU, and would likely result in high gastric residuals, intolerance, and overhydration/water toxicity. A review of Resident #46's progress note dated [DATE] revealed, Resident had multiple episodes of loose stool. Writer spoke with NP (Nurse Practitioner Y) and orders were for monitoring resident for more loose stool x 2 days every shift, [MEDICATION(S)] (antidiarrheal medication) 2mg (milligrams) ,d+[DATE] tabs . and consult to dietitian r/t (related to) enteral feeding formula . A review of Resident #46's progress notes revealed he had refused his bolus tube feeding on [DATE], [DATE], and [DATE]. A review of an [DATE] progress note revealed, .Resident continues to be aggressive verbally and requesting to go to hospital for evaluation and treatment. Resident #46 was transferred to the Emergency Department for evaluation and treatment on [DATE]. A review of Resident #46's progress notes revealed he readmitted to the facility on [DATE]. The progress notes revealed: [DATE] Called Hospital for clarification of feeding intake. Nurse on duty said that [MEDICATION(S)] 1.2 50cc/hr to be infuse (sic) up to 1200cc. Notified NP and she order (sic) to continue [MEDICATION(S)] 1.2@50cc/ph (per hour) until seen by dietitian. Order carries on. [DATE] H/o (history of) refusing tubefeeding, likely d/t h/o [CONDITION(S)] (Urinary Tract Infection) . A review of the only documentation by Consultant RD T for Resident #46 on [DATE] revealed, . Nutritional status Underweight . TF (tube feeding) is being tolerated . Resident has lost 10# (pounds) since admission. Weight loss as unplanned, unavoidable and likely r/t resident refusal of TF at times and diarrhea in November .CBW of 91.4# (pounds) is 67% of IBW (Ideal Body Weight) and 65% of UBW (Usual Body Weight) . POC (plan of care) goal for weight gain to reach 136#. Current TF is [MEDICATION(S)] 1.5 55cc x 20 hours and flush of 205cc q 6 hours to provide 1706ml, 1650kcal, and 61g protein; which is above estimated needs for fld/kcal/pro (fluid/calories/protein) . Further review of Resident #46's progress notes revealed: [DATE] . non-compliant elevating HOB (head of bed) at 30 degrees during tube feeding. Resident will lower HOB flat despite education . Tubefeeding is continuing with no problems . [DATE] Writer received order from outgoing nurse to change current tube feeding order to bolus feed of [MEDICATION(S)] 1.5 220 cc Q4h; tube feeding order to be re-instated pending delivery. [DATE] Resident was given a bolus feeding at 0430 (4:30 a.m.). residuals were check (sic) prior to feeding and the head of the bed was 30 degrees. The resident vomited stomach content and is noncompliance (sic) with keeping the head of the bed to at least 30 degrees. On coming nurse was notified NP was called no respond (sic). [DATE] .Resident alert, verbal able to make needs known with confusion .Writer noticed vitals unstable. had fever of 100.8 Temporal. w (with) oxygen saturation fluctuated between ,d+[DATE] (percent) new order by NP to put on 2L (of oxygen) nasal cannula . At 2pm resident was afebrile post Tylenol and motrin doses. Labs CBC (complete blood count) and BMP (basic metabolic panel) ordered STAT (immediately). Notified NP of lab results and CXR (chest xray). New order to start one time order of 0.9% NS 65ml/hr (Intravenous hydration). [MEDICATION(S)] (antibiotic) 500Q daily. When writer administered medication via peg, noticed resident overflow of coffee ground color residuals. Notified family and family wants to keep resident inhouse and not send out to the ER (emergency room ). Np ordered STAT KUB (an xray of the kidney, ureter, and bladder). order in place . Review of Resident #46's physician orders revealed there was no order for a STAT KUB nor an indication of why it was ordered. Review of Resident #46's Advanced Directives signed by himself on [DATE] revealed yes to being hospitalized , and Resident #46 was legally his own decision maker. A review Resident #46's progress notes dated [DATE] revealed, 3:06 PM . Verbal order to speak with family and ask son if it is okay to have residents placed on Hospice. Notified son of doctors request. (Son of Resident #46) stated that he would call his older brother and will call back later about resident being on hospice . and 4:06 PM Resident was observed in bed with no respirations. Non responsive when called by name. Vitals were unable to be obtained . A review of Resident #46's care plan for Nutritional Status initiated on [DATE] by CDM UU revealed it contained only one approach dated [DATE], obtain weekly weights x 4 weeks, then monthly if stable. On [DATE] Consultant RD/RD T initiated the other 13 approaches, including: Check for tube placement and residuals per facility parameters, Elevate HOB (head of bed) ,d+[DATE] degrees during tube feeding administration, Observe and report to physician PRN(as needed): s/sx (signs and symptoms) of Aspiration, and RD to evaluate monthly and PRN. Make recommendations for changes to tube feeding as needed. On [DATE] at 10:24 a.m., a phone interview was conducted with RD T. RD T reported that she was just helping out in the building until they found a dietitian and had been coming since [DATE]. RD T reported she just did the high-risk Residents as the CDM (CDM S) evaluated and assessed the other Residents. RD T reported that residents on enteral nutrition were supposed to be seen by the RD at least once per month. RD T reported she hadn't been in to do her visits for the month (of March) yet. When asked if she was aware of any issues with the Residents' tube feeding orders or administration, RD T reported she was not. On [DATE] at 12:50 p.m., the Administrator provided the hours the Dietitian had been in the building for the previous three months which revealed, [DATE]. 6.5 hours. [DATE] = 6 Hours. [DATE] = 7 hours. On [DATE] at 4:40 p.m., RD T reported that she had documented on Resident #46 on [DATE], and that he had lost some weight but also sometimes refused his tube feeding. RD T reported she could see that a few days later he was changed from the continuous recommendation that she wrote to a bolus regimen. When asked if she would have recommended the bolus for him, RD T stated, No. He had been tolerating it (continuous tube feeding). When asked if the CDM should be writing or recommending Tube feeding orders, RD T stated, No, that should typically be me. On [DATE] at 9:55 a.m., an interview was conducted with the Director of Nursing (DON). When asked why Resident #46's tube feeding was changed from a continuous feed to a bolus feed on [DATE], the DON could not say. When asked if it was appropriate for a nurse to change a tube feeding without an RD consult, for convenience, or without documenting the reason for the change, the DON stated No. On [DATE] at 11:23 a.m., a phone interview was conducted with NP Y. When asked about Resident #46's tube feeding being held because a KUB was ordered, NP Y reported that tube feeding is not normally held for that procedure. NP Y made no comment as to why the documentation stated that tube feeding and medications were held for a KUB. When asked if a Resident who is his own person and has an advanced directive to be hospitalized can be overruled by family, NP Y stated, The patient goes with his choice. If he wants to be hospitalized , then he (has the) right to go. A review of Resident #46's death certificate revealed, .date of death : [DATE] . Time of death: 4:20 PM . date signed: [DATE] (by the Medical Director) .Enter the chain of events - disease, injuries or complications - that directly caused the death: 2019-nCov acute respiratory disease, cerebral infarct, unspecified; other specified nutritional anemias; Peg tube status with dysphagia . Resident #15 A review of Resident #15's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] MDS assessment revealed she was assessed by staff to be severely cognitively impaired and relied on tube feeding to meet her nutritional needs. On [DATE] at 3:50 p.m., Resident #15 was observed in bed with Glucerna 1.2 running at 70 mL/hr. Per the tube feeding pump display it had already dispensed 1210 mL of tube feeding. The bottle was labeled that it had been hung on ,d+[DATE] (2022) but did not have a time that it was hung. A review of Resident #15's physician orders revealed an active order initiated [DATE] for Glucerna 1.5 via peg tube @ 70cc/hr x 20 hours for a total of 1400 cc and 2250kcal. On [DATE] at 7:57 a.m., Resident #15 was observed lying in bed with Glucerna 1.5 running at 70 mL per hour with a total of 540 mL of tube feeding dispensed. On [DATE] at 10:24 a.m., a phone interview was conducted with RD T. When asked about the last time she had assessed Resident #15, RD T reported she was on the schedule for her to see. When notified that Resident #15 had no nutritional notes since [DATE], RD T had no comment. RD T reported she wasn't aware of any issues with the staff not administering the correct tube feeding. On [DATE] at 3:53 p.m., Resident #15 was observed in bed and Glucerna 1.2 was again hanging and dispensing at 70 mL/hr. At 4:00 p.m., RD T and the DON were asked to observe Resident #15. RD T was asked if the correct tube feeding was hanging and reported that the wrong tube feeding formula was being dispensed. On [DATE] at 4:40 p.m., RD T reported that Resident #15 was supposed to be receiving Glucerna 1.5 and that the nurses reported it was likely due to a supply issue that the Glucerna 1.2 was being used. RD T confirmed that Glucerna 1.2 provided less calories per milliliter than Glucerna 1.5 and therefore it could not be substituted at the same rate. Resident #43 A review of Resident #43's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] MDS assessment revealed she was assessed by staff to be severely impaired for cognition. Per this assessment Resident #43 was totally dependent on one person for eating, received more than 51% of her nutritional needs from a tube feeding but also consumed a mechanically altered diet, and was marked for having significant weight loss. A review of Resident #43's medical record revealed she had no admission nutrition or enteral assessment and had no dietary progress notes documented. On [DATE] at 4:21 p.m., Resident #43 was observed in bed with a bottle of Glucerna 1.2 sitting on her bedside table that was three quarters full of tube feeding and was undated and unlabeled. On [DATE] at 10:24 a.m., a phone interview was conducted with RD T. When asked why Resident #43 who was on a tube feeding and had admitted on [DATE] had not yet been assessed, RD T reported she had been following her but had not documented anything. RD T reported that she had not yet been into the building during the month of [DATE]. On [DATE] at 9:00 a.m., Resident #43's bolus tube feeding administration by LPN A was observed. During the administration, LPN A used a measuring cylinder to measure out 350 mL of Glucerna 1.2 out of the 1000 mL ready to hang bottle. LPN A used a Styrofoam cup of ice water to flush the peg tube prior to starting the tube feeding. Upon administering the ice water flush, Resident #43 quivered in discomfort. LPN A then started to administer the tube feeding in portions, and when it did not go through quickly, he added ice water to the syringe to dilute it. LPN A then added ice water directly into the portioned tube feeding container and continued to administer the bolus. LPN A was observed squeezing the tubing and flicking the syringe to get the tube feeding to administer faster. When asked how long they would keep a bottle of tube feeding open for, LPN A reported it was 24 hours but that he threw away and got a new bottle every morning. LPN A left the bottle of tube feeding on Resident #43's bedside table. A review of Resident #43's physician order dated [DATE] revealed, Glucerna 1.2 via Peg Tube bolus 350 mL QID (four times per day) until 1400 mL and 1680kcal infused. Until Glucerna 1.5 comes in the (sic) contact Rd. On [DATE] at 12:42 p.m., Nurse Educator/RN D reported she had completed LPN A's nurse skills competency evaluation on [DATE]. RN D was then asked about the tube feeding administration observation of LPN A and the use of ice water to flush and dilute the tube feeding. RN D reported that when she had observed him just weeks before he had done it correctly. RN D reported she would re-educate LPN A Resident #901 A review of Resident #901's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #901 had no completed MDS in her chart. A review of Resident #901's progress notes revealed the following: [DATE] 2:34 AM Resident arrived in the building . at approximately 8:15 pm . Has [CONDITION(S)] in place with 6L (liters) oxygen . Resident has Peg tube in place and is NPO (nothing by mouth). Resident has a LUQ (left upper quadrant) nickel size opening covered with [CONDITION(S)] bag and has small amount of greenish drainage in bag . [DATE] 2:34 AM .Orders to give 250cc bolus (of) [MEDICATION(S)] 1.5 along with 250 cc water flush every four hours. [DATE] 5:58 AM Pt was given 250cc bolus of Javity (sic) 1.5 noted tube feed coming out of LUQ open area and collecting in the [CONDITION(S)] bag covering the wound. Bolus was stopped. Area was cleaned new bag was applied and monitored. Notified NP, waiting for further orders. There were no progress notes following the [DATE] 5:58 AM progress note, even though per the Resident Census sheet Resident #901 was not transferred back to the hospital until [DATE] at 6:09 p.m., almost 12 hours later. A review of Resident #901's chart revealed no documentation from any Physician or Nurse Practitioner. A Resident #901's MAR and TAR for [DATE] revealed, Enteral Feeding: Formula [MEDICATION(S)] 1.5 bolus 250cc Q4hours with 250 water flush was documented as being on hold for the [DATE] 4:00 AM and 8:00 AM dose, given late for the 12:00 PM dose, and not given for the 4:00 PM dose. A review of a Resident Transfer to the Hospital/Other Care Facility form dated [DATE] 3:49 p.m. for Resident #901 revealed Resident #901 was sent to the hospital, but was not complete and did not entail why the Resident was being sent out. A version of this form that was marked as in progress and was not fully completed contained the paragraph: Resident has an old peg site, that when bolus is administered through new peg site, all the formula passes through and into the old peg tube bag. Resident #903 A review of Resident #903's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] MDS assessment revealed she scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) assessment indicating moderately impaired cognition. Per this MDS, Resident #903 also had two unhealed stage three pressure ulcers. A review of Resident #903's face sheet revealed she discharged to the Emergency Department on [DATE] and did not return to the facility. A review of Resident #903 dietary notes revealed she was evaluated by former CDM UU on [DATE], [DATE], [DATE], [DATE], and [DATE]. Resident #903 was never seen by a RD during her admission, despite receiving tube feeding, having pressure ulcers, and having significant weight loss. A review of Resident #903's weight record revealed the following: [DATE] 172.6 pounds [DATE] 147.2 pounds (-25.4 pounds or -14.7% weight loss in 2 months.) [DATE] 147.2 pounds Resident #903 was not weighed for almost two months between September and November of 2021. Resident #903 was only weighed three times during her admission, despite receiving tube feeding and having significant weight loss. A review of Resident #903's Medication Administration Record (MAR) from [DATE] through [DATE] revealed the following: From [DATE] through [DATE], Resident #903's diet order read, Pt (patient) to receive Glucerna bolus 237ml for 4x day (4 times a day) with 375 cc H20 flush with each bolus which did not indicate the type of Glucerna (1.0, 1.2, or 1.5 calories/mL). Resident #903 received the correct number of boluses only four days out of those eight days it was ordered. On [DATE] and [DATE], Resident #903 received only a single bolus of .Glucerna 1.2. Administer 474 mL, providing only 568 calories per day. On [DATE], [DATE], and [DATE], the ordered Glucerna 1.2 was not available per the MAR. On [DATE] no substitute was documented as given. On [DATE] there is nothing charted on the MAR, but the progress note for that day stated, .MD stated that if facility is out of Glucerna, use whichever supplement in house that is lowest in glucose, highest in protein. On [DATE] nothing is documented on the MAR but the progress note for that day revealed, .TF [MEDICATION(S)] 1.0 cal received r/t no glucerna 1.2 . This did not indicate at what rate it was administered, and did not note whether the tube feeding was adjusted due to the facility using a lower calorie tube feeding product. There are no notes that the RD or CDM were notified or consulted. On [DATE], [DATE], and [DATE] there was no documentation that Resident #903 received any tube feeding. On [DATE], just prior to Resident #903's transfer to the hospital, an order was written and administered for 500mL bolus via peg x 1 now, but did not entail what the bolus was. The progress note for this day did not indicate if the bolus was tube feeding or a bolus of water. A review of Resident #903's progress notes revealed the following: [DATE] . patient had an increase in blood pressure and heartrate . writer observed patient sweating cool and clammy. BS (blood sugar) 249. Abdominal (sic) extended and round . audible wheezing noted . patient awaiting to be transported to (Name of Emergency Department) . [DATE] .Readmit from (Name of Hospital) via stretcher. Admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #903's care plan for Nutritional Status initiated [DATE] revealed, Resident has potential alteration in nutritional status R/T PMH of: gerd (gastroesphogeal reflux), diabetes, is a tube feeder; had peg placed [DATE] .Obtain dietary consult and follow recommendations . tube feeding per order . This care plan had no interventions regarding weight monitoring or to keep the head of bed elevated to prevent aspiration. There were no updates to the care plan since [DATE]. A review of the facility policy titled, Enteral Nutrition reviewed [DATE] revealed, 1. The interdisciplinary team, including the Dietitian, will conduct a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings . 3. The Dietitian, with input from the Physician and Nurse, will: a. Estimated calorie, protein, nutrient and fluid needs; . c. Recommend special food formulations .4. Enteral nutrition will be ordered by the Physician based on recommendations of the Dietitian . 7. The Dietitian will monitor residents who are receiving enteral feedings, and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings . 12. Staff caring for residents with feeding tubes will be trained on how to recognize and report complications associated with insertion and/or use of a feeding tube, such as: a. Aspiration; . 14. Risk of aspiration will be assessed by the Nurse and Physician and addressed in the individual care plan . A review of the facility policy titled, Enteral Feedings-Safety Precautions reviewed [DATE] revealed, .1. Maintain strict aseptic technique at all times when working with enteral nutr[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that Residents were: 1) provided feeding assistance and supervision per assessment; 2) Provided fluids of appropriate consistency to prevent dehydration; 3) assessed and monitored by a qualified nutritional professional to maintain adequate nutritional parameters and to address significant weight loss, and; 4) were weighed per physician order to monitor weight status for seven Residents (#6, #27, #43, #95, #145, #902, and #903) out of 17 reviewed for nutrition and hydration. This deficient practice resulted in significant weight loss, a lack of weight monitoring, and a lack of assessment with the potential for dehydration, tube feeding intolerance, and overall decline. Findings include: Resident #6 On 3/30/22 at 8:20 a.m., Resident #6 was observed laying in bed sleeping with his untouched breakfast tray on the overbed table with his door closed. A review of Resident #6's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of his 1/2/22 Minimum Data Set (MDS) assessment revealed he scored 1/15 on the Brief Interview for Mental Status (BIMS) assessment indicating severely impaired cognition and required supervision and one staff physical assistance for eating. A review of Resident #6's weight log revealed the following: 12/28/21: 138.7 pounds 2/12/22: 136.2 pounds 2/17/22: 137.8 pounds 2/21/22: 139 pounds 3/10/22: 139.9 pounds Resident #6 was not weighed for over a month after his first admission weight. On 3/31/22 at 10:59 a.m., Resident #6 was observed being weighed by Licensed Practical Nurse (LPN) A. Resident #6 was found to be 128.6 pounds, revealing a loss of -11.3 pounds in 3 weeks or -8.0% body weight loss. On 4/4/22 a review of Resident #6's record revealed the weight that was taken on 3/31/22 had not been logged, no repeat weight had been taken, and no dietary assessment had been conducted regarding the weight loss. On 4/4/22 at 1:51 p.m., an interview was conducted with the Director of Nursing (DON). When asked about why the weight taken on 3/31/22 wasn't logged and the weight loss was not addressed, the DON called LPN A by telephone. The DON reported that LPN A couldn't remember if he had logged the weight or not. When asked if weights should be documented in the medical record, the DON reported they should be. On 4/4/22 at 4:05 p.m., Resident #6 was observed up walking in the hallway with his Family Member (FM) HHH. FM HHH was asked if he had any concerns regarding his father's care and stated, Do you know how they are feeding him? FM HHH reported his father needed extensive encouragement and cueing with eating. When asked if he felt his father had lost weight since being at the facility, FM HHH reported his father looked like he had lost a lot of weight. A review of Resident #6's care plan for Nutrition initiated on 12/29/21 revealed, Resident has potential alteration in nutritional status .monitor for chewing/swallowing difficulty Monitor/record and report to MD (medical doctor) any S/S (signs and symptoms of) malnutrition; emaciation, muscle wasting, weight loss . Obtain dietary consult and follow recommendations On 3/30/22 at 10:24 a.m., a phone interview was conducted with Consultant Registered Dietitian (RD) T. When asked how many hours she was working in the building or how many Residents she was reviewing at the facility, RD T stated, There's no way to report anything. I'd have to go into each record to figure that out. RD T reported she was just helping the building out until they hired an RD. RD T was asked about the lack of weighing residents per the policy and reported she had no comment on the issue. On 3/30/22 at 4:46 p.m., during an interview Certified Dietary Manager (CDM) S reported she started as the CDM in September of 2021 along with another CDM. When asked which Residents she provided nutritional monitoring and care for, CDM S reported all the Residents except for those on tube feeding, with wounds, with weight loss, and [CONDITION(S)] patients. CDM S was asked if she obtained Resident preferences and stated that she was, and that they were supposed to be done within 72 hours of admission. CDM S reported she usually worked four to five days a week in the afternoons, from 4:00 p.m., until whenever she's done. CDM S admitted that she was working a full-time job elsewhere and was just carrying the load until they hired someone full time. Resident #43 On 3/29/22 at 8:29 a.m., Resident #43's tray was observed in the cart to go back to the kitchen with the other trays after the meal. A review of her plate of pureed food revealed none of it had been consumed. LPN A reported that Resident #43 only ate about 10% at each meal and received a bolus of tube feeding if she didn't eat much. A review of Resident #43's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 3/7/22 Minimum Data Set (MDS) assessment revealed she was assessed by staff to be severely impaired for cognition. Per this assessment Resident #43 was totally dependent on one person for eating, received more than 51% of her nutritional needs from a tube feeding but also consumed a mechanically altered diet, and was marked for having significant weight loss. A review of Resident #43's medical record revealed no nutritional assessments, evaluations, or progress notes. A review of Resident #43's weight log revealed the following: 3/1/22 125.6 pounds 3/24/22 133.4 pounds (+7.8 pounds or 6.2% gain x 3 weeks) 3/28/22 133.6 pounds 3/28/22 134.1 pounds Resident #43 was not weighed weekly after her admission, so it is unclear if there was significant weight gain, or if the admission weight was inaccurate. On 3/30/22 at 8:20 a.m., Resident #43's tray was again observed in the dirty tray cart with no bites taken from any of the food. On 3/30/22 at 8:28 a.m., CNA N was asked if she had assisted resident #43 with eating. CNA N reported that she had. When asked how long she had assisted the resident, CNA N stated, About five minutes the first time, and then someone else tried, and I went back again. CNA N reported Resident #43 had eaten a few bites, despite the meal tray showing no bites had been taken. On 3/30/22 at 10:24 a.m., RD T was asked why Resident #43 had no nutritional notes or assessments conducted. RD T reported she had been following the resident for a few weeks but had not documented anything. When asked if she had ever met the Resident, RD T reported she had not. On 3/30/22 at 12:05 p.m., Resident #43 was observed seated across from the nurse's station with a rolling table positioned in front of her. On the table was her lunch tray of pureed food and regular fluids. CNA N was observed standing in front of Resident #43 holding a spoon of pureed food in front of her face. CNA N put the spoon down and continued to stand in front of Resident #43 looking down at her with her hands on her hips. CNA N continued to offer the same bite of pureed food without describing what the food was or offering any of the other two pureed foods on the plate. On 3/31/22 at 8:00 a.m., Resident #43 was in bed and CNA YY was seated in a chair beside her bed. A spoon was in the meat portion of the plate, but the other two unidentified pureed foods were untouched. When CNA YY was asked what was on the plate, she said Oatmeal and I don't know what else. A review of Resident #43's care plan titled, Nutrition initiated on 3/2/22 revealed, Resident has potential alteration in nutritional status R/T malnutrition, cognitive and communicate deficits, assist with adl tasks needed, peg tube placement and use for nutrition . Administer tube feeding and water flushes per MD orders (initiated 3/30/22) .Elevate HOB 30-45 degrees during tube feeding administration (initiated 3/30/22) . Obtain dietary consult and follow recommendations (initiated 3/2/22). Resident #95 On 3/30/22 at 8:26 a.m., Resident #95 was observed in bed with just a brief on and a thin white blanket covering his head. Resident #95 had consumed 100% of his food, but had no beverages on his meal tray or at his bedside. A review of Resident #95's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #95 had no completed MDS assessments in his record. A review of Resident #95's record revealed he had not been assessed by the CDM or the RD since his admission to review his nutrition and hydration needs. A review of Resident #95's physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This diet order did not indicate what the level of thickness (nectar, honey, or pudding) should be for the fluids. On 3/30/22 at 9:52 a.m., Resident #95 was observed in bed. Resident #95 has no fluids at bedside or in his room at all. On 3/30/22 at 11:53 a.m., Resident #95 was observed with no liquids in his room. Resident #95 was noted to have a continued congestive cough. On 3/30/22 at 3:50 p.m., Resident #95 still had no liquids in his room. On 3/30/22 at 4:00 p.m., RD T and the Director of Nursing (DON) were asked to observe Resident #95. When asked if there was anything missing from Resident #95's room, the DON and RD T confirmed that Resident #95 did not have any beverages or hydration available to him. When asked about Resident #95's diet order being Thick Liquids and whether or not he had been assessed by a Speech Therapist, RD T reported that CDM S was supposed to do his assessment. On 3/30/22 at 5:35 p.m. and 3/31/22 at 12:45 p.m., Resident #95 was observed still with no liquids or beverages in his room. A review of the facility policy titled, Resident Hydration and Prevention of Dehydration last reviewed by the facility on 3/16/22 revealed, 1. The dietitian will assess all residents for hydration adequacy at least quarterly, and more often as necessary per resident need . 6. Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Resident #902 A review of Resident #902's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 11/15/21 Minimum Data Set (MDS) assessment revealed he was Severely Impaired per staff assessment and received tube feeding to meet his nutritional needs. A review of Resident #902 weight log revealed he was never weighed during his admission. A review of Resident #902's record revealed no nutrition or dietary notes. Resident #903 was never seen by the CDM or the RD. The facility was asked to provide the November and December 2021 MAR and TAR. The facility only provided the November 2021 MAR that included December 1. This MAR did not show that any tube feeding were documented as administered during his stay. A review of Resident #902's progress notes revealed, 11/29/21 . Resident received peg tube feeding, during feeding machine malfunctioned. Writer called RD, and Acting D.O.N (Director of Nursing) no answer, awaiting return phone call for bolus order . A review of Resident #902's Nutritional Status care plan initiated on 11/12/21 revealed, Resident has potential alteration in nutritional status R/T PMH of: malnutrition, cardiac disease, tubefeeder . This care plan contained only 4 interventions, including 11/12/21 Obtain dietary consult and follow recommendations. There were no interventions regarding weighing the resident, monitoring for signs or symptoms of aspiration, or to keep the head of the bed elevated to prevent aspiration. Resident #903 A review of Resident #903's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 11/17/21 MDS assessment revealed she scored 9/15 on the BIMS assessment indicating moderately impaired cognition. Per this MDS, Resident #903 had two unhealed stage three pressure ulcers and relied on tube feeding to meet her nutritional needs. A review of Resident #903's face sheet revealed she discharged to the Emergency Department on 12/9/21 and did not return to the facility. A review of Resident #903 dietary notes revealed she was evaluated by former CDM UU on 9/18/21, 9/26/21, 10/5/21, 10/11/21, and 12/8/21. Resident #903 was never seen by a RD during her admission. A review of Resident #903's weight record revealed the following: 9/16/21 172.6 pounds 11/18/21 147.2 pounds (-25.4 pounds or -14.7% weight loss in 2 months.) 11/19/21 147.2 pounds Resident #903 was not weighed for almost two months between September and November of 2021. Resident #903 was only weighed three times during her admission, despite receiving tube feeding, having pressure ulcers, and having significant weight loss. A review of Resident #903's care plan for Nutritional Status initiated 9/10/21 revealed, Resident has potential alteration in nutritional status R/T PMH of: gerd (gastroesphogeal reflux), diabetes, is a tube feeder; had peg placed July 14, 2021 .Obtain dietary consult and follow recommendations . tube feeding per order . This care plan had no interventions regarding weight monitoring or to keep the head of bed elevated to prevent aspiration. There were no updates to this care plan since 9/13/21. A review of the facility policy titled, Nutritional Assessment last reviewed by the facility on 3/16/22 revealed, 1. The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional risk assessment for each resident upon admission (within current initial assessment timeframes) and as indicated by a change in condition that places the resident at risk for or with impaired nutrition . identify at least the following components: . usual body weight . a description of the resident's usual intake and appetite . general appearance . the residents usual route(s) of intake . food preferences and dislikes (including flavors, textures, and forms . food restrictions .an estimate of calorie, protein, nutrient and fluid needs . special food formulations . Individualized care plans shall address, to the extent possible: a. The identified causes of impaired nutrition; b. the resident's personal preferences . time frames and parameters for monitoring and reassessment . A review of the facility policy titled, Weight Assessment & Intervention last reviewed by the facility on 3/16/22 revealed, 1. The nursing staff will measure resident weights on admission, and weekly for three weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record. 3. [NAME] weight change of 5% or more since the last weight assessment will be retaken. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 4. The Dietitian will respond within 24 hours of receipt of notification . 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: . a. 1 month - 5% weight loss is significant; greater than 5% is severe. 3 months - 7.5% weight loss is significant . 6 months - 10% weight loss is significant . Resident #27 During an observation and interview on 03/28/22 at 3:59 p.m., a white styrofoam cup with a straw was observed on Resident #27's overbed table. When asked about replenishment of fresh water, Resident #27 stated, This (water) is from the midnight shift last night. We did not get any fresh water on day shift - none this morning - this (water) is old. During an observation and interview on 03/30/22 at 3:59 p.m., a white syrofoam cup with a straw was observed on Resident #27's overbed table. The cup was dated with pen for 3/29/22 near the rim, just below the cup cover. Resident #27 said the water was from the night shift staff the previous nice and day shift did not bring her fresh water that day. Resident #27 stated, They facility staff) didn't offer water today. Resident #27 stated, When they (facility staff) get me up, they don't have to do anything for me the rest of the day. They don't come to do anything for me. Resident #16 During an observation on 03/28/22 at 3:34 p.m., Resident #16 was observed asleep in bed with a red blanket pulled up over his head. During an interview at this same time CNA NN said she was assigned to Resident #16's care and had assisted him with breakfast, but he did not eat anything for lunch. The meal tray was still present in his room, with pureed food underneath the insulated lid, and pudding, milk, and juice on the tray as well. Nothing appeared eaten. CNA NN said the lunch tray would remain in his room until dinner. No water for hydration was visible within reach of Resident #16 in the room. During an interview on 03/30/22 at 05:06 p.m. CDM S said water was provided to the residents on every shift. CDM S stated, They should have fresh water in the room, so it is easier for staff to assist the resident (who may need dining assistance). Resident #145 On 3/28/22 at 2:04 p.m., during an interview, Resident #145 stated she needed some help and at first stated she did not know why. Resident #145 then stated she needed something to drink and began to ask for Agua meaning water in Spanish. This Surveyor informed Resident #145 staff would be alerted to her need. The water was observed on a bedside table which was positioned against the adjacent bathroom wall approximately six feet away and out of reach of the Resident. On 3/28/22 at 2:10 p.m., Licensed Practical Nurse (LPN) B was notified of Resident #145's water needs. Resident #145 was heard calling out Agua (Water in Spanish) several times while LPN B and this Surveyor were walking back to Resident#145's room. LPN E assisted Resident #145 with drinking several sips of water from a straw and then placed the water back on the tray table within reach of Resident #145. LPN B was asked if Resident #145 was able to drink independently. LPN B stated, Yes, she can. LPN B stated Resident #145 was at the facility for hospice services and had been at the facility for approximately one week. On 3/30/22 at 8:09 a.m., there were no fluids available to Resident #145 and the bedside table was observed out of reach sitting against the adjacent bathroom wall approximately six feet away.

Based on observation, interview, and record review, the facility failed to ensure they had qualified dietary staff, to include a full time Certified Dietary Manager (CDM) or Registered Dietitian (RD), to oversee the nutritional care of all 45 Residents residing in the building. This deficient practice resulted in the lack of nutritional assessment and care for facility residents. Findings include: On 3/29/22 at 3:08 p.m., C#1003 reported he had not seen the Dietitian even one time since he had been admitted , and no one came to ask him what his food preferences were. C#1002 reported she has only seen a Dietary person one time. C#1006 reported that the meals served were not diabetic friendly, and the Dietitian never came down to talk to her about it. C#1007 reported she voiced concerns that her diet was elevating her blood sugars and staff told her to relax and let it be. C#1007 reported the staff told her she could move to another facility if she didn't like the kind of food that was being served. On 3/30/22 at 10:24 a.m., a phone interview was conducted with consultant RD T, who reported she had been filling in since December 2021 until the facility could hire a dietitian. RD T reported she was only responsible for the high-risk residents, including those on tube feeding, with wounds, and with significant weight loss. On 3/30/22 at 11:50 a.m., the Administrator was asked how often CDM S was in the building. The Administrator stated, She's not here 40 hours (a week). The Administrator reported the CDM was not full time, but that the facility had an ad out to hire a full time CDM and an RD. On 3/30/22 at 12:50 p.m., the Administrator provided the hours the RD had been in the building for the previous three months which revealed, 1/31/2022. 6.5 hours. 2/23/2022 = 6 Hours. 2/25/2022 = 7 hours. On 3/30/22 at 4:46 p.m., CDM S reported she started as a CDM in September of 2021 along with another CDM who was no longer at the facility. When asked which Residents she provided nutritional monitoring and care for, CDM S reported all the Residents except for those on tube feeding, with wounds, with weight loss, and [CONDITION(S)] patients. CDM S was asked if she obtained Resident preferences and stated that she was, and that they were supposed to be done within 72 hours of admission. CDM S reported she usually worked four to five days a week in the afternoons, from 4:00 p.m., until whenever she's done. CDM S admitted that she was working a full-time job elsewhere and was just carrying the load until they hired someone full time.

Based on observation, interview, and record review, the facility: 1) Failed to ensure that one Resident (#46) was assessed and monitored for change in condition and sent to the hospital per his advance directives; and 2) Failed to ensure that one Resident (#95) was monitored for signs and symptoms of aspiration after being placed on the wrong modified diet and failed to administer oxygen timely during respiratory distress, out of 17 residents reviewed for quality of care. This deficient practice resulted in Resident #46 not being hospitalized per his advance directive, and Resident #95 developing aspiration pneumonia and not being administered oxygen treatment timely, contributing to his death. Findings include: Resident #46 A review of Resident #46's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] Minimum Data Set (MDS) assessment revealed he scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition. A review of Resident #46's Advanced Medical Treatment Directive signed [DATE] by the Resident, who was his own responsible party, revealed he chose to have NO CARDIOPULMONARY RESUSCITATION (DNR). This document also included the section as follows: The following additional guidelines for treatment have been agreed upon: Not to be used - Oxygen; To be used: Antibiotics, IV fluid, Enteral Feeding/Peg Tube, hospitalization , Ventilation, and Blood transfusion. A review of Resident #46's vital signs revealed abnormal vital signs starting on [DATE], indicating a possible change in condition, as follows: [DATE] 3:06 p.m. Pulse 92 per minute ,d+[DATE] 4:30 p.m. Respirations 22 per minute, Pulse 99 per minute [DATE] 6:07 a.m. Respirations 28 per minute, Pulse 120 per minute A review of Resident #46's progress note dated [DATE] revealed, .Resident alert, verbal able to make needs known with confusion. Writer noticed vitals unstable. had fever of 100.8 (degrees Fahrenheit) Temporal. W (with) oxygen saturation fluctuated between ,d+[DATE] (%) new order by NP (Nurse Practitioner Y) to put on 2L (liters of oxygen) nasal cannula, Motrin Q (every) 6hrs, Tylenol Q6hrs X2days. [MEDICATION(S)] . STAT CXR (chest xray) 2View ordered. At 2pm resident was afebrile (without fever) post Tylenol and motrin doses . Notified NP of lab results and CXR. New order to start one time order of 0.9% NS 65ml/hr (Intravenous hydration). [MEDICATION(S)](antibiotic) 500 (mg) Q daily (every day). When writer administered medication via peg, noticed resident overflow of coffee ground color residuals. Notified family and family wants to keep resident inhouse and not send out to the ER. NP ordered STAT KUB. order in place. Will cont.(continue) to monitor patient oxygen level . There was no documentation or evidence showing Resident #46's advance directive to be hospitalized was followed. A review of Resident #46's progress note dated [DATE] 3:06 p.m. revealed, Notified (NP Y) of residents status. Verbal order to speak with family and ask son if it is okay to have residents placed on Hospice. Notified (Son of Resident #46) of doctors request. (Son of Resident #46) stated that he would call his older brother and will call back later about resident being on hospice . A review of Resident #46's progress note dated [DATE] at 4:06 p.m. revealed, Resident was observed in bed with no respirations. Non responsive when called by name. Vitals were unable to be obtained. Notified attending physician of residents status, Notified Family . On [DATE] at 9:55 a.m., an interview was conducted with the Director of Nursing (DON). When asked why Resident #46 was not hospitalized per his signed advanced directives when he started to have a change in condition on [DATE], the DON stated that they did a courtesy call to family. When asked to explain, the DON first stated, At this point I think they chose hospice. When asked where the hospice order and evaluation was, the DON reported she called the hospice and asked for notes. The DON stated, The doctor said we needed to call family to start hospice. When asked if it was what the family wanted, as the last note dated an hour before Resident #46 expired stated they still needed to discuss it with family, the DON stated, He (Resident #46) was declining. The DON could not explain why Resident #46's advance directive wishes of being hospitalized were not followed. Further review of Resident #46's medical record revealed no order for a hospice consult or admission. Resident #46's medical record contained no information about Resident #46 being on hospice, or why his advanced directives were not followed. On [DATE] at 1:51 p.m., the DON reported she had a note from the hospice nurse who did the evaluation for Resident #46. When asked if the facility had family approval to have the resident evaluated for hospice, or if there was a physician order to do so, the DON reported that normally the facility does but she was unable to find any documentation that it occurred. The DON asked why the progress note dated [DATE] at 4:06 p.m. did not include who called the time of death and when, the DON reported she did not know. On [DATE] at 4:18 p.m., an interview was conducted with the Administrator. When asked at what point a resident's family can override their advanced directives if they are their own person, the Administrator stated, When they can no longer make their own decisions. When asked if that would be when they were deemed incompetent by two physicians, the Administrator said yes. A review of a Communication Note on hospice letter head (provided by the DON) regarding Resident #46 revealed the following, Reg: (Name of Resident #46). On [DATE], (Name of Hospice) Hospice RN (unidentified) was in the vicinity of (Name of Facility) visiting hospice patients. A facility staff approached Hospice RN (unidentified) regarding a probable referral for Hospice care and request that RN (unidentified) see if patient would qualify under hospice. Upon seeing the patient and obtaining a brief medical history, patient qualified for hospice care. Informed facility that a Hospice referral and order will be required prior to admission under hospice care and before a full assessment can be done. Unfortunately, patient had passed the same day and was not admitted under Hospice care. (Name of Hospice RN GGG). This documented was undated and unsigned by the author. This document was also not in the medical record. A review of Resident #46's death certificate revealed, .date of death : [DATE] . Time of death: 4:20 PM . date signed: [DATE] (by the Medical Director) .Enter the chain of events: 2019-nCov (sic) acute respiratory disease, cerebral infarct, unspecified; other specified nutritional anemias; Peg tube status with dysphagia . The facility was asked to provide the physician statement/recapitulation regarding the death of Resident #46 (per the facility policy) on [DATE] at 3:44 p.m., and on [DATE] at 11:15 a.m. and 3:31 p.m. The physician statement was never provided. A review of the facility policy titled, Transfers and Discharges/Physician role last reviewed [DATE] revealed, .10. If the individual has diet, the final summary will review the individuals stay and identify factors contributing to death . Resident #95 On [DATE] at 8:15 a.m., Resident #95 was observed in his room, rocking on his bed with a wet, congested cough. Resident #95's oxygen concentrator was turned off with the tubing and nasal cannula lying on the floor and filter on the concentrator was dusty. Resident #95 had two empty pre-packaged cups of nectar thick juice on his bedside table. Resident #95 had eaten his meal unsupervised in his room. A review of Resident #95's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No comprehensive MDS was completed for Resident #95. On [DATE] at 10:32 a.m., Resident #95 was observed in bed in his room with the blanket over his head. Resident #95 removed the blanket from his head and took a sip from a pre-packaged cup of nectar thick juice from his bedside table. After drinking the juice Resident #95 began to cough and struggle to clear his throat. On [DATE] at approximately 10:33 a.m., Certified Nurse's Aide (CNA) N was outside of Resident #95's room. When asked why Resident #95 had been eating breakfast in his room with the door closed, CNA N reported that Resident #95 had behaviors or disrobing and wouldn't keep his mask on so she told him to stay in his room. On [DATE] at approximately 10:34 a.m., Licensed Practical Nurse (LPN) A was notified of Resident #95's cough by this surveyor and LPN A reported he would go assess him. LPN A assessed Resident #95's oxygen saturation and found it to be 81%. LPN A reported that the reading couldn't be accurate and went to find another pulse oximeter. The second pulse oximeter gave a result of 87%. When asked what he would do, LPN A reported he could provide a breathing treatment or an inhaler as well as oxygen. LPN A reported he would need to get new oxygen tubing as the current tubing had been lying on the floor. On [DATE] at 5:35 p.m., Resident #95 was observed rocking in bed. His meal tray was at his bedside with 100% of his food and fluids consumed. Resident #95 continued with a congested cough and slight wheeze. On [DATE] at 5:37 p.m., LPN A was asked about Resident #95's congestive cough and oxygen saturation. LPN A reported that when he checked Resident #95's lungs he heard some crackles so he had notified the Nurse Practitioner and she had ordered an Xray. A review of NP Y progress note on [DATE] revealed, .S: Following for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is laying comfortably, no cough and congestion noted no wheezing, no shortness of breath or respiratory distress . ,d+[DATE] chest x-ray .Pneumonic process in the right suprahilar region and in the right infrahilar region medially . shadow and appearing to be portions of the right upper and lower lobes better seen in right lower lobe .Pneumonia. Continue [MEDICATION(S)] . A review of Resident #95's physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This diet order did not indicate what the level of thickness should be for the fluids. There were no dietary or nutritional assessments in Resident #95's record to reflect the correct diet. On [DATE] at 9:52 a.m. and 11:53 a.m Resident #95 was observed in bed, with no fluids at bedside, with audible chest congestion. On [DATE] at 4:00 p.m., RD T and the Director of Nursing (DON) were asked to observe Resident #95. When asked if there was anything missing from Resident #95's room, the DON and RD T confirmed that Resident #95 did not have any beverages or hydration available to him in his room. When asked about Resident #95's diet order being Thick Liquids and whether he had been assessed, RD T reported that CDM S was supposed to do his nutritional assessment. RD T reported she would investigate the issue. A review of a new physician orders for Resident #95 dated [DATE] revealed RD T had downgraded Resident #95 to a Regular diet puree with honey thick liquids and no straw after the conversation on [DATE]. On [DATE] at 12:45 p.m., Resident #95 was observed curled up in blankets in his bed. There were no liquids or beverages in his room. On [DATE] at approximately 1:00 p.m., CDM S confirmed that Resident #95 had been on a nectar thick liquids prior to [DATE]. A review of NP Y progress note on [DATE] revealed, .S: Following for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is laying comfortably, no cough and congestion noted no wheezing, no shortness of breath or respiratory distress . ,d+[DATE] chest x-ray .Pneumonic process in the right suprahilar region and in the right infrahilar region medially . appearing to be portions of the right upper and lower lobes better seen in right lower lobe .Pneumonia. Continue [MEDICATION(S)] .#Dysphagia. Dietitian follows, optimize nutrition, monitor weight . A review of a hospital discharge document for Resident #95 prior to his admission to the facility dated [DATE] revealed .Adult diet: . Pureed; Fluid Consistency: Honey Thick; Additional Restrictions: No Straws, 1:1 Feed . This document confirmed that Resident #95 was supposed to admit to the facility on honey thickened liquids. On [DATE] at 2:52 p.m., an interview was conducted with SLP WW who reported that he had evaluated Resident #95 on [DATE] and that Resident #95 required a Pureed and Honey Thickened liquid diet. SLP WW also reported that the Resident did require supervision. On [DATE] at 3:24 p.m., a phone interview was conducted with RN P regarding Resident #95's admission. RN P reported she was just the charge nurse that helped with the admission. When asked where his diet came from, RN P reported she assumed it came from the discharge paperwork. RN P reported if they don't get a diet from the discharging hospital they put in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 3:43 p.m., a phone interview was conducted with RN BBB who reported it she was on the unit Resident #95 admitted to. RN BBB reported that she normally gets the diet orders from the hospital records, but if it's not there they would request a speech evaluation. RN BBB reported that she didn't remember putting Resident #95's orders in. When informed her name was on the admission diet order, RN BBB reported she didn't know. On [DATE] at 1:07 p.m., Speech Language Pathologist (SLP) WW was asked if he had evaluated Resident #95 for the appropriate diet consistency. SLP WW reported that he had not because as far as he was aware Resident #95 admitted on hospice services. SLP WW stated, When they (residents) come in on hospice we usually just do a screen., Per SLP WW, Resident #95 had not been screened on admission. When asked what diet order the facility was supposed to follow, SLP WW reported the Resident should be on whatever diet his was discharged from the hospital on. A review of Resident #95's Admission Nursing Comprehensive Evaluation dated [DATE] revealed the following, .swallowing difficulty: yes. Thickened liquids: yes (consistency blank) . fluid restrictions: no . On [DATE] at 1:15 p.m., Resident #95 was observed up in a chair across from the nurses station with a rolling tray in front of him with a larger Styrofoam cup of honey-thickened juice, and a smaller cup that had the label torn off. Resident was observed to be raising and lowering his shoulders while he was breathing, was rubbing his face, and had a productive wet cough and wheeze. On [DATE] at 1:27 p.m., this surveyor was notified Resident #95 was having respiratory distress. On [DATE] at 1:30 p.m., Resident #95 was observed across from the nurse's station struggling to breath and clear his airway. Hospice Registered Nurse (RN) II was observed trying to get a portable oxygen tank working. Hospice RN II was asked about Resident #95's Spo2 and stated it was In the 40's. Hospice RN II attempted to get another reading of Resident #95's SPO2 which revealed 35% read on his right-hand finger and read 47% on his left great toe. LPN AA reported it was hard getting a reading because his extremities were so cold. Hospice RN II and LPN AA continued to struggle with getting a second portable oxygen tank to function. On [DATE] at 1:40 p.m., CNA V was observed brining an oxygen concentrator down from Resident #95's room to the nurses station. LPN AA obtained clean oxygen tubing and the oxygen cannula was placed on Resident #95. On [DATE] at 1:42 p.m., LPN AA rechecked Resident #95's Spo2 which read 43% oxygen saturation with a heart rate of 128 beats per minute. On [DATE] at 2:35 p.m., Hospice RN II was asked about Resident #95 and reported his oxygen saturation was now between ,d+[DATE]% on oxygen. Hospice RN II reported that the Resident had also received a breathing treatment, [MEDICATION(S)], and that NP Y had been notified and they were discussing whether to send the Resident to the hospital for evaluation. On [DATE] at 3:54 p.m., Hospice RN II followed up to report they were holding fluids for Resident #95 because it seemed he was struggling to breath after drinking liquids. When asked about the liquids he had been consuming at lunch, Hospice RN II reported that he had a thicker liquid in a cup and then a thinner liquid in the little cup. On [DATE] at 11:23 a.m., a phone interview was conducted with NP Y. When asked about Resident #95, NP Y reported she had seen the Resident on [DATE] and didn't hear any appreciable crackling or wheezing and that the resident wasn't coughing or struggling to breath. When asked if Resident #95's death on [DATE] had been anticipated, NP Y reported that the resident was compromised and declined to provide further comment. NP Y further reported that they had thought Resident #95 was a full code at first and were planning to send him to the hospital. When asked what her expectations of staff were if a resident was in respiratory distress with oxygen saturation ,d+[DATE]%, NP Y stated, Bring them back to their room. Administer oxygen. Give maximal oxygen you could give. When asked if the Guardian of Resident #95 was notified when Resident #95 started to decline, NP Y reported that she did not know. A review of a progress note written by Hospice RN II and emailed on the DON on [DATE] at 10:24 a.m., reveal in part, Routine hospice visit around 1400 (2:00 p.m.), patient is seen sitting up on wheelchair at nurses' station, alert, drinking thickened liquids. Patient's skin and lips appear pale, with productive cough . crackles noted on bilateral lungs. Unable to obtain accurate oxygen saturation on upper extremities due to pale & cold skin. Facility nurse then obtained oxygen saturation @ (at) 82% on left foot second toe on room air .Hospice RN educated facility staff regarding risk for aspiration due to current condition . Started non-rebreather mask @ 10LPM (liters per minute). [MEDICATION(S)] neb given then every ,d+[DATE] hrs as needed. Monitor patient closely . (NP Y) seen and assessed the patient with no further orders made . At around 1600, Hospice nurse and facility staff seen (sic) patient on bed, unresponsive, with no BP (blood pressure), no HR (heart rate), no RR (respirations). Patient time of death is 1615 (4:15 p.m.) . On [DATE] at 4:18 p.m., the Administrator and the DON were asked about Resident #95 receiving nectar thick liquids when his discharge order from the hospital was for honey thickened liquids. The DON then stated, Nurses can do swallow evals . It's a standard of practice When asked to clarify, the Administrator reported the staff should have called the doctor or speech if they weren't sure on the diet orders. The DON was asked what the time expectation was for staff to administer oxygen if a Resident is experiencing respiratory distress. The Administrator stated, Immediately. Within seconds. A review of Resident #95's [DATE] MAR from [DATE] through [DATE] revealed: The order for [MEDICATION(S)] Sulfate Inhale 2 puffs every 4 hours as needed for DOB(Sic - SOB - shortness of breath) was never given. The order for budesonide-[MEDICATION(S)] inhaler twice per day was missed three times. A review of the facility policy titled, Pneumonia, [CONDITION(S)], Lower Respiratory Infections reviewed [DATE] revealed, .2. The staff will identify residents with symptoms that suggest possible [CONDITION(S)] or pneumonia . 3. The staff and physician will identify residents with risk factors that may predispose them to pneumonia, such as . clinically significant dysphagia . 4. The physician will identify individuals who may need hospitalization because of the severity of pneumonia or the presence of complications .

Based on observation, interview, and record review, the facility failed to provide adequate supervision and/or fall interventions to prevent falls, including a fall with major injury (fracture) resulting in harm, for four Residents (#6, #20, #27, and #145) of six residents reviewed for falls. This deficient practice resulted in a hip fracture for Resident #20 with continued sequalae following surgical repair, and the potential for injury for the other residents. Findings include: On 3/28/22 1:53 p.m., Resident #145 was observed resting in a bed with a metal bed frame and an air mattress in place and not functioning (unplugged). Three half rails were noted in place on the bed; two rails on the right side at the foot and head with a space in between, and a half rail on the left side at the head of the bed. In between the rails on the right hand side, a dark blue cushion was uncovered, unsecured and tucked in the space between these rails. There were two fall mats located in the room which were folded up and resting against a chair at the foot of the bed. A review of the hospital History and Physical, dated 3/24/2022 at 11:38 p.m. [Recorded as Late Entry on 3/25/2022 at 11:38 p.m.], read in part: HPI (History of Present Illness): (Resident #145) was transferred for continued medical management and rehab care from (local hospital) where she was hospitalized for inpatient hospice care after a traumatic fall . PMH (Past Medical History): [CONDITION(S)] ([CONDITION(S)]), traumatic fall, nasal bone fx (fracture), acute [CONDITION(S)], [CONDITION(S)] w (with)/thalamic bleed, acute [CONDITION(S)] (Urinary Tract Infection), asthma, pediculosis (lice infestation), generalized anxiety disorder, Alzheimer's dementia, multilevel C-spine [CONDITION(S)] disk disease, chronic debility . A review of the progress notes section for Resident #145 revealed the following: 03/24/2022 06:30 AM . bed left in lowest position with safety mat present @bedside . 03/25/2022 07:58 AM . bed left in lowest position with safety mat present @bedside . On 3/29/22 at 3:09 p.m., the floor mats were observed folded up and leaning against the wardrobe located near the room door. Resident #145 was resting in her bed. On 3/30/22 at 8:09 a.m., upon entering Resident #145's room, two floor mats were located in the room folded up and leaning against furniture. Resident #145 was resting in her bed. On 3/30/22 at 5:21 p.m., Resident #145 continued to have three side rails observed in place on the Resident's bed. There were no orders, measurements, assessment, or consent for the three half rails. On 3/31/22 at 01:00 PM an observation was made of Resident #145's bed with rails remaining in place and no assessment, consent, or orders provided by the facility at the time of exit. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were asked to provide evidence of the order, measurements, assessment, and consent for the half rails. On 4/4/22 at 1:08 p.m., a review of the Electronic Medical Record (EMR) Progress Notes for Resident #145 revealed the facility had the bed with side rails changed out and Resident #145 was currently resting in a bariatric bed. On 4/4/22 at 2:10 p.m., during an interview, the NHA was asked why the bed and bed rails were removed from Resident #145. The NHA stated they were starting the process over and removing the bed with bed rails until the required items for bed rail use could be completed. The NHA acknowledged the facility was out of compliance with regard to the use of bed rails on Resident #145. The NHA was asked for the facility policy for bedrails. On 4/4/22 at 2:20 p.m., the floor mats in the room were noted in place on the left hand side of the bed. A review of the EMR care plan on 4/4/22 at 2:54 p.m. revealed no floor mats used as an intervention for any precautions. On 4/4/22 at 3:00 p.m., One of the floor mats was observed leaning up against a chair in the room and the other floor mat was folded up into thirds on the floor and located approximately 2-3 feet from the edge of the bed. Resident #145 would likely have struck the floor versus landing on the floor mat if she were to have fallen out of bed. On 4/4/22 at 03:02 p.m., during an interview, Licensed Practical Nurse (LPN) AA was asked if floor mats were supposed to be in place for Resident #145 when she was in her bed. LPN AA confirmed the floor mats were supposed to be in place. This surveyor accompanied LPN AA to the room and showed her the floor mats as observed above. LPN AA agreed the floor mat should not have been folded up and not in the correct place. On 4/4/22 at 4:00 p.m., during an interview, the DON provided a policy on restraints and stated this was the closest policy she could find relating to the use of bed rails. The DON stated they follow Centers for Medicare/Medicaid guidelines for bedrail use. A review of the policy Assessing Falls and Their Causes, with a revised date of 8/1/2016, read in part: 2. Identify the resident's current medications and active medical conditions . There was no guidance within the facility policy for staff to assess for the risk of falls when admitting and/or initiating appropriate interventions to prevent falls for a resident with a significant fall history. Resident #6 On 3/30/22 at 11:54 a.m., Resident #6 was observed walking around near the nurse's station near the door of his room. Resident #6 was unsteady on his feet, wearing only regular socks, and started to reach out looking for something to steady his balance. Resident #6 was assisted to steady himself when LPN A offered him a hand. A review of Resident #6's medical record revealed he admitted to the facility on [DATE] with diagnoses including vascular dementia, stroke, and diabetes type 2. A review of his 1/2/22 MDS assessment revealed he scored 1/15 on the BIMS assessment, indicating severely impaired cognition, had a fall in the month prior to his admission, and had one fall since his admission to the facility. On 4/4/22 at 4:05 p.m., Resident #6 was observed up walking in the hallway with his Family Member (FM) HHH. Resident # 6 had a slipper on his left foot and a regular sock on his right foot. FM HHH reported that his father liked to walk but was at risk for falls. A review of Resident #6's care plan for Falls initiated 12/29/21 revealed the following: Resident is at risk for falling R/T: mobility and cognitive limits . Provide proper, well-maintained footwear . Resident #20 During interview on 3/28/22 at 2:25 p.m. and 3/30/22 at 1:43 p.m., Resident #20 was interviewed regarding falls in the facility. Resident #20 said facility staff had dropped her and she had a broken hip. Resident #20 was unsure what staff member was present when she fell and broke hip on 12/2/22. Review of Resident #20's MDS assessment, dated 9/2/21, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)], depression, and other muscle spasm. Resident #20 was totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, and scored 15 of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition. Review of a Fall Event Report for Resident #20, dated 12/2/21 at 6:19 p.m., revealed the following in part: CNA reported to writer that in the middle of peri care residents' upper body was too close to the edge of the bed and she was sliding off the bed. CNA lowered resident to the floor and called for help . The progress note said the Physician, family, and DON (Director of Nursing) were notified at that time (12/2/21 at 4:42 p.m.). Notification specified on the Event Report documented NO to Attending Faxed, Physician Notified, Resident Representative Notified, and Care Plan Reviewed. The CNA involved was not identified in the report. Review of Resident #20's progress notes revealed the following, in part: 12/2/21 4:42 p.m., CNA reported to writer that in the middle of peri care residents' upper body was too close to the edge of the bed and she was sliding off the bed, CNA lowered resident to the floor and call for help . (Authored by LPN B) 12/3/21 5:59 p.m., Received a report resident tested positive for Covid (presumptive) awaiting results for PCR. Patient alert, oriented, weak complains of feeling weak and reports pain (6) (6 out of 10 on pain scale) on Hip post fall 12/2/2021 .[Physician] notified .Order to send patient out to Hospital. 12/17/21 8:20 p.m., readmitted on 14 day observation post covid and Hemiarthroplasty hip . Review of a [Name] Therapy Screen, for Resident #2 by Occupational Therapy (OT) staff on 12/16/21 revealed the following, in part: Reason for Screen . Resident had a fall 12/2 . Therapy was told on 12/6/21 . Change from baseline (Circle): Falls (circled) . Educate staff on [illegible word, appears to be 'proper'] bed mobility. Pt (patient) had covid 19 and sent out to hospital on 12/2 . Review of Resident #20's acute care hospital History of Present Illness, admitted : 12/3/2021 revealed the following, in part: .bed bound needs hoyer lift/wheelchair for mobilization . present from [Facility Name] nursing home due to a fall. Per patient she is a 2 person assist for movement. She says only one person moving her at nursing home and she fell on to wheelchair, had left hip pain . Review of Resident #20's acute care hospital After Visit Summary, for the 12/4/21 - 12/17/21 hospital stay, revealed the following, in part: Current Visit, Past Procedures, 12/5/2021 Hemiarthroplasty hip . During an interview on 4/4/22 at 10:05 a.m., Licensed Practical Nurse (LPN) B said she did not recall who the CNA was that reported Resident #20 slipped from bed during pericare on 12/2/21. When asked about the provision of pericare by one CNA, for a resident with left-sided paralysis, LPN B acknowledge surprise that the CNA had done pericare alone for Resident #20. LPN B agreed it would be unsafe to roll Resident #20 alone (to clean the buttocks), and also agreed you would not complete pericare from the front position only - rolling would be necessary. LPN B confirmed she was called for assistance by the unidentified CNA, and found Resident #20 on the floor. During a telephone interview on 4/4/22 at 11:25 a.m., Resident #20's Durable Power of Attorney (DPOA) DD was asked about Resident #20's 12/3/22 hospitalization . DPOA DD said Resident #20 had a significant decline in her condition since the broken hip in early December 2021. When asked about notification from the facility, related to a fall for Resident #20, DPOA DD said Resident #20 was not able to reposition in bed due to left sided paralysis from a stroke in 2019. DPOA DD stated, I do not believe that they lowered her to the ground. She is not even able to turn herself in bed. I was heartbroken when I heard about it. I was very upset when they did not take her to the hospital (right away). I did not find out that she had gone to the hospital until the doctor called and said she was going to have surgery . The nurse called me and said we dropped her . said she (Resident #20) slipped . and she went down to the floor and she called for help . DPOA DD said that she believed the decline in Resident #20's current condition was a result of the fall with resulting hip fracture in December 2021. During a telephone interview with Confidential Witness #C1009 on 4/5/22 at 2:20 p.m., Resident #20's fall in the facility on 12/2/21 was discussed. Witness #C1009 said they were sad and unconsionably upset by the multiplicity of things that transpired with Resident #20's care. Witness #C1009 said the facility administration said Resident #20 did not have a fall, but nursing staff said there was a problem with the transfer from the bed to the wheelchair. Witness #C1009 stated, To be honest with you, a lot of that (fall information) was a little convoluted and camouflaged . During an interview on 4/4/22 at 3:15 p.m., the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed there was no investigation completed and no witness statements obtained for Resident #20's fall resulting in a broken hip (major injury). The CNA involved in Resident #20's 12/2/21 fall from bed was unable to be identified, and therefore unable to be interviewed. The facility was unable to provide staff schedules showing which nursing staff worked in the facility on 12/2/21 and 12/3/21 at the time of, and following Resident #20's fall with left hip fracture. Review of the facility Resident Abuse/Neglect policy, revised 3/9/22, revealed the following, in part: Incidents involving alleged, suspected or actual abuse (including misappropriation or exploitation) or resulting in serious bodily injury to the patient (including injuries of unknown origin), shall be reported to the state immediately, but not more than 2 hours after forming the suspicion .

Based on observation, interview, and record review, the facility failed to provide timely oxygen care, [CONDITION(S)] care, and maintain oxygen concentrators in a sanitary manor for three Residents (#15 and #95 and #902) out of five reviewed for oxygen care. This deficient practice resulted in a Resident (#95) not receiving timely oxygen support during respiratory distress, potentially contributing to his expiration, and the potential for further respiratory distress and infection. Findings include: Resident #95 On [DATE] at 8:15 a.m., Resident #95 was observed in his room. His oxygen concentrator was turned off with the tubing and nasal cannula lying on the floor. The filter on the concentrator was dusty. Resident #95 was rocking in his bed and had a congestive cough. A review of Resident #95's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #95 did not have a completed Minimum Data Set (MDS) assessment completed. On [DATE] at 10:32 a.m., Resident #95 was observed in bed in his room with a blanket over his head. Resident removed the blanket from his head and took a sip from the pre-packaged cup of nectar thick juice from his bedside table. After drinking the juice Resident #95 began to cough and struggle to clear his throat. On [DATE] at approximately 10:33 a.m., Certified Nurse Aide (CNA) N was observed in the hall outside Resident #95's room. When asked why Resident #95 had been eating breakfast in his room with the door closed, CNA N reported that Resident #95 had behaviors of disrobing and wouldn't keep his mask on so she told him to stay in his room. On [DATE] at approximately 10:34 a.m., Licensed Practical Nurse (LPN) A was notified of Resident #95's cough by this surveyor and reported he would go assess him. LPN A assessed Resident #95's oxygen saturation with a pulse oximeter and found it to be 81%. LPN A reported that the reading couldn't be accurate and went to find another pulse oximeter. The second pulse oximeter gave a result of 87%. When asked what he would do, LPN A reported he could provide treatments and inhalers as well as oxygen. On [DATE] at 5:35 p.m., Resident #95 was observed rocking in bed. His meal tray was at his bedside with 100% of his food and fluids consumed. The pre-packaged juice cups were noted to be nectar-thick consistency per the label. Resident #95 continued to struggle with a congested cough and slight wheeze. On [DATE] at 5:37 p.m., LPN A was asked about Resident #95's congestive cough and oxygen saturation. LPN A reported that when he checked Resident #95's lungs he heard some crackles so he had notified the Nurse Practitioner (NP Y) and she had ordered a chest X-ray. A review of NP Y progress note on [DATE] revealed, .S: Following for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is laying comfortably, no cough and congestion noted no wheezing, no shortness of breath or respiratory distress . ,d+[DATE] chest x-ray .Pneumonic process in the right suprahilar region and in the right infrahilar region medially . shadow and appearing to be portions of the right upper and lower lobes better seen in right lower lobe .Pneumonia. Continue [MEDICATION(S)] (antibiotic) . On [DATE] at 1:15 p.m., Resident #95 was observed up in a chair across from the nurse's station with a rolling tray in front of him with a larger Styrofoam cup of honey-thickened juice, and a smaller pre-packaged juice cup that had the label torn off. Resident was observed to be raising and lowering his shoulders while he was breathing, was rubbing his face, and had a productive wet cough and wheeze. On [DATE] at 1:27 p.m., this Surveyor was notified by another member of the Survey team that Resident #95 was having respiratory distress. On [DATE] at 1:30 p.m., Resident #95 was observed across from the nurse's station struggling to breath and clear his airway. Hospice Registered Nurse (RN) II was observed trying to get a portable oxygen tank to work. LPN AA and LPN FFF were also observed around Resident #95. Hospice RN II was asked about Resident #95's Spo2 and stated it was in the 40's. Hospice RN II attempted to get another reading of Resident #95's SPO2 which revealed 35% read on his right-hand pointer finger and read 47% on his left great toe. LPN AA reported it was hard getting a reading because his extremities were so cold. Hospice RN II and LPN AA continued to struggle with getting a second portable oxygen tank to work. On [DATE] at 1:40 p.m., CNA V was observed bringing down an oxygen concentrator from Resident #95's room down to the nurses station. LPN AA obtained clean oxygen tubing and the oxygen cannula was placed on Resident #95. On [DATE] at 1:42 p.m., LPN AA rechecked Resident #95's Spo2 which read 43% oxygen saturation with a heart rate of 128 beats per minute. On [DATE] at 2:35 p.m., Hospice RN II was asked about Resident #95 and reported his oxygen saturation was now between ,d+[DATE]% on oxygen. Hospice RN II reported that the Resident had also received a breathing treatment, [MEDICATION(S)], and that NP Y had been notified and they were discussing whether to send the Resident to the hospital for evaluation. On [DATE] at 3:54 p.m., Hospice RN II followed up to report they were holding fluids for Resident #95 because it seemed he was struggling to breath after drinking liquids. When asked about the liquids he had been consuming at lunch, Hospice RN II reported that he had a thicker liquid in a cup and then a thinner liquid in the little cup. Hospice RN II reported that NP Y had told them to continue monitoring his breathing. On [DATE] at 11:23 a.m., a phone interview was conducted with NP Y, who reported she had been working in the building for over a year. When asked about Resident #95, NP Y reported she had seen the Resident on [DATE] and wrote a progress note. NP Y reported she didn't hear any appreciable crackling or wheezing and that Resident #95 wasn't coughing or struggling to breath. When asked if Resident #95's death on [DATE] had been anticipated, NP Y reported that the resident was compromised. NP Y provided no further comment on Resident #95's death. NP Y further reported that they had thought Resident #95 was a full code at first and were planning to send him to the hospital. When asked what her expectations of staff were if a resident was in respiratory distress with oxygen saturation in the ,d+[DATE]'s, NP Y stated, Bring them back to their room. Administer oxygen. Give maximal oxygen you could give. When asked if the Guardian of Resident #95 was notified when Resident #95 started to decline, NP Y reported that she did not know. On [DATE] at 4:18 p.m., the Administrator and the DON were asked what the time expectation was for staff to administer oxygen if a Resident is experiencing respiratory distress. The Administrator stated, Immediately. Within seconds. A review of a progress note written by Hospice RN II and emailed to the Director of Nursing (DON) on [DATE] at 10:24 a.m., revealed in part, Routine hospice visit around 1400 (2:00 p.m.), patient (Resident #95) is seen sitting up on wheelchair at nurses' station, alert, drinking thickened liquids. Patient's skin and lips appear pale, with productive cough . crackles noted on bilateral lungs. Unable to obtain accurate oxygen saturation on upper extremities due to pale & cold skin. Facility nurse then obtained oxygen saturation @ (at) 82% on left foot second toe on room air .Hospice RN educated facility staff regarding risk for aspiration due to current condition . Started non-rebreather mask @ 10LPM (liters per minute). [MEDICATION(S)] neb given then every ,d+[DATE] hrs as needed. Monitor patient closely . (NP Y) seen and assessed the patient with no further orders made . At around 1600, Hospice nurse and facility staff seen patient on bed, unresponsive, with no BP (blood pressure), no HR (heart rate), no RR (respirations). Patient time of death is 1615 (4:15 p.m.) . Resident #15 On [DATE] at 3:50 p.m., Resident #15 was observed in bed with a nasal cannula in her nose. Observations of her oxygen concentrator revealed that the filter was very dusty and there was a dried black residue spilled on the concentrator. A review of Resident #15's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] Minimum Data Set (MDS) assessment revealed she was assessed by staff to be severely cognitively impaired and relied on tube feeding to meet her nutritional needs. On [DATE] at 7:55 a.m., Resident #15's oxygen concentrator was observed to still have black residue spilled on it and the filter was still full of dust. On [DATE] at 4:00 p.m., the Director of Nursing (DON) was shown Resident #15's oxygen concentrator and she confirmed that the filter was dusty and the concentrator was dirty. Resident #902 A review of Resident #902's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] Minimum Data Set (MDS) assessment revealed he was Severely Impaired per staff assessment and received tube feeding. A review of Resident #902's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following: An order dated [DATE] for ([CONDITION(S)]) Suction Q (every) 4 hours and PRN was discontinued on [DATE], and was only completed 4 times on [DATE] and not at all on [DATE]. An order dated [DATE] for [CONDITION(S)] care . with NS (normal saline) Q shift and PRN discontinued [DATE] had only been completed one time on [DATE]. Further review of this MAR and TAR revealed that despite the Resident being admitted on [DATE], there were no orders for [CONDITION(S)] care or suctioning until [DATE], and there was no evidence it was being done prior to [DATE]. A review of the facility policy titled, Oxygen Administration most recently reviewed [DATE] revealed, 1. Review the physician's orders for facility protocol for oxygen administration E. Concentrator exteriors will be cleaned weekly; associated filters will be cleaned weekly . Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs of symptoms of [CONDITION(S)] (cyanosis, [CONDITION(S)], tachypnea, diaphoresis, restlessness or confusion, dyspnea). 2. Vital signs. 3. Auscultate lungs. 4. Oxygen Saturation .6. Connect the delivery device to the oxygen source, date the tubing, and turn on the concentrator. NOTE: concentrators take ,d+[DATE] minutes to produce oxygen . A review of the facility policy titled, Pulse Oximetry (Assessing Oxygen Saturation) last reviewed [DATE] revealed, The purpose of this procedure is to monitor arterial blood oxygen saturation (SaO2) without the use of invasive devices . b. placement of oximeter. Impaired circulation . to the area in which the oximeter probe is placed will provide inaccurate data. Since the elderly often have impaired peripheral circulation, an ear probe may be used . 2. Normally SpO2 is between 9- and 100 percent; Sustained SpO2 below 70 percent requires immediate intervention Documentation. The date, and time that the procedure was performed, the value of the reading. 1. Any unusual findings and action taken .

This citation pertains to intake #MI 307. Based on observation, interview and record review the facility failed to provide monitoring and/or supervision to prevent elopement and respond to an alarm sounding door for one Resident (Resident #708) of four residents reviewed for elopement, resulting in immediate jeopardy (IJ) due to the likelihood of serious injury, harm, impairment or death. On 11/12/2021 at approximately 06:31 AM, Resident #708 was witnessed by Resident #711 outside of the facility trying to get back in. Resident #708 had exited the facility from an emergency door, unbeknownst to the staff, dressed in flannel pajama bottoms, a T-shirt, and socks, with an approximate outdoor temperature of 39 degrees Fahrenheit. R708 was cognitively impaired with a known history of exit seeking behavior. At 06:41 AM, Resident #708 was observed by Housekeeper A walking slowly against the wall of the building outside and was brought back into the facility at approximately 06:58 AM. Findings include: On 11/22/2021 at 08:32 AM, Resident #708 was observed awake, lying-in bed. An attempt was made to interview Resident #708; however, they were unable to answer questions appropriately. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #708 was most recently admitted to the facility on [DATE] with the diagnoses of: Cerebral Infarction, [CONDITION(S)] and Dementia. Resident #708 required limited assistance with bed mobility, transfers and ambulation, and had a BIMS score of 06 out of 15 (00-07= severe cognitive impairment). A record review of the Progress Notes for Resident #708 revealed the following: 09/05/2021 05:51 PM Res (Resident) A/Ox1-2 (alert and oriented to person and/or place), makes needs known, staff continuously redirecting res to not attempt to stand and ambulate independently, or self transfer, d/t (due to) unsteady gait and weakness. Res continues to attempt to exit building verbalizing .has to get out of here. Res does not listen and is combative with staff when re-directed. Res placed at nurse station for monitoring. 09/14/2021 05:58 PM A/Ox1, able to make needs known. Res continues to wander into inappropriate places and exit seeking, res with undesired sexual behavior toward staff such as hitting staff members on their buttocks. Res consistently attempts to self transfer and/or ambulate independently with unsteady wobbly gait, re-educated res to ask for help when needed, res verbalized understanding. Staff continuously re-directing res to quiet place and to maintain safety, res continues to resist. Res with no pain or discomfort identified. SW (Social Worker) notified. DON (Director of Nursing)/Administer aware. 09/27/2021 01:01 PM SW followed up with resident regarding behaviors- per bx (behavioral) log, resident displayed inappropriate sexual bx and per nurse resident has exit seeking bx as well .Resident is confused and unable to recall what .did over the weekend. Resident is followed by psych services. 11/12/2021 06:54 AM Writer informed that patient was observed outside of the building by staff member (Housekeeper A). Patient was observed on north side believed to have used Emergency exit door to get out and was observed on sidewalk walking. Patient redirected back inside without injury. Writer informed by [Housekeeper A] that patient was seen by her approximately 06:40 am. Patient was wheeled back down to hall. Patient has been up throughout the shift. being directed to sit down throughout shift. Unable to give a time of how long patient was off the floor and outside. Patient was last seen by writer and changed proximately 6 am . DON .Notified. Writer informed to contact the administrator .and to have everyone write a statement and place under door. Patient currently sitting in w/c (wheelchair) up at south nursing station. No further assistance needed at this time. Authored by Nurse K. 11/12/2021 03:12 PM SW called POA (Power of Attorney) .to follow up with facilities . would like me to send referrals to for a transfer. It has been discussed that resident requires a locked unit/memory care facility. POA does not have a preference for facility to send referrals to. SW sent referrals to facilities. 11/15/2021 10:46 AM Res alert/verbal up in w/c self-propelling, exit seeking. Staff continues to re-direct resident to maintain safety . On 11/22/2021 at 11:02 AM, Resident #711 was observed to be dressed and groomed ambulating in the hallway just outside their room. Resident #711's room was located at the end of the north hall with a clear view of the emergency exit door on the north unit. Resident #711 was interviewed in regard to what they saw on the morning of 11/12/2021. Resident #711 had explained that they are a light sleeper and heard noises from outside their room. Resident #711 explained that they got out of bed, walked out of their room and looked across the hall (about 15 feet) and saw that Resident #708 was outside the building looking through the window. Resident #711 was asked what they did when they saw Resident #708 outside and explained that they think they told someone and then went to back to bed. A record review of the MDS dated [DATE] revealed that Resident #711 was admitted to the facility on [DATE] with diagnoses that include Cerebral Infarct and Dementia. The Resident had a BIMS of 03, indicating an impaired cognition and needed limited assistance with bed mobility and transfers. On 11/22/21 at 11:11 AM, the Nursing Home Administrator (NHA) was interviewed in regard to Resident #708 exiting the building on 11/12/2021. The NHA was asked to explain what happened and revealed that she was able to view camera footage of Resident #708 self-propelling themselves from the south unit, heading toward the north side, a Certified Nurse Assistant (CNA) brought the Resident back to the nurses station on the south unit and went to give care to other residents. The NHA further explained that the Resident then self-propelled towards the north unit and sat in front of north station for a couple of minutes, then went down back to the end of north hall where the door then subsequently was opened by Resident #708. The NHA was asked if there was audio to the camera footage and explained there was not. The NHA stated, There was a red flashing light noticed on camera footage, indicating the door was sounding. The NHA was asked what the staff were doing at the time and explained that Resident #711 was observed to come out of their room, and then go to the north nurse's station (where there were four staff members sitting) to report that Resident #708 was outside. The NHA stated, I could see that [Resident #711] was frustrated that the staff wasn't listening to them. A staff member did get up to respond but then was waved to sit back down by the nurse. Another staff member was on their phone. They were agency staff. We reported their licenses to the board (state board of nursing) and will not allow them back in the building. A request was made to view the camera footage at this time, however the footage was not made available by the end of the survey. A review of the Facility Reported Incident (FRI) packet revealed the following: Incident Summary: Resident found outside the building by staff member. No physical injuries notes. Resident returned safely to building . Camera footage .on 11/12/2021 approximately 06:00 am, [Resident #708] was self propelling in .wheelchair in the facility. The resident is seen rolling .to the North side of the building, and was brought back by a CNA on the South side. Approximately 06:20 AM [Resident #708] is observed propelling .to the North side again. [Nurse L] from .agency, [Nurse M], from .agency and CNA N from .agency can be seen at the North nurses station for approximately 4 minutes before (Resident #708) self propelled down the back end of the North hall. At 06:30 AM [Resident #708] got to the emergency exit door located at the back end of the North hall. [Resident #708] got up from their wheelchair to open the door. The door has an alarm on it, and sounds immediately when attempted to open. The door will not release unless held for 15 seconds. The resident exited the building at 06:31 AM. The door alarm is sounding, which is evident by the red flashing light observed in the video. [Nurse L, Nurse M], and [CNA N] are still sitting behind the North nurses station .[Nurse L, Nurse M], and [CNA N] continue to sit at the North nurses station. Minutes later, [Housekeeper A] . is seen in the building bringing [Resident #708] back to the nurses station . A review of the witness statements revealed the following: Nurse K- .No one can give a clear time of how long patient was outside but that pt (patient) was observed outside approximately 06:40 AM. Nurse P- .observed [R708] being changed between 06:00-06:30 AM .was doing a safety watch on patient at south side nurses station .then observed a staff member wheeling [R708] into the building . CNA O- I was in 112A providing care I didn't see 212B. CNA N- I was walking down the hallway and another worker was bringing the patient back . Nurse M- Resident in room 212-B was last seen by writer by nursing station on north side, after writer was in room 110-A . Nurse L- I observed staff member pushing resident 212B down the hallway stating she observed the resident off the unit . On 11/22/2021 at 12:00 PM, Nurse K (assigned to Resident #708 on 11/12/2021) was interviewed via phone. Nurse K stated, (Resident #708) was my patient, (Resident #708) was on the south unit. We had three aides and two nurses down there that night. I gave (Resident #708) their 06:00 AM meds and had the aides change them. I had a 1:1 (another resident requiring one to one supervision) at the desk already. Then [Housekeeper A] brought them to me and said they were outside. I went down to the north side and asked them (the staff at the desk) what happened but none of them could tell me what happened. Just [Housekeeper A]. I couldn't hear any alarms because I was on the south unit. On 11/22/2021 at 12:45 PM, Nurse P was attempted to be contacted and interviewed via telephone. No return phone call was received by the end of the survey process. On 11/22/2021 at 12:49 PM, CNA O was attempted to be contacted and interviewed via telephone. No return phone call was received by the end of survey process. A record review of the Physician Orders for Resident #708 revealed the following: 11/12/2021-Elopement: Initiate Elopement Precautions - Take photo of resident and post at units, reception, and other exit areas, as appropriate; Make sure resident has name on band at all times; Check resident whereabouts Q (every) 30 minutes; Initiate wander protection device; etc. On 11/22/21 at 01:30 PM-Resident #708 was observed to be sitting up in their wheelchair in their room. Resident #708 was dressed and groomed. There was no wander device observed on the resident. On 11/22/2021 at 01:58 PM, the NHA was interviewed regarding Resident #708 exiting the building on 11/12/2021. The NHA was asked if the staff at the desk could hear the sounding alarms. The NHA stated, Yes, they just didn't respond. I was livid when I saw the video. Their statements were [NAME], they didn't add up. They probably aren't going to talk to you because I reported all their licenses. One of them was on the phone, the other one just waved [Resident #711] off. The NHA was asked when Resident #708 was brought in the building and stated, Around 06:58 AM. The NHA was asked what Resident #708 was wearing and explained that Resident #708 was wearing gripper socks, and red flannel pajamas and a gray shirt. The NHA was asked to clarify the order written for a wander protection device and stated, We don't use a wander guard system (a system that utilizes bracelets to alarm when close to an alarmed door). On 11/22/2021 at 02:17 PM, Housekeeper A was interviewed via telephone and was asked to explain what happened on her way to work on 11/12/2021. Housekeeper A stated, I was pulling into work and saw (Resident #708) literally scaling the walls on the outside of the building. I immediately stopped my car and got out. (Resident #708) was probably seven feet away from the door. When I approached the Resident, they kept telling me, 'It's cold!' They had pajama pants on, a T-shirt and socks on. I walked with them around to the door and brought them in the building. A review of the care plans for Resident #708, revealed there were no care plan initiated for exit seeking behaviors until 11/12/2021. On 11/23/2021 at 10:01 AM a paper was taped to the window at the side of the north emergency exit door that read the following: Please ring doorbell for entry. A review of the facility policy titled Elopements (undated) revealed the following: .Staff shall report and investigate if need be all cases of missing residents .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse .If an employee observes a resident leaving the premises, he/she should: a. Attempt and or to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity . The Administrator was notified of Immediate Jeopardy on 11/22/21 at 04:01 PM and a plan of correction was requested to remove the immediacy that began on 11/12/2021. The facility provided the following removal plan. Immediate Jeopardy was removed on 11/22/2021 as validated by the team on 11/23/2021. Removal Plan: Issue Cited: The facility failed to provide monitoring and supervision to prevent the elopement of Resident #708 (R708) from an emergency door of the facility. Identification of Residents Affected or Likely to be Affected: While all residents have the potential to be affected, no other residents were identified. [Resident #708] was the only resident that exited the building. Beginning 11/12 - [Resident #708] was immediately put on a one on one. Beginning 11/12- Elopement books were updated. Beginning 11/12 - All residents had an elopement reassessment completed. The residents with high scores had their care plans were updated. Actions to Prevent Occurrence/Recurrence: All door alarms are checked twice daily to ensure the alarm is audible. All staff was in-serviced on elopements. Elopement drills will be done weekly x4, then monthly. Staff were educated on timely response to alarming doors and checking surrounding areas for possible elopement Charge nurse/individual overseeing facility at time of alleged incident will contact Administrator immediately and direct staff to do a head count to ensure all residents are in the building. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 11/22/2021. Although the immediate jeopardy was removed on 11/22/2021, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, as sustained compliance could not be verified by the State Agency.

This Citation Pertains to Intake Number MI 165. Based on interview and record review, the facility failed to provide monitoring and supervision to prevent elopement and adequately investigate and implement interventions to prevent falls for one Resident (#13), from 3 residents reviewed for supervision and safety. This deficient practice resulted in Resident #13's elopement and repeated falls with injury,hospitalization s and multiple fractures. Findings include: A review of Resident #13's medical record revealed an admitted [DATE] with diagnoses including dementia, anxiety, [CONDITION(S)], [CONDITION(S)], acute [CONDITION(S)] and [CONDITION(S)] (brain disorder). The Minimum Data Set assessment dated [DATE] revealed Resident #13 was moderately cognitively impaired. Nursing progress notes revealed: 08/10/2021 08:35 PM New admit day #1 .Resident wanders frequently in hallway, anxious, frequently redirected. Frequent checks . 08/12/2021 04:43 AM New admit day #2 .in bed at change of shift, alert x3, confused at times . Resident wandered throughout the night and had to be redirected multiple times. 09/02/2021 06:43 AM .alert and sitting by the nurses station at change of shift .At approximately 0200 am, resident was observed at back west entry facility door trying to exit. Resident redirected back towards nurses station Resident began to grab the hands of another resident and started tell (sic) resident, come on, lets go. Resident continued to pull at the other resident towards exit door. attempts made to distract resident, resident continued to exhibit exit seeking behaviors . 09/08/2021 04:41 PM Resident noted exiting the building and seen by maintenance and housekeeping supervisor and redirected back into the building. DON (Director of Nursing,) Administrator notified, unable to reach daughter . During an interview on 11/2/21 at 3:43 PM, the Nursing Home Administrator (NHA) revealed she was aware of Resident #13's elopement on 9/8/21. The NHA explained Resident #13 was at the exit door and held it long enough to release the lock. The NHA said there was not an elopement, but Resident #13 may have had one foot out the door. The NHA revealed there was no written investigation or incident report documenting the event or follow up. The NHA stated, I did not put it in a progress note .There should have been an incident report. The NHA said Resident #13 was exit seeking and was redirected. The NHA named two staff members (Staff J and Staff K) who redirected Resident #13 back into the building. During an interview on 11/3/21 at approximately 9:40 AM, the previous DON I stated she did recall Resident #13 was observed at the exit door. The previous DON I revealed she did not review the progress note of 9/8/21 until Friday 9/10/21. The previous DON I stated there was a discrepancy in the [progress] note and what was reported, and we discussed this. The previous DON I continued stating Licensed Practical Nurse (LPN) D, the author of the progress note dated 9/8/21, was asked to clarify the note. A copy of the clarified note was requested and was provided on plain paper (not printed from the medical record), and it was hand signed by LPN D. The clarified note read, While in another resident's room, writer heard alarm sounding and came out of resident's room and ran towards the alarming door. I was approached by Maintenance and Hsk (Housekeeping) supervisor with [Resident #13], they both stated that [Resident #13] had opened the exit door and was re-directed without difficulty. Immediately after resident was placed on one on one with sitter. The previous DON I revealed if Resident #13 exited the building it would be considered an elopement, we would have to report it and start an investigation. The previous DON I confirmed no other investigation documentation was available. On 11/3/21 at 8:27 AM Staff J was interviewed via telephone and recalled Resident #13's elopement on 9/8/21. Staff J revealed an exit door alarm was sounding as she walked in the hallway returning from a morning meeting. The Maintenance Director (Staff) K was near her and said, Why is that alarm going off? Staff J stated, I started running to the door. Staff J said no other nurses or aides were seen in the hallway. Staff J stated, I got to the door and found it was cracked open. I could not see anyone. Staff J explained, if the locked door was pushed and held, after a while it would open and alarm. Staff J stated, I ran out the door to the end of the sidewalk and turned left and saw [Resident #13] going to the back end of the parking lot where there are a lot of employees cars . [Resident #13] was a small lady and could move fast. Staff J said Resident #13 was repeating I just want to go home. Staff J was able to get Resident #13 to move back toward the building. By then, Staff K had arrived with a wheelchair for Resident #13 whose legs were getting weak and took her back into the building. The nurse (LPN D) wheeled Resident #13 back to her room and wrote a statement. When Staff J was asked about an investigation, she stated, They did not ask me about it .They did not ask me for a statement. On 11/3/21 at approximately 11:10 AM, during an interview regarding the elopement of Resident #13, LPN D stated she heard the alarm, went down the hall to the exit door, and saw Staff J and Staff K with Resident #13. LPN D took Resident #13 back to her room. LPN D said she did not see Resident #13 on the outside of the building. During a telephone interview on 11/3/21 at 12:05 PM, Staff K recalled walking back from the morning meeting and said the door at 1 north was chirping. We definitely heard it. It is quite loud. Staff K said he approached the door, and it was opened a crack. Staff K explained, When someone opens the door, it swings shut but not all the way. Staff K said, [Staff J] got there first and I went and grabbed a wheelchair . I went outside and [Staff J] was there walking [Resident #13] back toward the door. When asked where he saw Resident #13, Staff K said, six or seven steps out the door when I got there. Staff K said they got Resident #13 in, and LPN D took the Resident back to her room. When asked about the follow up to the event, Staff K said no one asked him what had happened or took a statement from him. Nursing progress notes dated 8/10/21, 8/12/21, and 9/2/21 recorded Resident #13's wandering behavior. Resident #13's Care Plan dated 9/2/21 revealed, Resident experiences wandering and exit seeking behaviors (moves with no rational purpose, seemingly oblivious to needs or safety). The only intervention listed for the problem read: Place resident in a secure environment. No updates were listed after the elopement of 9/8/21. The facility policy and procedure Elopements dated 10/24/21 read in part: Staff shall promptly report any resident who tries to leave the premises .5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: .Complete and file an incident report; and Document relevant information in the resident's medical record. The policy was absent any information regarding protocol for investigation, evaluation, and analysis following elopements. On 9/30/21 a complaint was filed with the State Agency (SA), which read in part: . the resident (#13) fell and hurt herself .was trying to go to the restroom at the time of her fall . resident had a previous fall that did not produce injury but during this fall the resident broke 3 ribs, her clavicle, and fractured her pelvis .resident was in the hospital for a while then returned to the facility .on 9/29/21 .the resident fell yet again .concerned the facility does not have the appropriate fall precautions in place for the resident .[concerned] the resident is [not] being monitored appropriately. During a phone interview on 11/2/21 at 8:07 AM, Family Member M stated Resident #13 fell at least four times at the facility. During a follow up phone interview on 11/4/21 at 3:45 PM, Family Member M recalled the hospitalization of 9/11/21, I did not know anything until I went to the hospital, and they told me about all of the fractures. Family Member M stated she spoke with the previous DON I who said, Resident #13 fell in the bathroom. The nursing progress notes revealed: 09/09/2021 06:39 AM .I reached out to redirect [Resident #13] to bed and pt (patient) attemped (sic) to slide along bed rm (room) wall, writer assisted res (Resident) to floor writer and staff assisted [Resident #13] to bed. Resident denied any pain or discomfort at that time, resident did not hit her head. Skin assessed and ROM (Range of Motion) performed no abnormalities noted. Resident's RP (Responsible party) and NP (Nurse practitioner) notified. 09/09/2021 06:42 AM Resident closely monitored throughout MN (midnight) shift . Resident got up throughout night ambulating in her room and to nurses station. Re-directed when needed. Provider Nurse Practitioner progress note revealed: 09/09/2021 9:10 AM .evaluated in bed, calm, comfortable answered questions appropriately, denies pain and discomfort . pleasant, calm. Further nurse progress notes revealed: 09/09/2021 04:49 PM at approx. 245pm (2:45 PM) this afternoon resident complained of pain to right hip/pelvis area . orders received for stat xray . 09/09/2021 05:35 PM .resident (#13) seated up at nurses station in wheelchair, has multiple attempts to stand and self transfer and walk up to nurses station . 09/09/2021 10:08 PM Resident is up in wheel chair at nurses station. She states that she has no pain or discomfort. Resident was observed walking at nurses station with attending nursing aide .X ray completed . 09/10/2021 12:26 AM X-ray results negative. No evidence of acute fracture or dislocation. The radiology report of 09/09/2021 at 10:44 PM read in part: Findings: There is no radiographic evidence of acute fracture or dislocation. The ischiopubic lines are intact. Further nursing progress notes revealed: 09/11/2021 05:05 AM .at about 11:40 pm (09/10/21) resident was observed on the ground next to bed on laying on her right side. Unaware that she had fallen. Resident c/o (complaint of) chest pain while holding chest .911 arrived within 5 minutes and resident was taken to [hospital] .NP, DON along with daughter aware of situation. 09/21/21 7:28 PM .patient (readmitted ) at 6:40pm from (name of) Hospital . The Hospital Physician Note dated 9/11/21 at 12:50 AM, read in part: (Resident #13) who presents to (hospital name) .after fall on (blood thinner medication) that happened two days ago. This was unwitnessed fall; patient did hit her head and lose consciousness. Patient was found in her bathroom at her residential living facility. At that time the facility ordered pelvic x-ray which was reportedly normal, no further workup was done . Facility physician progress note following readmission revealed: 09/24/21 10:05 AM .(Resident #13 was) at (hospital name) following an unwitnessed fall in the nursing home .In the facility, pelvic x-ray was normal. Patient was ultimately sent to hospital for mental status change. Patient was found to have a left rib fracture, left clavical (sic) fracture, right superior and inferior pubic rami fracture (pelvis fractures) . Further nursing progress notes revealed: 09/22/2021 06:15 PM Resident observed sitting on the floor next to her bed .Resident stated that she was trying to get to the bathroom . 09/27/2021 03:53 PM .placed in chair after breakfast. Resident was observed on her knees in front of w/c (wheelchair) . 09/29/2021 08:00 PM Nurse was informed that resident had a fall that was unwitnessed. Resident has history of self transferring despite staff encouraging her to call when needing assistance. Nurse went into resident room observed resident with blood all over face, and blood on sheets. Clots observed on shirt and sheets. Nurse got report that resident has been saying I want to go to the hospital earlier, and also has been speaking of falling repeatedly today .NP and Daughter notified, Emt (Emergency Medical Transport) called immediately arrived in approximately 6 minutes. 09/30/2021 11:30 AM .resident (arrived) at 10:15am from hospital by ambulance. Resident had fall unwitnessed on September 29,2021 . 10/06/2021 06:54 PM writer summoned to residents room, upon entering, writer observed resident on floor, knee down at bedside [with] wheelchair in front of her. when asked what happened, resident stated, I want my daughter. 10/8/21 03:50 PM .taken to [hospital] . No further progress notes recorded. Resident did not return to the facility. During a phone interview on 11/3/21 at 3:10 PM, LPN L stated she remembered Resident #13's fall on 9/10/21 and stated the Resident was always confused .I knew she had a fall prior a day or two before and her pain site always changed around, we were getting x-rays of all her extremities .I was doing med pass and I left the light on. Later I found her on the floor next to her bed . LPN L said Resident #13, due to her complaints of chest pain, was sent to the hospital. LPN L stated, We usually do an incident report, and we do neuros (neurologic assessments), but we could not do it as she was sent out .I reported it to the facility. Following multiple requests to the facility for all incident reports and investigation files for Resident #13, the only four documents for the six falls (9/9/21, 9/10/21, 9/22/21, 9/27/21, 9/29/21 and 10/6/21) provided were: Safety Events - Fall dated 9/9/2021 Safety Events - Fall- Post Fall assessment dated [DATE] which included Incident occurred 9/10/21 Safety Events - Fall dated 9/22/2021 Safety Events - Fall dated 9/28/2021 included Fall actually occurred on 9/27 All documents listed above had a status of open and were not completed. The Safety Event dated 9/9/21 revealed Interventions Ineffective. The Safety Event dated 9/12/21 for fall on 9/10/21 at 11:40 PM was written by LPN L and read in part: .Was Fall Witnessed? No .Stated chest hurts .Resident UNABLE to rate pain .Verbalization/vocalization: Sighing, moaning, calling out, cries, grunts, moans, gasps .Reddened Abrasion .behind right shoulder .No Injury Noted to head, extremities, or trunk .Care Plan Reviewed: No . The Safety Event dated 9/22/21 read in part: .Was Fall Witnessed? No .Outcomes of Interventions: not completed .Care Plan Reviewed: No . The Safety Event dated 9/28/21 read in part: .Fall actually occurred on 9/27 .Was Fall Witnessed? No . Outcomes of Interventions: not completed. During an interview with the DON on 11/3/21 at 10:40 AM, the falls of Resident #13's were reviewed. The facility did not have documentation of investigations following the Resident's falls to prevent recurrence. The DON stated, All falls should have a (Safety) Event report and a Post Fall Assessment completed by the nurse and full investigations should have been started. The DON confirmed all four fall documents were incomplete at the time and date of this interview and were marked as still open. During an interview on 11/3/21 at 11:40 AM, previous DON I stated she did her own investigation of Resident #13's fracture injuries. She stated, I interviewed the staff. When asked to review the investigation and interviews, previous DON I confirmed none were documented. When asked about the unfinished open status of the Safety Events Fall documents from Resident #13's falls on 9/9/21, 9/10/21, 9/22/21, and 9/27/21, previous DON I confirmed these documents remained opened. The previous DON I stated she could close the reports, but they never were closed. The Care Plan for Resident #13 included a Problem Start date: 08/11/21 Category: Falls .Resident at risk for falling R/T (related to): mobility limits, assist with transitions, fall risk at 18 (over 10 indicated fall risk) . The only updated intervention added to the Fall Care Plan following the fall of 9/9/21 were labs ordered. After the fall on 9/10/21, and upon return from the hospital on 9/21/21, no additional interventions were put in place for Resident #13's Fall Care Plan, and a fall was documented on 9/22/21. After the fall on 9/29/21, upon return from the hospital on 9/30/21, no additional interventions were put in place in Resident #13's Fall Care Plan. The facility policy Falls and Falls Risk, Managing dated 9/21/21 read in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling .The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .If the resident continues to fall, staff will re-evaluate the situation, conditions or circumstances and whether it is appropriate to continue or change current interventions. This policy was absent any information regarding protocol for investigation, evaluation, and analysis following falls.

This citation pertains to Intakes MI 035, MI 950, MI 883 and MI 928 Based on observation, interview and record review, the facility failed to monitor, supervise, and provide an environment free from sexual abuse for one Resident (R900) of two sampled residents reviewed for sexual abuse, which began on 8/8/2021 between the hours of 10:00 PM and 11:00 PM when Resident (R901) was observed on top of Resident (R900) moving up and down in a sexual motion. This deficient practice resulted in an Immediate Jeopardy (IJ) and the likelihood for serious sexual and/or psychosocial harm (based on the reasonable person), injury, impairment or death. Findings include: A review of the complaint dated 8/10/21 noted the following: (R900) is diagnosed with Dementia. (R900) has been at a rehabilitation center since May for subdural hematoma that required a craniotomy. (R900) had plans to go home back to (their family) .(R900) was sent to the ER (emergency room ) by the rehab nursing home out of concern for sexual assault that potentially happened between (R900) and another resident. The facility found (R900) without any clothes on and on the floor in (R901's) room. R900 was transferred to the hospital on 8/9/21 and prior to survey exit had not returned to the facility. An attempt was made to contact the hospital social worker on 8/12/21 at 12:55 PM, a voicemail was left with callback contact number, but contact was not possible prior to survey exit. A review of the Incident Report Statement taken over the phone by the NHA from CNA A noted the following, I (CNA A), came out of another resident's room and saw the call light on for room (R901). The door was closed, when I entered, I saw two wheelchairs by the door. I moved one to be able to walk through the room. After moving the wheelchair, I saw (R901) and (R900) laying on the floor together naked. (R901) was on top of (R900). I tried to get (R901) off (R900), but (R901) was resisting. I went to get the nurse. When (Previous/suspended DON) and I got back to the room (R901) was on the bed pulling up (their) pants. (R900) was still lying on the floor naked. A review of the Incident Report Statement dated 8/9/21 with the NHA and SW M interviewed R901 noted the following: NHA: Did (R900) touch your penis? Resident (901): No (R900) didn't. NHA: Did you touch (R900's) vagina? Resident: Yea. SW M: What did you touch (R900) with? Resident (901): My hands. A review of the Police Department report dated 8/8/21 noted the following: Upon arrival I met with (Previous/suspended DON), who stated that tonight at approximately 2300 (11:00 PM) hours .staff member, walked in on two residents having sexual intercourse. Stated that CNA A was doing (their) rounds and observed the door . was closed. Advised that the door is never closed and (the CNA A) found that unusual. Opened the door, walked in and observed (R900) on (their) back on the floor, next to the bed, with (R901) on top of (R900). Advised that they were having sexual intercourse. Grabbed (R901) by the shoulder in attempted to pull (R901) off of (R900) but (R901) pushed (CNA A) away from . called for help to the other staff members (the CNA A called the DON) . (DON) . observed (R900) on the floor with (their) gowned undone and observed (R901) putting (their) underwear back on. Although the facility has cameras in the hallways, the NHA stated the video was only able to go back 72 hours. It was not confirmed if R900 went to R901's room on their own or if R900 was coerced to go to R901's room. A review of the conclusion/summary Investigation that was signed by the NHA on 8/12/21 at 1:21 PM noted the following: After a thorough and exhaustive investigation was completed, and with due diligence, the IDT (Interdisciplinary Team) has determined that (The Facility) cannot substantiate abuse, exploitation, and/or sexual misconduct. R901 remained in the facility and was not under supervision after the 8/8/21 incident. On 8/16/21 at 8:45 AM, Family Member B was interviewed by phone about the incident that occurred, with R900 and R90 on 8/8/21 at the nursing facility. Family Member B revealed, They (the facility) called me and said that (R900) was found on the floor naked in (R901's) room .How does something like that happen .(R900) is home now and (R900) is always crying and yelling out .I am so angry with whatever happened to (R900) .No one is telling me exactly what happened. A review of the medical record reflected R900 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R900 was readmitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R900 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 (severe impairment). A review of R900's Cognitive Limits care plan (start date 5/17/21) problem noted: Resident has cognitive limits r/t (related to) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Approach Start Date: 5/17/25 Maintain safety when up and when in room. A review of R900's ADL (Activities of Daily Living start date 5/17/21) care plan problem noted: Resident has a self care deficit rt dementia: weakness, mobility limits; is here for pt (physical therapy) ot (occupational therapy) and slp (speech language therapy), requires assist with adls. Approach Start Date: 05/17/2021 Locomotion: Wheel chair use with 1 person assist .Dressing: 1 person assist . Approach Start Date: 05/17/2021 Transfer: x1 assist . Approach Start Date: 05/17/2021 Restrict my movement to my room . Approach Start Date: 05/17/2021 Dressing: 1 person assist . Approach Start Date: 05/17/2021 Bowel Function: incontinent . Approach Start Date: 05/17/2021 Bladder Function: incontinent. A review of R900's progress notes and care plan did not note any documentation of sexual behaviors. A review of the medical record reflected R901 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The BIMS score document provided by the Interim DON (Director Of Nursing) on 8/17/21, reflected R900 had a BIMS score of 11 out of 15 (moderate impairment) dated 8/9/21. A review of R901's Falls care plan (start date 11/10/20) noted the following: Approach Start Date: 11/24/2020 Nursing frequent visual checks when (901) is up to (their) wheelchair . A review of R901's [CONDITION(S)] Drug Use care plan (start date 10/17/20) noted the following: Approach Start Date: 01/06/2021 monitor (R901) when he is in the activity room for phone use; expect call back from 911 when he calls to ensure his safety. R901's care plan interventions before 8/8/21 that addressed any issues related to sexual misconduct A review of R901's Behavioral Symptoms care plan (start date 08/08/21) noted the following: Approach Start Date: 08/08/2021, Discourage resident from acting on feelings and impulses . Approach Start Date: 08/08/2021, Respect resident's needs for privacy and space. Avoid unnecessary touching. R901's Behavioral Symptoms care plan was noted to reflect a new approached implemented on 8/18/21 during the survey that reflected: Resident currently on 1:1 to monitor behaviors. On 8/16/21 at 10:08 AM, R901 was observed in the hallway in a wheelchair, alone, outside of the kitchen area asking for coffee. R901 was asked if they could talk and R901 said, What do you want .I know what you want to talk about so you can ask me right here (in the hallway). R901 was asked to have a discussion in their room agreed. On 8/16/21 at around 10:08 AM, R901 was interviewed in their room, that was located at the far end of the hall, away from the nurses' station and queried about the incident with R900. R901 stated, (R901) came to my room and asked for sex so I said yes of course. R901 was asked if R900 touched their private area and R901 said, No. I touched (R900's) vagina .(R900) did not touch my penis .we took our clothes off. On 8/17/21 at 9:43 AM, Social Worker (SW) M revealed The Administrator (NHA: Nursing Home Administrator) and I went and talked to (R901) .(R901) said that (R900) asked if (they) wanted sex and (R901) said (they) were not going to say no .were alone for about ten minutes .(R901) said that there was no penetration and (901) only touched (R900's) hips and butt .(R901's) memory is good some days and bad other .(R900) was showing some signs of sexual behavior .(R900) was very touchy. On 8/17/21 at 9:52 AM, the NHA, Interim DON, and the Clinical Corporate Operations were queried about the incident with R900 and R901. The NHA said, They were found in (R901's) room on the floor next to each other without clothing .(R900) was interviewed by the police but had no memory of what happened. The DON was asked the BIMS for R901 and stated, Around 10. The DON left the room and returned with a BIMS assessment for R901 dated 8/9/21 with a score of 11 out of 15 (moderate impairment). The Interim DON stated, (R900) went to (R901's) room, how is it (R901's) fault? On 8/17/21 at 11:46 AM, CNA A was interviewed via phone about the incident with R900 and R901. CNA A stated, I was exiting another resident's room and noticed the call light was on. I tried to open the door and noticed the wheelchairs were blocking the door . (R901) was on top of (R900) moving in a sexual motion like they were having sex. I tried to pull (R901) off (R900) and (R901) pushed me away. I ran out the room and called the DON. We ran back to the room and (R901) was getting off (R900) and pulling up (901) shorts. (R900) was laying on the floor with (their) legs open. On 8/17/21 at 3:38 PM, Nurse N was interviewed via phone about the incident with R900 and R901. Nurse N stated, I was outside on a break when this happened. I came back inside and saw the DON in the room (R901). The DON told me what happened, and I had never heard anything or dealt with this type of issue. The CNA, (CNA A) was looking after the fall residents. We were challenged that night with staffing. (R901) was acting up earlier yelling saying (their) head was hurting .The rest of the night (R901) was ok. On 8/17/21 at 4:10 PM, the NHA was interviewed and queried about their statement of R900 and R901 being found on the floor naked. The NHA stated, (CNA A) was the first witness and told me during the interview that (R900 and R901) were on the floor next to each other. The NHA was asked about the discrepancy about R901 being on top of R900, versus only being found on the floor next to each other. The NHA said, (R901) was on top on (R900), but (CNA A) did not say it was sexual. A review of the facility's Resident Abuse/Neglect policy with a revision date of 1/30/19 noted the following: The facility will not condone any form of resident abuse or neglect .An ongoing review and analysis of abuse incidents .The implementation of changes to prevent future occurrences of abuse. The Immediate Jeopardy (IJ) started on 8/8/2021, was identified on 8/18/2021 and the Administrator was notified of the Immediate Jeopardy on 8/18/2021 and was asked for a plan to remove the immediacy. The IJ was removed on 8/19/2021, based on the facility's implementation of the removal plan as verified onsite on 8/19/2021. The facility provided the following removal plan: Removal Plan 1. Female number #900 does not reside at the facility anymore. She was assessed by the charge nurse and was sent to the hospital to be evaluated. Resident # 901 was placed on a 1:1 until outside placement is found, starting 8/18/21. Resident # 901 was assessed by the charge nurse and physician at the hospital. No noted injuries or adverse reaction was documented. Resident # 901 care plan and care guide was reviewed and updated. Both resident's legal guardian and physician were notified on August 9, 2021 at 12:30am. 2. All residents are at risk for this deficient practice. All alert residents were interviewed if they were sexually abused or know if any patients were abused. All residents responded no to not being sexually abused and no to knowing anyone else was sexually abused. 3. Due to residents being cognitively impaired and unable to effectively communicate sexual trauma, the residents will be followed by nursing to evaluate any changes in behavior, emotional distress, and changes in baseline. Cognitively impaired residents will be evaluated by psych services during the next psych visit on 8/20/2021 to rule out any sexual abuse. If sexual abuse is suspected by psych services, a medical exam will be ordered immediately. 4. The facility policy on abuse was reviewed and deemed appropriate. All staff was in-serviced on the different types of abuse and supervision to ensure all patients are safe and free from abuse. The staff that was not present was in-serviced over the phone on Wednesday, August 18, 2021. The following was text and discussed via phone with staff: Abuse types: Sexual, emotional, physical, neglect, verbal, mental, involuntary seclusion, misappropriation of belongings Any allegations of abuse MUST be reported to the Administrator immediately (Administrator phone number listed) A hard copy of the abuse policy will be attached to paychecks. 5. The facility will audit 20% of the current resident population, twice a week for 4 weeks then monthly/PRN, to ensure residents are free from abuse and safety is in place. Results will be reviewed in QA meeting monthly x3. Date of compliance 8/19/2021. Administrator will maintain compliance. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy.

This citation pertains to intake MI 819 and MI 931. Based on interview and record review, the facility failed to effectively assess/monitor a change in condition, and provide prompt acute care following noted guarding during transfer in the morning and fall the same day (in the afternoon) for one sampled resident (R914) of four reviewed for falls, resulting in delayed treatment, transfer to higher level of care, and un-addressed pain. Finding include: A review of intake MI 819 revealed: [R914] has been receiving physical therapy at Lakeside Manor for rehabilitation .is diagnosed with dementia. On 8/5/2021 at 1:14 AM, .Lakeside Manor contacted 911 stating that [R914] broke [their] hip. No details were provided by the facility. [R914] was transported to the emergency for examination. The medical examination confirms an acute multiple part intertrochanteric left femur fracture of the left public ramus . A review of R914's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed that the resident was admitted into the facility on [DATE] (with preferred language of Arabic), and was severely cognitively impaired with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS dated [DATE] revealed that the resident required limited assistance from one person for bed mobility, extensive assistance from one person for transfers, walking in room, locomotion on unit, dressing, toilet use, and personal hygiene. On 8/17/21 at 9:29 AM, the facility was asked to provide any and all incident/accident (I/A) reports for R914 for the duration of the resident's stay at the facility. The facility provided one I/A report, titled Unusual Occurrence Report, dated 8/4/21 at 3:30 PM. A review of R914's medical record and progress notes revealed the following: -Progress note dated 8/3/2021 at 7:38 AM: Resident received in bed, alert with language barrier; all needs anticipated and met. VSS (vital signs stable), resident refused all medication, resident kept hitting writer's hand away, left note in NP (Nurse Practitioner) book to f/u (follow-up). ADL (activities of daily living) care completed by nursing staff in a timely manner. Bed left in low position, call light left within reach, frequent checks. -Date/Time: 08/04/2021 09:10 AM (Created Date: 08/04/2021 02:13 PM, by NP H) .Evaluating this patient noted guarding [their] left hip during transfer. Patient was also noted with mild rash on the right ischial area. Patient has language barrier however .was noted noncooperative to care and transfer. No apparent respiratory distress .ASSESSMENT/PLANS: #Left hip pain. Will order x-ray, pain management . -Two radiology orders for R914 were reviewed and indicated that LPN D entered orders for a RT (right) Hip and a Rt Tibia/Fibula X-ray at 12:32 PM on 8/4/21. -The radiology report from Medical Diagnostic Services, INC included, Study Description: Pelvis, RT Hip C/O (complaints of) Pain. The report also included, Performed Date: 8/4/21, Reported Date Time: 8/4/21 (at) 13:50:41 (1:50 PM and 41 seconds) . Technique: Pelvis with right hip, 3 views. Comparison: None. Findings: There is an acute complete left intertrochanteric fracture present with moderate displacement resulting in varus angulation. Left lesser trochanter fragment is mildly medially displaced. Superior and inferior pubic rami are intact. The bony mineralization is moderately decreased. Soft tissues are unremarkable. Moderate narrowing of acetabular-femoral joint spaces with subchondral [CONDITION(S)] in the roof of the acetabulum. Impression: 1. Acute left intertrochanteric femoral fracture with moderate displacement with varus angulation. 2. Left lesser trochanter fragment is mildly medially displaced. 3. Moderate degree of osteopenia/[CONDITION(S)]. 4. Moderate degree of [CONDITION(S)]. -Progress note dated 8/4/2021 at 3:28 PM by LPN D: Received Client at 7am. Client received all prescribed medications vital signs were taken .Family notified at 3:44 pm about fall from wheelchair on to [their] bottom and no physical or mental status changes. NP notified at 3:40 pm and x-ray ordered STAT. Will continue to monitor . -The facility-provided Unusual Occurrence Report, included: Incident Date: 8/4/21, Time 3:30 PM, Location: Hall. What was resident doing before incident? Sitting in w/c (wheelchair) across from nursing station. What preventative devices were in place prior to incident? [Blank]. Baseline Level of Consciousness: [Blank]. Changes? [Blank] .Describe the incident based in resident's own words or what the first responder observed: [Blank]. Nature of Occurrence: Unable to Determine. Locate location of Injury: [Right hip circled on diagram]. Resident Outcome: [Blank]. Intervention: X-Ray to Right leg; Hip. Name of MD Notified: [NP H], Time Notified: 3:40 PM .What did you do to try to prevent the incident from happening again? [Blank] . Signed by LPN D. -Pain assessment dated [DATE] at 8:51 PM by LPN D: Pain Site: Hip Pain. Character of Pain: Unable to Verbalize Pain. On a scale of 0-10, how does resident rate intensity of pain if able, or indicate based on observation: 7 - Severe Pain - Horrible/Intense. Duration of Pain: [Blank]. Onset of Pain: [Blank]. Other Expressions of Pain: Frowning/Grimacing, Hitting/Pushing Away, Holding/Splinting/Guarding. What brings pain on or increases pain? moving. Extremity or Trunk Pain: Restricted Movement/Limited Range of Motion, Weight Bearing Limitation - Unable/unwilling to bear weight. .Does resident exhibit any of the following as a change in mental status of new onset? Agitation, Confusion. Interventions - Indicate measures taken: Relaxation Techniques/Biofeedback . Notification Guidelines: (boxes checked) Hip/Joint Pain - Associated with a fall or other trauma, Other Pain - With altered mental status, Severe/Excruciating Pain of new onset. -Licensed Practical Nurse (LPN) D administered PRN (as-needed) acetaminophen (Tylenol) capsule; 500 mg; 1 tablet at 8:41 AM on 8/4/21 due to a pain score of 2 out of 10 (mild pain). No additional pain medication administrations or orders were found for the resident on 8/4/21 upon review of the medical record. -Progress Note dated 8/4/2021 at 8:55 PM by LPN D: Received report that client has a fractured right hip from x-ray. DON and NP notified. Skin assessment and pain assessment updated. -Progress Note dated 8/5/2021 at 12:13 AM by LPN D: Per NP has requested for writer to send client out to [specific hospital]. [Transport Company] was called at 12:14 am transportation stated will be at facility in an hour. endorsed over to next nurse. -Progress Note dated 8/5/2021 at 1:04 AM: Resident transported to [different acute care hospital] @ (at) 12:45 am, via EMS accompanied by 2 EMT's r/t RT Hip FX (fracture). -The Former Director of Nursing (DON) entered in the following order for R914 on 8/5/21 at 9:45 AM: Transfer to acute care facility 2/2 (secondary to) possible fracture. On 8/19/21 at 3:16 PM, LPN D was interviewed via phone regarding caring for R914 and what occurred on 8/4/21. LPN D indicated she did not know if the fall on 8/4/21 was the only one the resident had experienced while in the facility. LPN D explained, When I came in that morning and aide was getting [R914] up, she told me she had seen a bruise on [the resident's] leg, we were trying to [get the resident to] stand up to see .NP saw the resident .asked to order an X-Ray. I was working on the floor by myself that day. Then [R914] had a fall and [their] left leg was bent, was sitting in front of [their] wheelchair. We put [R914] in [the] chair and put [the resident] to bed. I called the doctor, they hadn't come in to do the X-Ray yet, I made the [Former DON] aware .[Later I was] talking to [the Former DON] not sure what time, she checked her emails and saw it was a fracture when the results came back .The bruise had been there previously on [their] hip. The previous shift didn't tell me if [R914] had a fall. LPN D indicated that the resident put themselves in and out of bed frequently. LPN D was asked if she asked the resident if they had fallen, to which LPN D replied, [R914] didn't speak English at all. LPN D posed that she thought possibly R914 fell during the night and put themselves back in bed, then fell again later on during her shift, but indicated she could not be sure. LPN D stated she had, Called for transport later on after the X-Ray results .[was told] it was a 3-4 hour wait .then called again and [the resident] was sent out at around midnight. LPN D was unable to recall the initial time transportation was called for R914 to be sent out to the hospital. On 8/19/21 at 3:51 PM, the Nursing Home Administrator (NHA) and current, Interim DON were interviewed. When queried regarding the expectation for diagnostic testing and timeliness of transfers after finding change in health status such as a fracture, the Interim DON responded, The routine timeframe can take up to 24 hours, STAT usually 4-5 hours. When asked if a fracture is found on a radiology report, how long should a resident be waiting to be sent out for acute care, the Interim DON stated, [Staff should] Notify the Physician or NP they will give you an order to send out, depending on if [the resident] is in lots of pain would call 911. Or notify [transportation company] and they will give an ETA. When asked if a log was kept of when the facility's transportation company was notified to come transfer a resident out, the Interim DON stated the facility did not have a log and, It would just be in the progress notes. When queried regarding the order for R914's transfer not being entered into the medical record until 8/5/21 after 9:00 AM, the NHA and Interim DON were unable to provide any further information. A review of the facility's policy/procedure titled, Incidents and Accidents/Physician Role, revised 6/1/2016, revealed, Physician will help the staff evaluate and manage clinically significant incidents or occurrences. The facility will collect and analyze information on incidents and accidents. Complications from incidents and accidents involving residents/patients, staff, and visitors will be minimized .The facility will document and manage incidents and accidents appropriately .Staff will follow the facility's protocols for managing, documenting, and notifying others of incidents and accidents. When an incident involving a resident/patient occurs, a nurse will evaluate the individual for possible injury. If there is an injury or other significant acute change of condition, a nurse will communicate promptly with the attending physician .As indicated, the physician will authorize appropriate testing and treatment or transfer of the individual for acute or emergency care .The physician will document pertinent medical information related to an assessment, or conversations with a resident/patient or family member, in the medical record. The documentation should be factual and not speculative, and should provide a basis for any medical opinions and conclusions . A review of the facility's policy/procedure titled, Falls and Fall Risk, Managing, dated 12/2020, revealed, 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy did not address post-fall procedures. A review of the facility's policy/procedure titled, Change in a Resident ' s Condition or Status, revised 6/1/2016, revealed, 6. The Nurse Supervisor/Charge Nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status .

This citation pertains to intake MI 977. Based on interview and record review, the facility failed to adequately assess/monitor, initiate/implement individualized care plan interventions for skin management, and/or prevent the new development/worsening of pressure ulcers for one sampled resident (R915) out of a total sample of 22 residents, resulting in the development of a Stage II (partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed or open/ruptured serum-filled blister) pressure ulcer and a Stage IV (full thickness loss of skin, extending down and presenting with exposed bone, tendon or muscle) pressure ulcer. Findings include: A review of R915's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 00/15 indicating severely impaired cognition and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the 5/30/21 MDS assessment Section M - Skin Conditions revealed, Is this resident at risk of developing pressure ulcers? Yes. Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? No. A review of R915's MDS discharge assessment dated [DATE] revealed that the resident was discharged (unplanned) from the facility to an acute care hospital on 6/13/21. Further review of the discharge MDS assessment Section M revealed, Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? Yes. Current Number of Unhealed Pressure Ulcers at Each Stage: Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. 1. Number of Stage 2 pressure ulcers: 1 2. Number of these Stage 2 pressure ulcers that were present upon admission/reentry: 0. Unstageable - Slough and/or eschar (dead tissue): Known but not stageable due to coverage of wound bed by slough and/or eschar. 1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar: 1 2. Number of these unstageable pressure ulcers that were present upon admission/reentry: 0. On 8/17/21 at 9:44 AM and at 11:20 AM, Confidential Witness E was interviewed via phone regarding R915's stay at the facility. Witness E explained that they were unable to see the resident due to quarantine restrictions for 14 days after R915 was admitted on [DATE]. Witness E stated they were able to talk with R915 on the phone during that time but it didn't help, due to the resident having Dementia. Witness E continued and stated, I got to see [R915] finally after 14 days (on approximately 6/8 or 6/9) and [the resident] told me that [their] butt hurt. I asked one of the staff why it hurt, they said it was probably just because [R915] was lying in bed .Three days later (Friday, 6/11/21) I saw [R915] and brought [them] some food .Then, Sunday night (6/13/21) they (facility staff) called me and told me to go to [hospital], they had to rush [R915] there. Confidential Witness E explained that once at the hospital, They (hospital staff) asked me how long the wound had been like this and we (family) said 'What wound?' Witness E explained that they saw R915's wound and said, Oh my gosh, where did that come from? It was 5 inches long, 4 inches wide and an inch deep. There was dried blood and oozing blood. [R915] was admitted to the hospital and they did a debridement to pull the dead skin away and scrape the dead skin away. Shortly after, they had to do another debridement .The doctor said it was a Stage IV pressure wound (full thickness tissue loss with exposed bone, tendon, or muscle where slough or eschar may be present) that went to the bone and I did see the wound going to the bone .I went back to the facility to get [R915's belongings]. I told [former Director of Nursing (DON)] how terrible they treated [R915] and how badly [R915] was doing and she snapped her fingers at me and walked away. When asked if they were ever contacted by or spoke in-person with a wound care nurse/team about R915 while they were at the facility, Witness E stated, Not there, we had no idea there was even anything wrong with [R915]. [R915] kept saying [their] butt hurt, so how were we supposed to know what was going on? R915's hospital documentation was obtained and reveled the following: 6/13/21 at 6:05 AM (General Surgery Consult): .Skin: .sacral decubitus ulcer (SDU) (also known as pressure ulcer) with surrounding eschar, some bleeding, and granulation tissue .Rectal exam showing sizeable SDU with some eschar . 6/13/21 at 9:28 AM (History & Physical Internal Medicine): [Family] unhappy with the care patient received at the ECF (extended care facility), patient noted to have poor oral intake, also developed multiple Pressure injuries .patient has history of dementia is AO (alert and oriented) times 1-2 with behavioral disturbance, requiring assistance with . activities of daily living, is nonambulatory .Physical Examination: .skin: Multiple pressure injuries noted over the buttock and sacral (POA) (present on admission) .Assessment/Plan: .Multiple pressure injuries -POA . 6/16/21 at 9:32 AM (Infectious Disease Consult): [R915] was seen by surgery .was noted to have a stage IV necrotic sacral decubitus ulcer .underwent a bedside debridement .Recommendations .3. Will discuss status of sacral decubitus ulcer and [MEDICATION(S)] with surgery and then will determine the antibiotic course . A review of R915's assessments and progress notes over the duration of their stay at the facility revealed the following: -Admission Nursing Comprehensive Evaluation assessment dated [DATE] at 8:00 PM included, admitted and Time: 05/24/2021 07:00 PM .Skin: .Indicate Location on the body: Pressure Ulcer .Does the resident have a Stage III IV pressure ulcer in an area affected by incontinence? Yes . [Completed by Licensed Practical Nurse (LPN) F]. No additional documentation related to a Stage III or IV pressure ulcer was found. -Admission Body Observation assessment dated [DATE] at 2:49 AM included, Pressure Sores: Yes, describe. - coccyx .Describe any additional body marks or sores: Writer unable to complete full skin observation; resident combative.[Completed by Licensed Practical Nurse (LPN) F]. -Corresponding admission progress note dated 5/25/21 at 7:06 AM completed by LPN F included, .Resident is incontinent of b&b (bowel and bladder), bedbound, per outgoing nurse, has a stage 1 (intact skin with nonblanchable redness of a localized area usually over a bony prominence) on coccyx. All needs and concerns anticipated, unable to meet due to resident's combative behavior. Staff attempted to assist resident with with ADL's (activities of daily living), VS, and skin assessment, resident hit and kicked at staff. -Weekly Skin assessment dated [DATE] at 3:07 PM included, No Identified Concerns. No additional weekly skin assessments were found. -Progress note dated 6/10/2021 at 2:52 PM by LPN G included, Resident is alert and oriented times one is an assist times two with all adl care and transfers. Resident is transferring to room [ROOM NUMBER] on south unit. Report given to receiving nurse along with medications .[Resident] has no open areas on skin . -Progress note dated 6/11/2021 at 2:35 PM included, .Unstageable pressure ulcer to the coccyx area observed. Stage 2 measuring 3 x 2 cm (centimeters) to Lt (left) hip. area cleanse with soap and water pat dry and applied [NAME]/[MEDICATION(S)], cover with 4 x 4 and tape in place. wound care consulted . -No nursing progress note or skilled daily charting were present in R915's record on 6/5/21 or 6/8/21, and no skilled daily charting was present in R915's record on 6/8/21, 6/9/21, or 6/10/21. The progress note on 6/9/21 did not address the resident's skin. Multiple refusals of care were noted in R915's progress notes after 5/25/21, however, upon review of R915's care plan and progress notes, revisions to R915's plan of care for skin management and/or behavioral management were not made after 5/25/21. No notification of R915's responsible party was noted in the record regarding the new observed skin areas. -Per R915's progress notes, the resident was transferred out of the facility via 911 to the hospital on 6/12/21 just after 11:00 PM. R915's care plan included the following: Problem Start Date: 05/25/2021: Risk for alteration in skin R/T (related to): mobility limits, incontinence, w/c (wheelchair) bound, weakness, multiple comorbidities, stage 1 to coccyx, braden of 13 (moderate risk for development of pressure ulcers). Approach Start Date: 05/25/2021: Apply moisture barrier after incontinent episodes and as needed. Approach Start Date: 05/25/2021: Braden assessment per policy Approach Start Date: 05/25/2021: Dietary consult as needed Approach Start Date: 05/25/2021: Ensure cushion to w/c when up and Encourage and assist with wieght (sic) shifts Frequently when up, Float heels when in bed using pillows or Soft heel boots, Assist with turning and repositioning When in the bed. Approach Start Date: 05/25/2021: Observe skin with daily care Approach Start Date: 05/25/2021: Provide 1 person assist with toileting as needed Approach Start Date: 05/25/2021: Provide assist with repositioning at regular intervals Approach Start Date: 05/25/2021: weekly skin assessments Last Reviewed/Revised: 05/25/2021 11:22 AM. Problem Start Date: 05/25/2021, Category: Behavioral Symptoms: Resident has behaviors r/t to dx (diagnosis) of dementia; hx (history) of agitation; was found to have [CONDITION(S)]; refusing food and care; hit and kicked staff; is on psych med. Approach Start Date: 05/25/2021: Administer medications per order Approach Start Date: 05/25/2021: Assign consistent staff member. Establish a trusting relationship with resident. Approach Start Date: 05/25/2021: Discourage resident from acting on feelings and impulses. Approach Start Date: 05/25/2021: Do not confront, argue against, or deny resident. Explore resident's underlying feelings (e.g., anxiety, fear, etc.). Approach Start Date: 05/25/2021: Encourage resident to discuss feelings, impulses, and hallucinations to validate reality. Approach Start Date: 05/25/2021: Maintain a consistent routine. Approach Start Date: 05/25/2021: Promote clear and open communication. Approach Start Date: 05/25/2021: Provide safe, quiet, low-stimuli environment. Approach Start Date: 05/25/2021: Respect resident's needs for privacy and space. Avoid unnecessary touching. Last Reviewed/Revised: 05/25/2021 11:22 AM. A search of R915's medical record for all POC (Point of Care - documentation of care provided, such as assistance with ADLs, toileting, eating, hygiene, etc. generally recorded by nursing assistants) Responses From 05/24/2021 To 06/14/2021 was conducted and returned the following response, No POC data found for the selected search criteria. A review of R915's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Order: Weekly Skin Assessment, Frequency: Order Once A Day on Tuesday, Special Instructions: RECORD SKIN ASSESSMENT UNDER, OBSERVATIONS Start/End Date: 05/25/2021 - Open Ended. The order was charted off as being completed on Tuesday, 6/8/21, however, upon review of R915's documented observations, as well as the rest of R915's medical record, no skin assessment for that date was found. Order: [NAME]/[MEDICATION(S)] 50/50 ointment; 50/50; Amount to Administer: 1 application; topical, Frequency: Once a Day, Special Instructions: Wash area with saline solution, pat dry apply to coccyx daily and PRN (as needed), Start/End Date: 06/11/2021 - Open Ended. No skin related treatment orders were noted in the record prior to this date. Order: Turn and reposition. PRN, Frequency: Every Shift, Start/End Date: 06/11/2021 - Open Ended. The facility was asked to provide any and all wound care documentation for R915 during their stay at the facility. The facility provided a copy of the progress note dated 6/11/2021 at 2:35 PM and a copy of the [NAME]/[MEDICATION(S)] 50/50 ointment wound care order from 6/11/21 with no further information provided. The facility was asked to provide any hard copy shower sheets for R915 (that may have included any additional skin assessments) on 8/19/21 at 1:49 PM. The Nursing Home Administrator replied on 8/19/21 at 3:15 PM, We could not locate shower sheets for [R915]. On 8/19/21 at 11:07 AM, the facility's current wound care nurse, LPN C was interviewed and indicated that she has only been the facility's designated wound care nurse since July 12th. Upon questioning who was in the position prior to her, LPN C did not believe there had been a wound care nurse in the facility around the time of May-June 2021. LPN C was then asked what the facility's next steps would be for a resident admitted with a Stage 1 pressure ulcer on the coccyx. LPN C indicated that a Stage 1 would be, Up to the floor nurses to monitor and treat if needed. Wound care does Stage 2 and above. When queried regarding what skin management interventions she would expect floor staff to put into place for a Stage 1 pressure ulcer, LPN C stated, They would put in an order to clean the area with wound cleaner and place a dry dressing. When queried whether she would expect to see that put into the care plan and/or physician orders, LPN C stated, It would be in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Probably wouldn't put a Stage 1 on the care plan. When queried if nursing assistants (CNAs) document skin management interventions in the medical record, LPN C indicated she was unsure and stated, I am just getting used to [EHR software]. When queried regarding frequency of skin assessments, LPN C stated, Skin assessments are done weekly on a shower day. Upon review of R915's medical record with LPN C, LPN C acknowledged no weekly skin assessment observation in the resident's record for the week of 6/6/21 (due in the eMAR on 6/8/21). LPN C also acknowledged that two wounds were observed on R915 on 6/11/21 despite documentation on 6/10/21 that the resident had no skin issues. LPN C was unable to provide any further information. On 8/19/21 at 3:51 PM, the Interim Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed. When queried regarding documentation of implementation of care plan interventions as well as POC documentation, the Interim DON acknowledged that she had, Identified a lack of POC documentation present in the charting, and added, It should be there for every shift for ADL care, etc. The Interim DON was asked where interventions are documented in the record as carried out, related to preventing skin breakdown, such as for a resident with no skin issues or a skin issue like a Stage 1 pressure ulcer not managed by wound care. The Interim DON replied, Usually for a Stage 1 they would initiate [MEDICATION(S)] q (every) shift and normally it would be in the TAR. When asked if skin management interventions get documented in the record, to which the Interim DON replied, Under the skin care plan, not necessarily signed out but staff can view it to know it was an intervention. When queried regarding LPN G noting no skin areas on R915 on 6/10/21, and the resident being subsequently noted on 6/11/21 with an unstageable pressure ulcer and a Stage II pressure ulcer, the Interim DON replied, That would be a problem .There should have been a weekly skin assessment documented under the observation tab for that week. The NHA and Interim DON were unable to provide any additional information related to R915's pressure ulcers, as the resident had already been discharged prior to the NHA and Interim DON filling their current roles. A review of the facility's policy/procedure titled, Prevention of Pressure Ulcers, revised 8/1/2016, revealed, Review the resident's care plan to assess for any special needs of the resident .The facility should have a system/procedure to assure assessment are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed .Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate .Documentation: The following information should be recorded in the resident's medical record: 1. The type of skin care give. 2. The date and time the skin care was given. 3. The position in which the resident was placed. 4. The name and title of the individual who gave the care. 5. Any change in the resident's condition. 6. The condition of the resident's skin (i.e. the size and location of any red or tender areas). 7. How the resident tolerated the procedure or his/her ability to participate in the procedure. 9. If the resident refused the care and the reason(s) why. 10. Observations of anything unusual exhibited by the resident. 11. The signature and title of the person recording the data .Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice.

Deficient Practice Statement #1 This citation pertains to Intake: MI 929 Based on interview and record review, the facility failed to prevent, monitor, and supervise a male resident (R920) with a known history of inappropriate flirtatious behaviors of one sampled resident reviewed for supervision, resulting in R920 touching a female resident (R919) inappropriately on their breast, and the potential for other inappropriate behaviors towards staff and residents. Findings include: A review of MI 929 noted the following, Summary of Occurrence On 6/24/21 at approximately 9am resident [R919] told nurse that [R920] touched [them] inappropriately on [their] left breast on 6/22/21 . A review of R919's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Encounter for other orthopedic aftercare-orif fingers, Anxiety disorder due to known physiological condition. According to R919's Minimum Data Set (MDS) assessment dated [DATE], R919 had a Brief Interview for Mental Status (BIMS) score of 10/15 indicating a moderately impaired cognition and required extensive assistance for Activities of Daily Living (ADLs). R919 left against medical advice from the facility on 7/14/21. Further review of R919's medical record revealed the following progress notes: 06/24/2021 7:09 PM. Writer was made aware by client that [they were] touched inappropriately. Writer immediately made abuse coordinator, Social Worker, Unit Manager and DON (Director of Nursing) aware of the situation. 06/24/2021 [Recorded as Late Entry on 06/29/2021 03:48 PM] 3:48 PM Alleged incident that occurred on 6/22/21, reported to abuse coordinator/administrator and social worker on 6/24/21. [R919] reported [they were] was touched inappropriately by [R920] . A review of The Facility Reported Incident revealed the following: Statements taken from residents, [R919] states I was sitting in a chair by the lamp reading a book and not paying attention to my surroundings. I felt something touch my breast it startled me and I jumped. I looked to my left and [R920] was standing there and I pointed my finger at [them], I told [them] not to ever touch me again . On 8/18/21 at 3:30 PM, R920 was asked about an incident in which they touched another resident on their breast. R920 stated, No, I didn't touch anybody. God to honest truth I didn't touch nobody. A review of R920's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included, Encephalon, [CONDITION(S)], and [CONDITION(S)]. R920's MDS dated [DATE] revealed a BIMS score of 10/15 indicating a moderately impaired cognition. R902 was independent with supervision for ADLs. Further review of R920's medical record revealed the following care plan: Problem Start Date: 02/23/2021 Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by: Resident makes sexual advances and inappropriate sexual comments towards female staff members. [R920] also walks around holding [their] foley bag and will not use a leg bag and he will not leave a privacy bag on over the bag. Approach Start Date: 08/04/2021 Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Approach Start Date: 04/21/2021 assist [R920] with [their] catheter bags and encourage [them] to use a privacy bag. Approach Start Date: 02/23/2021. Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Approach Start Date: 02/23/2021 Do not engage resident in sensitive topics such as any sexual conversations; report behavior immediately. Approach Start Date: 02/23/2021 Maintain a calm environment and approach to the resident. Approach Start Date: 02/23/2021 Observe and report socially inappropriate/disruptive behaviors when around others . A review of the facility's statement provided by R920 revealed the following, [R902] did you touch a residents breast in the library? Resident stated yes. Why did you touch her there? Resident stated my mind told me to. What do you mean by your mind told you to? Resident stated I don't know it passed through my mind. What happened after you touched [R919]? Resident stated nothing Did the other resident say anything to you? Resident stated no, [R919] didn't. A review of R920's progress notes revealed the following: 02/12/2021 [Recorded as Late Entry on 02/17/2021 10:52 AM] 10:50 AM SW (social worker) spoke to resident regarding inappropriate behaviors in behavior log at nurse's station. Resident exhibited undesired sexual behavior towards staff. SW spoke to resident regarding incident and [they] stated [they] did not mean to offend anyone. Discussed appropriate vs (versus) inappropriate behaviors towards staff and other residents. 02/23/2021 Nursing .7:24 AM Writer informed by female staff that resident has been saying sexually inappropriate things when they are in [their] room. Staff stated that resident stated, 'Go over in the corner, bend over and pull your pants down.' At other times, staff states that resident has been observed lying in bed naked and fondles himself when they enter into the room. Will notify DON and oncoming nurse. 02/23/2021 Social Services .10:13 AM. Per behavior log at nurses station, resident has been exhibiting sexually inappropriate behaviors towards staff. SW spoke to resident about these behaviors and we discussed appropriate behaviors. Resident admitted to behaviors and stated [R920] understands it is inappropriate and will refrain from these behaviors in the future. SW consulted psych about behaviors- waiting for order to be sent over for medication. 03/21/2021 Nursing .5:09 AM. Resident has showed aggressive behaviors towards female staff during shift. Resident stated to writer 'I would love to pull your hair.' Resident then asked writer if [they] could touch writers skin. When writer stated to resident that wasn't appropriate, resident laughed and walked away. Residents vitals stable, medication administrated as directed by MAR (medication administration record). Resident has needed constant redirection and education about inappropriate comments made to staff. Care plan interventions in place, writer will continue to monitor. 04/05/2021 Social Services .2:23 PM. SW spoke to resident following undesirable sexual behavior/comments towards staff listed in the behavior log. SW reiterated the importance of appropriate behavior to resident and [R920] stated [they understand] . 05/20/2021 Nursing .5:04 AM. Resident socially inappropriate toward writer. Resident stared at writer in hall during p.m. medpass. When asked if [they] needed anything, Resident continued to stare, looked writer up and down then stated 'You got a nice shape'. When told by writer [that they were] behaving inappropriately, Resident laughed and continued to blanky stare until writer walked away. Logged in behavior book. 06/24/2021 [Recorded as Late Entry on 06/29/2021 03:50 PM] 3:50 PM Administrator and social worker interviewed [R902]- [they] stated [that they] did touch another resident's breast. When asked why [they] touched another resident's breast, [R920] responded 'my mind told me to'. Social worker then asked what [they] meant by that and asked [R902] if [they have] been having any A/V (auditory/visual) hallucinations. [R902] stated [they have] not had any hallucinations. [R902] acknowledged that [they] will not touch another resident again. Social worker notes that [they have] not had any physically inappropriate behaviors like this prior to incident. On 8/19/21 at 9:06 AM, all Incident and Accident reports were requested from the facility and were informed that there were no reports for R920. On 8/19/21 at 11:08 AM, an interview was completed with Nurse C about R920's behaviors and they stated, [R920] can be very sexual, and will make sexual inappropriate comments to staff and residents and has had to be redirected out of women resident rooms. Nurse C explained that the resident has had to be moved twice because of their behaviors, and further explained that one move was due to them making inappropriate sexual behaviors as their room was in the middle of the hallway and would comment on the women walking by. The second move was due to the resident constantly looking into other women resident rooms. Nurse C explained that R920's behaviors tend to escalate after phone calls with their sister, and reports that they have heard pornography playing on the phone during R920's phone calls. On 8/19/21 at 11:23 AM, CNA L was asked about R920's behaviors and explained that their behaviors have been inappropriate to the point where their room had to be moved because they would be very loud while they self-pleasured themselves causing staff to tell them that they needed to quiet down. CNA L also explained that there was an incident in which R920 attempted to take a severely cognitively impaired resident into their room but was redirected before they entered R920's room. On 8/19/21 at 2:07 PM, and interview was completed with Social Worker M about the incident between R919 and R920 and explained that she and the previous Nursing Home Administrator (NHA) talked to both R919 and R920. Social Worker M explained that R919 reported that R920 touched their breast on the outside of their clothes, and they in turn reacted by asking R920 what they thought they were doing. Social Worker M explained that R920 stated that the voices in their head made them touch R919, and that they apologized and stated they would not do it again. Social Worker M was asked about R920's behaviors and explained that R920 would make inappropriate comments to staff, pleasure themselves while praying very loudly in the middle of the day resulting in a room change as it made their roommate uncomfortable, and their room was in the middle of the hallway. In addition, R920 would request to have their foley catheter changed and would be located lying in bed pleasuring themselves when staff arrived. Social M explained that the resident's sister explained that R920 will talk to her and other family members in an inappropriate manner and have to be told not to talk to them in such a way. A review of the facility's findings following their investigation of R919 and R920 revealed the following, After complete investigation, it is substantiated that [R920] did touch [R919] inappropriately on [their] left breast . On 9/18/21 at 3:55 PM, an interview was attempted to be completed with the DON and NHA regarding the incident between R919 and R920 however, neither were in their positions and did not investigate the incident. They were asked their expectations regarding abuse and explained that abuse is not acceptable. A review of the facility's Resident Abuse/Neglect policy outlines the following, [Nursing Home] will not condone any form of abuse or neglect . Deficient Practice Statement #2 This citation pertains to Intake: MI 225 Based on observation, interview and record review, the facility failed to identify and prevent a skin abrasion for one sampled resident (R909) of one reviewed for accidents resulting in the resident having a 12 x 7 centimeter abrasion on their back, causing pain. Findings include: A review of Intake MI 255 revealed the following, .[R909] resides at [Nursing Home]. [They have] a diagnosis of Dementia with behavior disturbances. On 7/2/21, at approximately 11:59 PM [R909] arrived at [Local Hospital] .[R909] has an abrasion 12 X 7 centimeters in size toward the right-hand side of [their] mid back. The abrasion is a bright pink discoloration. [R909] does not feel safe at [Nursing Home] . A review of R909's medical record revealed that the resident was admitted into the facility on [DATE] with diagnoses that included Unspecified Dementia with Behavioral Disturbance, Hypertensive Heart Disease without Heart Failure, and Altered Mental Status. A review of the resident's Minimum Data Set assessment dated [DATE] notes that the resident had a Brief Interview for Mental Status score of a 2/15 indicating a severely impaired cognition. Further review revealed that the resident was independent with supervision for Activities of Daily Living. A review of R909's progress notes revealed the following: 07/03/2021 Nursing .1:47 AM At approx 8:40 pm writer informed by nursing staff that resident punched her in the face. Resident was immediately escorted to [their] room. Nursing staff was assessed by writer. Administrator informed of situation. Ambulance called to remove resident from facilty. At 10:50pm emt (emergency medical transport) arrived . Further review of R909's medical record revealed an Admission Nursing Comprehensive Evaluation with an observation date of 07/01/2021 at 07:40pm and a completed date of 07/01/2021 at 10:51pm. Under the evaluation for skin, it indicated the following, Skin. Any s/sx (signs or symptoms) of dehydration check must be assessed and documented in the nurses notes. Contact RD (registered dietician) and or Physician is indicated, Areas identified on body must be explain (explained) in detail, in nurses notes and treatments indicated, in indicated. No identified concerns was checked off on the form. On 8/18/21 at 2:45 PM, Nurse O was interviewed regarding R909's transfer to the hospital on 7/3/21. Nurse O explained that CNA A (Certified Nurse Assistant) went to the common area to give R909 a snack, and as they were attempting to redirect R909 to their room, the resident punched CNA A in the face. Nurse O explained that CNA A was able to subdue R909 who was redirected to their room where they calmed down and eventually fell asleep. Nurse O explained that the resident was then sent to the hospital, and denies that the resident was restrained in any way. On 8/18/21 at 2:58 PM, CNA A was interviewed regarding R909's transfer to the hospital due to their combativeness. CNA A stated that R909 was combative and resistant during their shift, and was wandering into other residents' rooms. CNA A explained that they tried to prevent R909 from going into another resident's room and tried to guide them away and was punched in the face. CNA A explained that after they were punched, she informed the nurse that she needed a break and is unsure what happened after she left for her break. On 8/18/21 at 9:23 PM, all Incident and Accident reports were requested from the facility however, they reported that they did not have any. On 8/19/21 at 2:09 PM, the emergency department transfer form was requested for R909, however it was not received by the end of the survey. A review of hospital medical records revealed the following upon R909's admit.Patient complains of pain on [their] back stating [they were] injured while staff were fighting against [them] .[They are] able to recall some of the night's events. [R909] states [they do not] want to go back to the facility .Otherwise [R909] has no complaints except for the pain to [their] back .Findings: Lesion present. No [CONDITION(S)] or rash Comments: There is a 12 by 7 cm (centimeter) abrasion to the patient's back. Please see photos in chart. Patient states this injury occurred while [they were] scuffed pulling with staff at the nursing facility [they] transported from . An observation was made of the photo located in R909's hospital record. The abrasion was observed on the right midsection of the resident's back, pink in color and 12 x 7 cm in size. On 8/19/21 at 3:55 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were asked about R909 however, both are new their current positions. The DON was shown the photo of R909's back, in which she responded that the abrasion appeared old. It was explained to the DON that the upon admission, the resident's skin assessment had no identified concerns, and upon admission to the hospital, the resident's back had an abrasion. The DON and NHA did not offer an explanation. A review of the facility's Incidents and Accidents/Physician's Role was reviewed and did not address when incident reports should be completed and skin assessments upon discharge.

This citation pertains to 8. Based on observation, interview, and record review the facility failed maintain a environment free of accident hazards, with ensuring fall mats in place and call light in reach for two sampled residents (#401 and #403) of three reviewed for falls, resulting in R401 falling out of bed and diagnosed with a broken left collar bone. Findings include: A review of the intake summary noted, Call button was not clipped to [R401's] gown, [R401] fell out of bed and broke [R401's] collar bone trying to get it off the floor. [Facility] is always negligent about the call buttons. On 12/10/20 at 10:28 AM, R401 was observed in bed watching television, R401's call light was observed to be on floor under the bed. R401's floor was not observed with floor mats in place. On 12/10/20 at 12:11 PM, R401 was observed in bed eating lunch, R401's call light was observed to be on the floor under the bed. R401's floor was not observed with floor mats in place. On 12/10/20 at 12:19 PM, the DON (Director of Nursing) was informed and asked about the R401's call light. The DON confirmed that the call light was under the bed. The DON was observed to pick the call light up off the floor, placed it on the back of R401's mattress, and tucked it under the pillow. The call light cord was observed to not have a clip on it. The DON stated, It should've been in arms reach I will have maintenance come and put a clip on it. R401's floor was not observed with floor mats in place. A review of R401's medical record revealed the following progress notes: 11/08/2020 7:05 AM Resident observed on floor on the right side of her bed. When asked what happened, resident stated I was trying to get my remote because it fell out of the bed. Usually I can grab the cord and pull it up, but I guess I rolled too much and rolled out of bed. Resident's bed was observed in the lowest position. Resident was observed free of any incontinent episode . (Physician) notified of incident. Due to resident prescribed anticoagulant, NP (Nurse Practitioner) wants resident transferred to (local hospital) for CT (Computerized Tomography) scan w/o (without) contrast due to allergy. Upon return to facility, resident will have order for fall precautions; bed remain in lowest position and floor mats on either side of the bed. Bed remote and call light to remain within reach at all times . Further reviewed of R401's medical record noted, Post Fall Observation: 11/08/20 07:27 AM . Interventions: Medical Care Provided Post Fall: emergency room Visit. Evaluation Summarize potential factors that could have contributed to the fall. Bed remote fell on floor. Plan of Care. Describe measures to be taken to prevent further falls. Fall precautions. Bed in lowest position. Floor mats on either side of the bed. 11/08/2020 4:52 PM Resident returned from (Local hospital). [R401] has a broken left collar bone. Left arm in a sling. [R401] states [R401] is comfortable for now but will need a pain pill later tonight so [R401] can sleep. Resident is sitting up in bed with dinner served. Call light within reach, bed at lowest position, floor mats in place . Physician orders: 11/08/2020, left arm sling every shift. End date: open ended. R401's Care plan noted, Problem: Problem state Date: 07/01/2017. Category Falls. [R401] is at risk for falling R/T (related to) muscle wasting and atrophy. Has dx (diagnosis) of cva ([CONDITION(S)] accident ) with left side weakness, and has fall hx (history); FALL RISK SCORE OF 15, IS ON PSYCHOACTIVE MEDS, ANTIHYPERTENSIVE AND [CONDITION(S)] MEDS. 11/8 I rolled out of bed. Goal: Short term goal target date: 01/03/2021. Resident will have risk for fall/injury minimized through the review date. Approach: Start Date: 11/09/2020 Clamp for bed controller. 11/08/2020 Bilateral floor mats. Start Date: 07/01/2017 Keep call light in reach at all times. 12/10/20 at 1:50 PM, the DON was asked if R401 has an active order for floor mats to be in place while in the bed. The DON stated, I will look into it. A review of R401's fall risk assessment dated [DATE] noted, . Evaluation Fall Risk Score of 10 or higher represents a high risk for falls. Total Fall Risk Score: 15.0. Level: At Risk. 12/10/20 at 2:01 PM, the DON reported, Yes [R401] does have an active order for the fall mats. They may not had been transferred with [R401] during the room change. R401 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis of [CONDITION(S)] accident. R401's Minimum Data Set (MDS) assessment noted R401 with an intact cognition and required assistance with activities of daily living. R403 On 12/10/20 at 10:14 AM, R403 was observed in a low bed watching TV. R403's call light was observed hanging behind R403's headboard along the wall. R403 was asked if they could reach the call light and stated, No I just ask [R402] (R403's the roommate) to grab it for me. R403 continued, [R402] should be on the pay roll. [R402] helps me get what I need. A review of R403's medical record noted R403 was admitted to the facility on 10//07/20, with diagnosis of [CONDITION(S)]. R403's Minimum Data Set (MDS) assessment noted R403 with an intact cognition and required assistance with activities of daily living. A review of the facility's policy titled, Nurse Call Chapter: Resident Safety dated, 2/1/2018 noted, Policy: All residents will have access to a nurse call device while in their room. The device will be operable by the resident with consideration for any physical disabilities or limitations s/he may have . Procedure: 1. Nursing staff are responsible for assuring that call light cords are within reach of all residents . 4. It is the responsibility of staff to round throughout the shift to assure call lights remain in reach of residents. 5. Call light cords must have a clip, located near the call button area. The clip will allow call lights to be secured within reach of residents. Staff is required to affix new call light clips as needed. Extra call light clips are maintained in the nursing supply area located on each floor . A review of the facility's undated policy titled, Falls and Fall Risk, Managing Chapter: Protocols and Standards noted, Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation: Prioritizing Approaches to Managing Falls and Fall Risk. 1. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident fall risk benefits several possible interventions, the staff may choose to prioritize interventions .

Based on observation, interview, and record review, the facility failed to place new admissions and/or [MEDICAL TREATMENT] residents on a designated unit and under isolation precautions to monitor for signs/symptoms of COVID-19 (Coronavirus 2019, an easily transmitted respiratory illness) per the Centers for Disease Control and Prevention (CDC) guidelines, failed to place signage indicating which residents were under isolation for being new admissions/re-admissions/[MEDICAL TREATMENT], failed to conduct COVID-19 testing of residents admitted into the facility, failed to maintain a cohesive and comprehensive infection control program, and failed to ensure personal protective equipment (PPE) was readily available and used while caring for new admission/[MEDICAL TREATMENT] residents. This deficient practice affected eight sampled residents (R701, R703, R704, R705, R706, R707, R708, and R709), potentially affects all residents and staff, and increases the risk of transmission of COVID-19 throughout the facility which resulted in an Immediate Jeopardy (IJ). The IJ started on 9/8/20 and was identified on 10/1/20. The Administrator was notified of the Immediate Jeopardy on 10/1/20 at 1:45 PM and was asked for a plan to remove the immediacy. The IJ was removed on 10/2/20, based on the facility's implementation of the removal plan as verified onsite on 10/2/20. Although the IJ was removed, the facility's deficient practice remained widespread. No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 10/1/20 at 10:16 AM, R709 was observed sitting out in the hallway near the 100 unit nurses' station. R709 did not have a mask on and was ambulatory. When queried, R709 stated they lost their mask. Licensed Practical Nurse (LPN) A approached R709 and gave them a mask to put on. On 10/1/20 at 10:20 AM, the Director of Nursing (DON)/IP (Infection Preventionist) approached and stated the Low 100 hall, was the isolation unit for new admissions into the facility. The DON then walked to the low 100 hall to observe the rooms. The DON asked if the residents in the Low 100 hall rooms were supposed to be under isolation with PPE. At this time, R703's ([MEDICAL TREATMENT] resident - leaves the facility multiple times a week to receive treatments) room was observed to not be under isolation, not marked with a sign on the door, had the door open, and had no PPE available near the room. Staff was observed wearing just a surgical mask when in R703's room. The DON confirmed the observation at this time. R704's room was then observed to not be under isolation, not marked with a sign on the door, had the door open, and had no PPE available near the room. When queried regarding where PPE was located for these rooms, the DON stated, We have three carts I'm putting together. The DON was then asked if she had COVID-19 test results for R703 and R704 and stated, Yes, they should be on file. And (R705) should be moving over to the other unit. R705 was observed at this time in a room not under isolation, not marked with a sign on the door, with the door open, and with no PPE available near the room. A staff member was observed in the room with R705. R705 had on no face mask, and the staff member had on gloves and a mask, but had on no eye protection or gown. LPN A was near and was queried regarding where new admissions were placed for observation of COVID-19. LPN A stated, Everyone on this side of the double doors is (under observation) and new admits. When queried how he knew which residents were under observation if there are no signs posted and no PPE near the rooms, LPN A stated, That's just how it's been implemented. When queried what PPE is worn in the rooms of residents who are either [MEDICAL TREATMENT] or newly admitted into the facility, LPN A stated, Just the surgical masks at the moment. Everyone on this side, about four people, are under quarantine for new admits. When queried regarding new admissions being tested for COVID-19 after coming into the facility, the DON stated, Yes. And staff is getting tested weekly. When the DON and LPN A were queried regarding R709, the DON stated, (R709) just came back from the hospital. LPN A stated, Been less than 14 days. R709's room was observed to not be under isolation, not marked with a sign on the door, had the door open, and had no PPE available near the room. On 10/1/20 at 10:40 AM, the DON was asked to provide the facility's COVID-19 infection control surveillance and tracking information. Continued tour throughout the 100 hallway at this time revealed: On 10/1/20 at 10:45 AM, R706's room on the High 100 hall was observed to not be under isolation, not marked with a sign on the door, had the door open, and had no PPE available near the room. On 10/1/20 at 10:50 AM, a staff member was observed talking with R704 in their room wearing just a mask. The staff member did not have on eye protection, gloves, or a gown and the room continued to not be marked as under isolation. On 10/1/20 at 10:51 AM, R707 was observed ambulating with a walker out of their room and into the High 100 hallway to talk to LPN A who was at his medication cart. R707 had no mask on, and their room was observed to not be under isolation, not marked with a sign on the door, had the door open, and had no PPE available near the room. R707 went back into their room, then proceeded to come back into the hallway with no mask on to speak to LPN A again. LPN A was not observed to offer R707 a mask or direct them back to their room. LPN A was then asked when R707 was admitted to the facility. R707's record was reviewed with LPN A and it was noted that the resident was admitted into the facility on [DATE]. When asked if the resident has been here for longer than 14 days, LPN A stated, Definitely less than. I know they were implementing the entire 100 hall as a quarantine unit but I don't think it's happened yet. On 10/1/20 at 10:54 AM, R708's room was observed to not be under isolation, not marked with a sign on the door, had the door open, and had no PPE available near the room. On 10/1/20 at 10:55 AM, the Speech Therapist (ST) was queried on the facility's protocol for isolating residents who are new admissions. The ST stated, The residents have to wait 10 days in their room. When asked how she knew which residents were under isolation, the ST stated, I keep track myself, I'm given their admitted . I'm just aware because I'm the evaluating therapist. When queried regarding what amount of PPE is worn in rooms with new admissions or [MEDICAL TREATMENT] residents, the ST stated, Mask and gloves. We are supposed to start wearing face shields, we are working on that. I have one but we are waiting on more. On 10/1/20 at 10:57 AM, R707 was observed ambulating in the hallway with no mask on. R707 approached and was queried regarding wearing a mask. R707 stated, I know, and turned around and ambulated back to their room. On 10/1/20 at 11:10 AM, the DON brought some infection control information for review. When queried if they were also undertaking the IP role, the DON stated, I'm doing everything. I got hired on September 1st (2020). An, Infection Prevention and Control Assessment Tool for Long-Term Care Facilities, assessment was observed to be filled out but was not signed or dated. When queried, the DON stated she did not complete that assessment and, It was in the book when I came here. When queried regarding the COVID-19 infection surveillance and tracking information, the DON provided a book that contained multiple COVID-19 policies, procedures, and audit tools that were blank. When queried regarding COVID-19 testing being conducted for residents who leave for [MEDICAL TREATMENT] or for new admissions, the DON stated, (New admits) are tested (at the hospital/other facility) within 72 hours of being admitted to our facility. When queried regarding the last positive COVID-19 case in the facility, the DON indicated she did not know. The Nursing Home Administrator (NHA) was present and stated she believed the facility has been COVID-free since July 2020 and stated, The last round of resident COVID-19 testing was in July 2020. When queried regarding COVID-19 testing of new admissions, the DON stated, That would be under the admission information. The DON was asked if new admission residents are not tested in the facility after entering and stated, As long as they are tested within 72 hours of coming in and they're negative. Then we test them within 14 days. The DON was then asked to provide COVID-19 test results of residents who were at or past 14 days since admission and stated, I will have to get them. The DON continued and stated, I'm hired to do infection control but I don't do infection control every day because I'm doing this job (DON). The DON indicated the facility has a COVID-19 rapid test machine but has no transcript of test results. When asked if she had written down any results taken by the rapid test machine, the DON stated, No, I did not write them down. At this time, the DON was asked to provide test results for residents who completed their 14 day isolation period after admission/re-admission, and COVID-19 infection control surveillance and tracking information. On 10/1/20 at 11:53 AM, the NHA approached and was queried regarding testing of residents for COVID-19 in the facility. The NHA stated, It's not in our policy to test residents after the 14 day isolation is up. But we do isolate residents for 14 days after they are admitted . We have caddies in place, PPE, and signs. The caddies are there now. On 10/1/20 at 11:56 AM, a tour throughout the 100 hallway was conducted with the NHA. Containers of PPE were noted outside of the rooms of residents R703, R704, R706, and R709, but not outside of the rooms of R705, R707, or R708. No signage was noted on any of the rooms, and the doors remained open. When asked if everyone who was under isolation now had a PPE caddy, the NHA stated, Everyone on isolation has a caddy now. At this time, R708's room was observed without a PPE caddy or sign for isolation precautions. Certified Nursing Assistant (CNA) B exited out of R708's room and then entered back into it wearing only a surgical mask. On 10/1/20 at 12:03 PM, R709 was observed in the doorway of their room. The door was open and no signage indicating the room was under isolation was present. A PPE caddy was next to the resident's room. When queried regarding the PPE caddy, R709 stated, I don't know what that's for. When asked if the resident had one outside of their room when they first got to the facility, R709 stated, No, it's the first time I've seen it. At this time, upon walking down the hall towards R708's room, the DON was approached and asked if R708's room should be under isolation precautions and have a PPE caddy available. LPN A was observed coming out of R708's room at this time wearing only a surgical mask. The DON stated, No, then stated, Wait. (R708) should (be under isolation) until tomorrow. When asked if there was a PPE caddy for R708, the DON stated, No. On 10/1/20 at 12:05 PM, when queried again regarding the facility's infection control COVID-19 surveillance and tracking, the DON stated, They are doing a full set of vitals inside the MAR (medication administration record) on each shift. When asked if that is considered the surveillance and tracking of infection for COVID-19 for the facility, the DON stated, If (the residents) have any signs or symptoms of COVID then we put them on the tracking. When asked if she had her COVID-19 tracking list available now, the DON stated, No. No one has signs and symptoms of COVID that have been here less than 14 days. When queried regarding if the rest of the residents in the facility were being tracked for COVID-19 signs/symptoms, the DON stated, I don't have a line listing for September. Because no one had signs and symptoms of COVID in our building. When queried regarding a tracking log of new admission/re-admits/[MEDICAL TREATMENT] residents with admission and isolation precaution dates, the DON indicated she did not have one. When queried regarding employee call-offs and symptom tracking, the DON stated, I would have to get that from the scheduler. When queried regarding environmental surveillance completed in the facility or any COVID-19 education provided to staff in September 2020, the DON stated, I'll have to ask for (environmental surveillance) and I did one inservice on PPE and N95 masks. When queried how she is keeping track of who is under 14-day isolation precautions after admission/re-admission, the DON stated, Admissions has been helping me out. I look at the new admissions every day I come in. We just update it every day with admissions. The DON was unable to provide a tracking log with dates of admission and isolation for residents who were new admissions, re-admits, or receiving [MEDICAL TREATMENT] outside of the facility for the month of September 2020. When queried regarding R709's isolation status, the DON stated, (R709) was admitted on ,[DATE] then went out to the hospital and came back. A review of R709's record at this time revealed that R709 was sent out to the hospital on [DATE] and re-admitted on [DATE]. Initiation of isolation precautions upon re-admission were not mentioned in R709's progress notes. When queried regarding R705's isolation status, the DON stated, (R705) should be on isolation. When informed a PPE caddy was not noted by R705's room, the DON stated, They (staff) are going to share it, there's a larger size one between rooms. The DON continued and stated, Since I've been here basically I have been doing the DON role. I've been keeping up with infection control with UTIs (urinary tract infections) and things. And with COVID, just making sure we (staff) get tested . When asked if there was a full-time infection preventionist at the facility, the DON stated, No. I've been trying to do it all, trying to get it together. When queried regarding COVID-19 assessments in the resident record, the DON stated, The care plan directs when they do assessments. They do vital signs every shift. I haven't been putting in orders for isolation. When asked if the nurses conduct a respiratory assessment on the residents in the facility, the DON stated, No. On 10/1/20 at 12:52 PM, the DON was queried regarding what PPE should be worn in resident rooms who are under isolation precautions for COVID-19 monitoring, the DON stated, You can just wear a surgical mask in the isolation room. Goggles and gown. Wait, no. The KN95 (or N95 - a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) is what you wear inside the COVID isolation room for residents under observation (new admission/re-admits/[MEDICAL TREATMENT]). Goggles and gown. When the DON was informed that staff were not observed wearing that PPE in the resident rooms who were supposed to be under isolation, the DON stated, Okay. On 10/1/20 at 2:00 PM, upon review of the 100 hallway, R703 and R704's rooms were still not marked as being under isolation precautions, and the doors remained open. A housekeeping cart was observed outside of R704's room. Signs for the removal of PPE were observed on the PPE caddies outside of the rooms, however the signs did not indicate what level of isolation the rooms were under. R705's room was now observed to have a PPE caddy outside of the room but was not marked as being under isolation. R706 and R709's rooms remained unmarked of isolation status. R707 and R708's rooms continued to have no PPE caddies or signs regarding being under isolation precautions. On 10/1/20 at 2:04 PM, Housekeeper C was observed cleaning R704's room. Housekeeper C was observed to have on a cloth mask covered by a surgical mask. Housekeeper C had on no gown and no eye protection. When queried regarding if she was educated on what PPE to wear while cleaning isolation rooms, Housekeeper C stated, Just what I have on. The residents come from the hospital and are quarantined for 14 days. I asked if I should wear a gown. They said I don't need to because they are from the hospital. The 14 day thing is just a precaution. On 10/1/20 at 3:24 PM, CNA D was observed walking in the hallway with her mask pulled under her chin and not covering her mouth or nose. An unidentified resident in a wheelchair was observed sitting near the nurses' station with no mask on. On the 100 hall at this time, the rooms previously not marked with isolation precaution signs now had signs on the open doors that read, See nurse before entering room. The signs did not indicate what level of isolation precautions the room was under. On 10/1/20 at 3:31 PM, R707 and R708's rooms continued to have no PPE caddies or signs regarding being under isolation precautions. On 10/2/20 at 8:03 AM, upon entrance into the facility, the front doors were open. Upon entering the lobby, no staff were present at the desk to conduct screening. Upon knocking on a closed administrative staff door, Registered Nurse (RN) E came out of the room and was asked if there was anyone present to conduct entrance screening. RN E did not provide an answer. RN E then looked in multiple drawers at the front desk, looking for a thermometer. RN E stated, I am going to have to go in the back and get it. At 8:10 AM, this surveyor was still waiting to be screened. RN E came back to the front desk and stated, The receptionist must be running late, she is usually here at 8 AM, that's when the doors unlock. When queried who screened the staff that came on shift at 7 AM, RN E stated, They must have taken the thermometer back, they sign themselves in, take their temperature, then go clock in. On 10/2/20 at 8:48 AM, the DON was queried if a staff member is always supposed to be present at the desk to conduct visitor/staff screening for COVID-19. The DON responded, Yes. When informed of the situation this morning at 8:03 AM, the DON stated, Someone should have been there, that's not my expectation for that to have happened. And we've started the surveillance of residents in the facility. We started taking temperatures yesterday. When queried if that meant there was no infection control COVID-19 surveillance for September 2020, the DON stated, There were the temps on the MAR. When queried if she had any documented surveillance of COVID-19 as part of the facility's infection control program for September 2020, the DON stated, No. On 10/2/20 at 9:30 AM, a tour through the facility was conducted. R709 was observed walking in the 100 hallway without a mask on, then walked back to their room. A sign remained on the door that read, See nurse before entering room. The sign did not indicate what level of isolation precautions the room was under. At this time, Housekeeper C was observed in room [ROOM NUMBER], which had a PPE caddy outside of the door and a, See nurse before entering room sign on the door. Housekeeper C was observed wearing a cloth mask underneath a surgical mask and had gloves on. Housekeeper C was observed without eye protection or gown. When queried regarding the room being under isolation and what PPE was supposed to be worn, Housekeeper C stated, Just what I have on, which is a mask and gloves. When queried if she was educated on wearing eye protection or a gown in the rooms as well, Housekeeper C stated, No. At this time, all the doors on the 100 unit were observed to be open. A resident who resided in room [ROOM NUMBER] (not under isolation) was observed wandering in the 100 hallway near the isolation rooms. On 10/2/20 at 9:40 AM, R709 was observed in the 100 hallway asking for water with no mask on. LPN E at the nurses' station told R709 they were supposed to remain in their room. R709 replied to LPN E and stated, I've never heard anything about that until now, and attempted to pour themselves water from the water pitcher on the medication cart near the nurses' station. On 10/2/20 at 9:46 AM, Housekeeper C was observed in room [ROOM NUMBER], which had a PPE caddy outside of the door and a, See nurse before entering room sign on the door. Housekeeper C was observed wearing a cloth mask underneath a surgical mask and had gloves on. On 10/2/20 at 9:56 AM, R709 was observed walking in the hallway near the front lobby with an unidentified staff member. R709 had their mask pulled under their chin so it was not covering the mouth or nose. On 10/2/20 at 10:55 AM, R701's record was reviewed and revealed the following progress notes: 09/08/2020 3:22 PM Resident left for dentist appointment at 2:30pm with facility driver. Expected time to retune (sic) was not specify. Administrator and DON notify about resident appointment. 09/08/2020 5:52 PM Resident return back to facility at 5:15pm with facility driver. writer asked resident for paper work and follow up appoint .resident asked for pain medication and order schedule meds was administer to patient. 09/09/2020 (Recorded as Late Entry on 09/09/2020 06:45 AM) 5:43 AM Resident in stable condition upon leaving for scheduled MD appointment this morning at 530am. No signs or symptoms of distress/discomfort. At this time, R701 was interviewed and asked if they were put in a room under isolation precautions when they went out to their appointments on 9/8/20 or 9/9/20. R701 stated, No. I came back to this same room. I was not put under isolation. R701's Minimum Data Set (MDS) assessment dated [DATE] was reviewed and revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. On 10/2/20 at 11:07 AM, the DON was queried on how staff knows what type of isolation precautions the residents are under on the 100 hallway. The DON stated, They are all under droplet precautions. I put the 'See nurse before entering room' signs up yesterday. When queried how staff know what level of isolation the rooms are under and what PPE is to be used, the DON stated, The nurses know because we gave it to them in report. It's posted on the caddies. When informed that what is posted on the caddies appears to just show how to remove PPE but does not indicate what level of isolation the room is under, the DON stated, Well I'm assuming it should. Well we told staff yesterday what kind of PPE they should be having on. Should have on goggles or face shield, gown, N95 mask, gloves. When queried if that included housekeepers, the DON stated, Yes. When queried regarding residents remaining in their rooms if under isolation precautions, the DON stated, They are supposed to be in their rooms but we do have people who wander. We re-direct them and make sure they have a mask on. When informed about the multiple observations of R709 in the hallway with no mask on, the DON indicated she was not aware that happened. When queried if the doors on the isolation unit should be kept open or closed, the DON stated, The doors should be shut, to not spread any infection. When queried if the facility was testing residents who completed their 14 day isolation after admission/re-admission to increase certainty that they did not have COVID-19, the DON stated, No. If they have no symptoms we move them over (to general population). We aren't accepting residents to the facility without a negative test within 72 hours of admission. We haven't done facility wide testing of residents since July as far as my understanding. The new residents have to have a negative test before they come in here. I did get hired September 1st for infection control but was asked to step in interim for DON. Basically I'm just making sure staff get tested and making sure residents are negative before they come in. I would have to clone myself to be DON and do everything else. I am trying to move forward to get everything together now. Trying to get the hall together for quarantine. We had a CDC webinar last Wednesday about the 14 days and about testing. I'm putting an infection control book together now for COVID. As far as surveillance sheets and mapping, I don't have them. No infection control monitoring, tracking, or surveillence data was completed or provided for September and/or October 2020 by the DON who was also overseeing the IP program. Upon review of R706's record, no COVID-19 test result prior to admission was found. The DON was asked for R706's negative COVID-19 test but did not provide one prior to survey exit. On 10/2/20 at 12:43 PM, the NHA and Clinical Nurse Consultant (CNC) were interviewed and queried regarding the observations of Housekeeper C cleaning isolation rooms without full PPE. The NHA stated, Really? That may have been before we talked to her. When queried regarding marking isolation rooms with the level of isolation, the CNC stated, It should say on the PPE form on the caddy. When informed that the sheet only indicated how to remove PPE and did not indicate the level of isolation the room was under, the NHA stated, Okay, it doesn't say droplet but it should. When queried if the rooms under isolation precautions on the 100 hallway should be open or closed, the CNC and NHA both stated, Closed. When queried regarding the observations of residents in the hallway, without masks, who were supposed to be under isolation precautions (R707 and R709), the NHA stated, We need to keep them cued (to stay in their room). When queried regarding the observed infection control concerns in the facility, COVID-19 surveillance and tracking, as well as a full time IP nurse in the facility, the NHA stated, We started active screening of residents (for COVID-19). The DON is the IP but has only been here since September 1st. It is what it is, it's a learning experience. Review of R701's record revealed they were originally admitted into the facility on [DATE] and went out of the facility on 9/8/20 for an outside appointment. Review of R703's record revealed they were originally admitted into the facility on [DATE] but left the faciity on Tuesdays, Thursdays, and Saturdays to receive [MEDICAL TREATMENT] at an outside facility. The facility provided a COVID-19 test result for R703 that was negative but resulted on 8/7/20. Review of R704's record revealed they were originally admitted into the facility on [DATE]. The facility provided a COVID-19 test result for R704 that was negative but completed on 9/10/20. Further review revealed the following progress notes that indicated the resident left the building for an outside appointment on 9/24/20: 09/24/2020 02:32 PM, Pt (patient) out to ortho appt (orthopedic appointment) at 2pm accompanied by facility transport driver; transferred safely. Awaiting return. 09/24/2020 06:33 PM, Pt returned .from ortho appt at 4:45pm accompanied by facility transport driver. 0 new orders at this time . Review of R705's record revealed they were admitted into the facility on [DATE] at 3:00 PM. The facility provided a COVID-19 test result for R705 that was negative but completed on 8/25/20. Review of R706's record revealed they were admitted into the facility on [DATE] at 5:00 PM. The facility did not provide a COVID-19 test result for R706 prior to survey exit. Review of R707's record revealed they were admitted into the facility on [DATE] at 3:00 PM. The facility provided a COVID-19 test result for R707 that was negative but completed on 9/9/20. Review of R708's record revealed they were admitted into the facility on [DATE] at 3:00 PM. The facility provided a COVID-19 test result for R708 that was negative but completed on 9/16/20. Review of R709's record revealed they were originally admitted into the facility on [DATE] at 1:00 PM. Further review revealed the resident was sent to the hospital on [DATE] and returned to the facility on [DATE]. A review of R709's record revealed a COVID-19 test result of negative in the hospital dated 9/21/20. A review of the facility's policy/procedure titled, COVID-19 Protocol, revised 5/5/20, revealed: .Newly admitted patients will be quarantined for 14 days from date of admission. If patient remains asymptomatic, then the quarantine will be discontinued. Resident may be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their exposure (or admission). Testing at the end of this period can be considered to increase certainty that the resident is not infected .Residents with negative test results will be provided masks to wear outside of their room (or on medically necessary appointments) unless contraindicated .Procedure for Person Under Investigation: Until transport, the patient will be placed under isolation in a private patient room with the door closed or cohort with another patient who also has the same microorganism, The assigned nurse will don (apply) PPE and complete a q (every) shift assessment to identify symptoms and risk factors . The policy/procedure did not address isolation of [MEDICAL TREATMENT] residents. A review of CDC guidelines revealed: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown: Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Reference: CDC, Preparing for COVID-19 in Nursing Homes, Last Updated June 25, 2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. Reference: CDC, Responding to Coronavirus (COVID-19) in Nursing Homes, Last Updated April 30, 2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html. Immediate Jeopardy Removal Abatement Plan Facility has implemented the following: All staff and visitors entering building will be screened by Staff member by taking temperature and asking if they have had any of the following symptoms: Fever (100 F) or more, new cough, Sore throat, New SOB, Muscle ache/Chest pain or chills All residents admitted within the last 14 days were placed on the isolation unit and will be monitored for signs and symptoms of COVID-19 One identified resident that was not in isolation unit was moved to isolation unit One resident identified on isolation u(TRUNCATED)

This citation pertains to MI 565. Based on observation, interview and record review the facility failed to implement interventions to prevent worsening and or development of wounds and promote healing for two sampled residents (R901, R902) of three reviewed for wound and pressure ulcer care resulting in the development of and likelihood of worsening pressure sores and wounds. Findings include: On 07/23/20 at 8:50 AM, R902 was observed to be laying on their back and buttocks in bed. The shoulders square to the bed, with the head of the bed around 30 degrees. No device was observed to hold the resident toward the left or right side. The lower legs and heels rested on the bed. No protective boots were on the feet. A low air loss mattress was in place. The resident did not respond to name. On 07/23/20 at 10:34 AM, R902 was observed to be laying on their back and buttocks in bed, but with the right shoulder up slightly and the right arm behind their back. A splint was visible on the right hand. The head of the bed up around 30 degrees. No device was observed to hold the resident toward the left or right side. The lower legs and heels rested on the bed. No protective boots were on the feet. On 07/23/20 at 12:47 PM, R902 was observed with Nurse A. R902 was observed to be laying on their back and buttocks in bed. No device was observed to hold the resident toward the left or right side. The lower legs and heels rested on the bed. No protective boots were on the feet. The right foot was observed to have a rolled gauze dressing in place which covered the right heel. The dressing was dated for 07/18/20. Nurse A removed the dressing to reveal a purple black area appearing as a deep tissue injury (A pressure-related injury to skin tissues under intact skin that results from prolonged pressure to that area) to the plantar surface (bottom) of the foot. The wound was in the middle (arch area and extended across the width of the foot. It appeared in the shape of a pot with the handle to the medial (inside). The nurse measured the wound to be 4 cm (centimeters) long and 9 cm wide the handle was 2 cm. A more pale and light yellow area appeared to the middle and outside of the foot. This appeared as an intact and deflated blister. Nurse A reported upon touching the area that it felt like it still had some fluid in it. When asked about the wound to the foot, Nurse A reported they thought it was a reddened area and did not remember the wound to be like that. Nurse A was then queried about the heels resting on the bed, no device to turn the resident side to side and care planned interventions and reported there should be a device in place. A search of the room revealed no type of protective boots were in the closet or room area of R902. At 2:24 PM, it was observed that R902 had healed pressure ulcers to the sacral/lower back/gluteal cleft area and right hip which appeared as light pink in color. On 07/22/20 at 2:00 PM, CNA B (assigned CNA for R902) was queried about care plan interventions for R902 and indicated understanding. Protective boots were applied at 2:04 PM. On 07/23/20 at 6:00 PM, the wound of R902 was reviewed with the wound consultant Nurse Practitioner (NP). The NP was asked about the observation of Nurse A about the presence of a blister. The NP reported this was not known to them and would reassess the wound on the next visit. The NP confirmed the current wound assessed was on the plantar surface of the right foot. A review of the clinical record for R902 revealed: R902 was last admitted into the facility on [DATE]. R902 had [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) Assessments indicated no pressure or diabetic ulcers for the dates of 01/16/2020 or 4/16/2020. The MDS dated [DATE] indicated a [MEDICAL CONDITION] but not pressure ulcers. The MDS further indicated R902 was totally dependent on one or two staff for bed mobility, transfer, dressing, locomotion, bathing, dressing, toilet needs and eating. A weekly nursing skin assessmet dated 07/14/20 revealed: Observations Details: Pressure Ulcer-right heel. An Activities of Daily Living (ADL) care plan dated 01/09/19 indicated Resident has a self care deficit related to status [REDACTED]. A Risk for alteration in skin related to fragile, multiple wounds; requires total assist with adls; has bowel and bladder incontinence; and multiple comorbidties (risk factors); has a history of healed pressure ulcers; Braden is 10 (High Risk). Approach: 01/22/19; soft heel lift boots on while resident is in bed. A Wound Consult note dated 01/17/20 revealed: Wound #1 right, lateral, plantar foot is a deep tissue injury and has received a status of not healed. 1.0 cm by 0.5 cm. Wound bed has dark maroon base . Wound # 2 Right buttock stage three (full thickness skin loss) . Wound #3 left buttock stage three .Treatment recommendations: Dry Dressing every 2 days and as needed, right foot . A Wound Consult note dated 03/07/20 revealed: Wound #1; Right lateral foot is a stage two (partial thickness skin loss) pressure injury, 3 cm by 2.2 cm .moderate amount of drainage .not healed .Wound #2 Right Buttock Stage three .not healed .Treatment recommendations: Dry Dressing every 2 days and as needed, right foot .Pressure relief/offloading: low air loss mattress, frequent repositioning, elevate bilateral lower extremities, soft heel lift boots. A Wound Consult note dated 03/28/20 revealed: Wound #1; Right lateral foot is a stage two pressure injury, has received outcome of resolved .Wound #2 Right Buttock Stage three .not healed .Treatment recommendations: Dry Dressing every 2 days and as needed, right foot .Pressure relief/offloading: low air loss mattress, frequent repositioning, elevate bilateral lower extremities, soft heel lift boots. A Wound Consult note dated 04/18/20 indicated wounds resolved. A Wound Consult note dated 06/12/20 and 06/19/20 revealed: Wound #8; Right, lateral foot is a diabetic ulcer .not healed, initial measurements 2 cm length by 3.5 cm width .dry discolored base .Treatment recommendations: Dry Dressing every 2 days and as needed, right foot .Pressure relief/offloading: Elevate bilateral lower extremities, float heels soft heel lift boots. A Wound Consult note dated 06/26/20 added Wound #9, right is a diabetic ulcer .not healed .initial measurements are 3.5 cm length by 7 cm width .no drainage .dry discolored base. A Wound Consult note dated 07/10/20 indicated wound eight resolved and wound nine remained unchanged. A Wound Consult note dated 07/17/20 indicated wound nine remained unchanged and Pressure relief/offloading: Elevate bilateral lower extremities, float heels, soft heel lift boots. A physician order [REDACTED]. A physician order [REDACTED]. R901 A review of the clinical record for R901 revealed: R901 was admitted into the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated moderately impaired cognition and the need for the extensive assistance of two persons for bed mobility and transfer and the extensive assistance of one person for dressing, hygiene and toilet needs. The MDS further indicated R901 did have moisture associated skin damage (usually related to incontinence) and was at risk for pressure ulcers, but R901 had no pressure related or other identified wounds. A progress note by Nurse G dated 05/17 /20 at 12:51 AM revealed: Open wound on right heel and coccyx area. Coccyx non draining, large amount of bloody drainage on right heel, black eschar (necrotic/dead tissue/unstageable pressure sore) also present. Wound care completed on coccyx and left heel, left heel red (stage one pressure sore) and boggy, skin prep applied to area. No prior care of the heels was documented. The previous nursing progress note was dated 05/14/20. The care plan dated 04/30/20 revealed: Resident has actual impairment to skin integrity of right buttock related to pressure related injury. Resident has potential/actual impairment to skin integrity of the '(Specify Location)', related to suspected deep tissue injury. Support: Ensure cushion to wheelchair when up; encourage and assist with weight shifts and repositioning; Follow Facility protocols for treatment of [REDACTED]. The heel wounds were not part of the care plan provided for review. The care plan dated 05/15/20 indicated R901 had a potential nutritional problem was morbidly obese with a need to maintain weight between 250 and 256 pounds. A review of the Treatment Administration Record for May 2020 revealed treatment of [REDACTED]. Day shift on 5/19, 5/20 and 5/22 recorded treatment as a '9' or see progress notes, which noted dressing not available or not cpmleted as ordered. A review of the physician orders [REDACTED]. Orders dated 05/18/20 for Xeroform (medicated dressing) to right heel every shift until evaluated by wound care and Skin prep to left heel every shift and Wound care consult, one time only for wound care. A wound consult was not completed prior to discharge on 05/22/20. On 07/23/20 at 5:07 PM, Contact with the complainant for R901 on 07/23/20 indicated the facility had not reported the wound to them and R901's heel wound had not yet healed. Pictures and a hospital note dated 05/24/20 revealed the presence of black eschar on a right heel wound. A nurse note by Nurse H dated 05/22/20 at 10 AM documented in the note text, discharged home. No additional information was documented in the discharge note. An admission and discharge nursing assessment for R901 was requested from the Administrator, but not provided prior to survey exit. It was reported that a change in the electronic medical record provider had occurred since the discharge of R 901. Documents had to be provided by the Administrator from the prior electronic medical record provider. On 07/23/20 at 9:36 AM and 4:20 PM Nurse D was asked about R901. Nurse D recalled R901 as dependant for their care needs. Upon review of the documentation in the medical record for the development of heel wounds, the buttock wounds and the care plans, Nurse D indicated they likely had been the admitting nurse for R901. An admission note for this resident was not found in the electronic record. A review of the care plan with Nurse D revealed no interventions for elevation of the heels or heel protection while in bed before nor after the development of heel wounds for this resident. The care plan did indicate the presence of a deep tissue injury to the tailbone/coccyx area. When asked about the absence of the interventions and care plan for the heels, Nurse D acknowledged the need to add interventions for the heels to the care plan. On 07/23/20 at 4:50 PM, the Physical Therapy notes for R901 were reviewed with the Therapy Manager and Therapist E. Bed mobility was noted as mod assist on admission, which indicates the need for the therapist to supply 50% of the effort to complete the task. R901 had progressed to contact guard assist which indicated improved bed mobility, but the Therapist acknowledged R901 may not move around due to their cognition. On 07/22/20 at 1:08 PM and 3:05 PM, the above concerns were reviewed with the Interim DON who reported interventions should be in place per the physician orders, nursing care plan and resident needs. Orders and documentation for R902's wounds were also reviewed and revealed a wound care order for a dry dressing to the right foot to be changed every two days and as needed. The DON reported the floor nurses were doing the treatments. The DON agreed the dressing to the right foot should have been changed on 7/20/20 and 7/22/20. At 3:05 PM and 4:10 PM upon further review the DON and Nurse C reported the day nurse (Nurse C) had endorsed the wound care to the night shift on those dates and had documented, but not completed the dressing change. A review of facility policy titled: Prevention of Pressure Ulcers (revised 8/1/2016) revealed, 1. Review the resident's care plan to assess for any special needs of the resident. General guidelines: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time .2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head, around the ears, elbows, shoulder blades, back bone, hips, knees, heels ankles and toes. 3. Pressure can also come from splints, casts bandages and wrinkles in the bed linen. 5. Once a pressure ulcer develops it can be extremely difficult to heal .Change position at least every two hours or more frequently if needed .areas of healed Stage III or IV pressure ulcers are more likely to have recurrent breakdown .Risk factor-poor nutrition .Risk Factor-Lowered Mental awareness .additional risk factor-Diabetes .Cognitive impairment .Risk Factor-Immobility: every attempt should be made to float heels(keep heels off of the bed by placing a pillow from knee to ankle or with other device as recommended by therapist and prescribed by the physician. A facility policy titled Care Area Assessments, Assessment and Care Planning (revised 8/1/2016) revealed: Each resident comprehensive care plan is designed to: h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program .1. Care plan goals and objectives are defined as the desired outcomes for a specific resident problem.

This Citation Pertains to Intake Number MI 749. Based on interview and record review, the facility failed to identify risk, implement fall prevention interventions, and evaluate appropriateness and effectiveness of interventions for one (#44) sampled Resident with a known history of falls, resulted in an Immediate Jeopardy (IJ) when the Resident fell , suffered a severe injury, and subsequently died . The Immediate Jeopardy (IJ) started on [DATE] and was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] and was asked for a plan to remove the immediacy. The IJ was removed on [DATE], based on the facility's implementation of the removal plan as verified onsite on [DATE]. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings include: Record review revealed Resident #44 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Nursing Comprehensive Evaluation dated [DATE] revealed the Resident was alert to person and time only and required the assistance of one person and a walker for ambulation and transfers. Review of the resident's care plan entitled, Falls: Resident with hx (history) of falls (Start Date: [DATE]). The care plan included one intervention, Encourage to use call light: Once A Day; 9:00 AM (Approach Start Date: [DATE]). Review of facility provided Unusual Occurrence Report for Resident #44 on [DATE] revealed, Incident Date: [DATE]; Time: 7:22 AM . Location: Resident Room . Resident observed laying on back on floor in between the dresser and chair in room . Nature of Occurrence: Fall . Indicate location of injury: (back of head circled) . Resident Outcome: Bruise/Hematoma . MD Notified: 7:22 AM . Family/Legal Representative notified: 7:30 AM . Measures immediately implemented to prevent reoccurrence: Call light within reach; Frequent Rounding; Immediately sent to ER for eval . Person preparing report: (Nurse K) . An interview was conducted with Witness J on [DATE] at 5:58 PM. When queried regarding Resident #44, Witness J stated, (Resident #44) died on the 30th from a bleed. With further inquiry, Witness J indicated Resident #44 fell in the facility on [DATE], hit their head, and died from an intercranial hemorrhage. Witness J further revealed the Resident had been taking [MEDICATION NAME] (blood thinner medication) and had been admitted to the facility from the hospital for a mild stroke. After being notified of Resident #44's fall and transfer, Witness J indicated they went to the hospital Emergency Department to see Resident #44. Upon arrival to the Emergency Department, Witness J stated, (Resident #44) told me what happened. It was around 6:00 AM. (Resident #44) was in their room in bed. There was a nurse in the room and (Resident #44) told the nurse they had to go to the bathroom. The nurse told (Resident #44) they don't do that (assist Residents to the bathroom) and that they had to put on their call light (for a Nursing Assistant to come assist them). (Resident #44) said they put on their call light, but no one came in, so they went (to the bathroom) by themselves. They fell backwards when they were going back to bed. Witness J then revealed Resident #44 never fully recovered and was placed on Hospice prior to their death. At this time, Witness J shared Resident #44's death certificate. The Certificate of Death was dated [DATE] and revealed Resident #44's cause of death as Complications Following Subdural and Subarachnoid [MEDICAL CONDITION] . Approximate Interval Between Onset and Death: 6 Weeks . The Death Certificate further revealed, Manner of Death: Accident . Date of Injury: [DATE] . Describe How Injury Occurred: Fall . Location: Lakeside Manor . Record review of Resident #44's medical record documentation on [DATE] revealed the following progress notes: -[DATE] at 1:11 PM: Nursing . New admit day #2 . pt (patient) appears A/O (Alert and Orientated) x 2 w/ mild confusion at times. Pt presents w/ very pleasant affect & able to make all needs known at this time. Pt observed ambulating w/ walker from home but becomes very unsteady at times. W/C (wheelchair) assigned to pt. Education provided regarding safety awareness & w/c safety. Pt also informed to request assistance when transferring Pt currently on [MEDICATION NAME] ([MEDICATION NAME]) therapy; PT/INR (laboratory testing) to be obtained Tues & Fri . call light encouraged. -[DATE] at 3:05 PM: PM&R (Physical Medicine and Rehabilitation) consult to evaluate rehab needs, pain mgmt. and coordination of therapy course . Patient was admitted to (Hospital) on [DATE] s/p (status [REDACTED]. D/t (due to) weakness (Resident) was transferred to subacute rehab . I was asked by nursing staff to see patient for decreased independence and back pain. Patient was sitting up right in wheelchair, and seemed stressed that they are unable to get themselves into bed . Complains of lower back pain and inability to do things themselves . LE (Lower Extremities) generalized weakness . Assessment: Gait dysfunction . Difficulty walking .Debility . -[DATE] at 7:40 AM: Nursing . Resident had a unwitnessed fall. Observed resident laying on his back on the floor in between the dresser and chair in his room. No s/s (signs/symptoms) of distress. Resident has c/o (complaints of) pain 3 out of 10 in head. Bruising noted to the back of head. Resident is currently on [MEDICATION NAME] 2.5 mg (milligrams) one time a day. MD notified and advised to transfer . to hospital. (Family) notified via voicemail. BP (Blood Pressure) ,[DATE], P (Pulse) 55 . Review of Resident #44's Admission Fall Risk (Acuity), dated [DATE] revealed, Observation Details: Mental Status . Intermittent Confusion, Poor Recall, Judgment, Safety Awareness . Balance and Gait . Required Use of Assistive Devices . Ambulation/Elimination Status . Impaired Mobility/Continent (assist with toileting) . Does the Resident have a history of falls in last 3 months? . One or Two Falls . Fall Risk Score- Score of 10 or higher represents a high risk for falls . Total Fall Risk: 15 . Initiate Plan of Care . Additional review revealed an order for [REDACTED]. Review of Resident #44's Laboratory Testing Results in the Medical Record revealed PT/INR laboratory testing was completed once, on [DATE] at 8:49 AM, while the Resident was residing at the facility. Review of Resident #44's hospital referral documentation revealed an Emergency Report History and Physical, dated [DATE], which disclosed, Final [DIAGNOSES REDACTED]. The patient has been falling frequently. Last fall was several days ago . has not hit head in over a week . A phone interview was conducted with Nurse K on [DATE] at 11:40 AM. When queried regarding Resident #44's fall in the facility on [DATE], Nurse K indicated they were assigned to care for the Resident on the day of the fall and stated, It was towards the end of my shift and I heard someone yelling help. I went in and saw (Resident #44) on the floor. I got someone to help me get (Resident #44) up. When asked about the location of the Resident in the room and what the Resident was doing, Nurse K stated, I wasn't sure where they were going. (Resident #44) was near the dresser and the chair by where the TV is (at end of the bed). When asked about the Resident's condition when they found them on the floor, Nurse K stated, He was pretty confused. With further inquiry regarding Resident #44's baseline mental status, Nurse K stated, (Resident #44) had moments of being out it. With further inquiry, Nurse K stated, There was no bruising but towards the back of (the Residents) head was a little red. When asked what interventions were in place to prevent falls at the time of the fall, Nurse K revealed the Resident was on frequent checks. With further inquiry pertaining to fall prevention interventions, Nurse K indicated they were not aware of any other interventions in place. On [DATE] at 11:52 AM, an interview was conducted with Nursing Assistant [MI] When queried regarding Resident #44's fall on [DATE], Nursing Assistant L indicated they did not have the Resident and did not remember the incident. Nursing Assistant L then reviewed the assignment sheets and stated, (Nursing Assistant M) had that Resident. A phone interview was attempted to be conducted with Nursing Assistant M on [DATE] at 11:59 AM but was unable to be completed due to the phone number provided by the facility no longer being in service. An interview was conducted with the Director of Nursing (DON) on [DATE] at 12:04 PM. When queried regarding interventions to mitigate the risk of falls and injury from falls for Residents who are at risk for falls within the facility, the DON stated, We put people closer to the nurses' station, do frequent checks, fall mats. When queried regarding Resident #44, the DON revealed the Resident had frequent falls prior to admission to the facility. When asked what fall interventions in place for Resident #44 due to their history of falls and [MEDICATION NAME] therapy, the DON indicated frequent rounding was in place. Resident #44's fall care plan was reviewed with the DON at this time. When queried regarding Resident #44's fall care plan only including the intervention to encourage call light use, the DON did not provide an explanation. When asked about the Resident's room in proximately to the Nurses' Station, the DON reviewed the Resident's medical record and indicated the Resident was in room [ROOM NUMBER]. With further inquiry, the DON revealed room [ROOM NUMBER] is at the end of the hall and not near the Nurses' Station. The DON then stated, Yes, we should have had (Resident #44) closer to the Nurses' station, done frequent checks and fall mats. When queried regarding the last time the Resident had urinated prior to the fall, the DON stated, I'm not sure. When queried regarding Resident #44's order for PT/INR monitoring twice a week on Tuesday and Fridays and no results for [DATE], the DON reviewed the Resident's medical record and confirmed no diagnostic results were present in the medical record. The DON indicated the results may not have been scanned into the record from the lab and that they would look into it. No laboratory testing results for [DATE] were received from the facility by the conclusion of the survey. Call light software report data availability was requested from the facility on [DATE] at 8:44 AM but not received by the conclusion of the survey. Record review of facility policy entitled, Falls and Fall Risk, Managing (No Date) revealed, Based on previous evaluations and current data, the staff will identify intervention related to the resident's specific risks and causes to try to prevent the resident falling and try to minimize complications from falling . The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling . The facility's removal plan: Resident identified to be affected by the alleged deficient practice. The identified Resident # 44 has expired after being discharged to the hospital Residents with the potential to be affected by the alleged deficient practice. Residents who have a high risk for falls are at risk. We have initiated new fall assessments on every resident to identify this fall risk. This will be completed by end of day. New care plans have been implemented to provide fall risk interventions and CNA care guides have been updated with this information. Staff huddles are in process to inform nursing staff of fall risk residents. Nursing staff who are not on-site will be contacted via phone to inform of the location of this information and will receive in-service education. Systemic Measures PRIOR TO ADMISSION: 1. Starting with the next admission, The Director of Nursing will screen residents preadmission information for evidence of fall risk to determine if resident can be safely admitted based on current staffing and availability of fall prevention interventions. 2. New referral will be reviewed to identify previous history of falls and falls with major injury. 3. Once the decision to admit has been made, nursing leadership will meet with the receiving nursing team to give report on the expected need of the new admission. FOLLOWING ADMISSION: 4. The receiving nurse will conduct an assessment and identify residents at risk for falls. 5. DON/Nurse Manager will Identify if there is appropriate interventions in place. In absence of the DON nurse manager, a designated nurse will complete this task. 6. The identified Nurse will assure baseline care plan is completed with initial fall risk information and interventions. ONGOING MONITORING: 1. Should a resident be identified as a fall risk, nursing staff will notify the physician and set interventions in place as needed for each individual. 2. Review of medications to assure which medications might potentially put resident at risk for falls. 3. Nursing Team will complete quality audit tool at least once per week on residents identified with falls risk. 4. Results of quality audit tools and incident reports reviewed during daily clinical review meetings and discuss during the scheduled risk meetings. Team to complete care plan revisions with focus on fall prevention. 5. Schedule meeting/care conference with individuals identified at heightened falls risk. Include the patient representative in this discussion to decrease falls. 6. Physician/extender will review fall risk month and document in the EMR. QAPI 1. The Director of Nursing/ Manager will round on fall risk residents daily. 2. QAPI committee will review findings at least quarterly to review data on falls and assure benchmarks are being met. This information will be used to drive policy changes, staff education, and training.

Based on observation, interview and record review, the facility failed to institute and operationalize policies and procedures to ensure care of pressure ulcers (wounds caused by pressure) per professional standards of practice, for two (#'s 14 and 18) of four Residents reviewed for pressure ulcers resulting in lack of implementation of interventions for a Resident with multiple stage three pressure ulcers, pressure ulcer worsening, unnecessary pain, and the likelihood for infection and decline in overall health status. Findings include: On 9/23/19 at 10:09 AM, an observation occurred of Resident #18 in their room. The Resident was laying in bed positioned on their back. The Resident's heels were positioned directly on the mattress. Heel boots (padded boots to protect/reduce pressure on heels) were observed sitting in a wheelchair in the room. An interview was conducted with the Resident at this time. When asked if they had a pressure ulcer, Resident #18 replied, Yes. With further inquiry, Resident #18 stated, They usually patch it (pressure ulcer) in the morning. When asked where the pressure ulcer was located, Resident #18 indicated they had sores on their buttocks and heels. When asked if the pressure ulcers were painful, Resident #18 replied, Yes. Record review of Resident #18's medical record on 9/23/19 revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total assistance to perform Activities of Daily Living (ADLs). The MDS further indicated the Resident had four stage three (full thickness tissue loss) pressure ulcers and one unstageable pressure ulcer (wound bed covered by slough, white, stringy tissue, and/or eschar, black colored, necrotic tissue). Review of Resident #18's Resident Care Guide revealed the Resident was non weight bearing, utilized a mechanical lift for transfers, had pressure reduction devices in their chair and bed, and needed to be repositioned every 2 hours. The Resident Care Guide further revealed, Areas to Avoid . Coccyx/Buttocks . Heels . An interview was conducted with Resident #18 on 9/24/19 at 9:53 AM in their room. The Resident was observed in bed, positioned on their back with their heels positioned directly on the mattress. While laying in bed, the Resident was observed displaying facial grimacing while attempting to move their legs in bed. When asked if they were in pain, Resident #18 revealed they were. With further inquiry, Resident #18 indicated they were experiencing pain in their feet, heels, and buttocks. When queried regarding getting out of bed and repositioning, Resident #18 revealed they require assistance for turning and to get out of bed. When queried regarding the frequency staff reposition them in bed, Resident #18 laughed and indicated facility staff had still not fixed the broken drawer in their dresser. Upon request, Resident #18's dresser drawers and closet door were opened. Inside the closet door, a form entitled, Turn/Reposition Record was observed. The form contained one entry which revealed, Date/Time: 9/18, 10:30 AM; Position: B (Back) .(Facility Staff Initials) . When asked how often staff assist them to reposition in bed and in their wheelchair, Resident #18 indicated staff do not regularly reposition them in bed and not at all when they are in their wheelchair. On 9/25/19 at 8:30 AM, Resident #18 was observed laying in their bed positioned on their back. Wound care observation for Resident #18 was completed on 9/25/19 at 10:03 AM with Wound Care Nurse B, Nurse D and Nursing Assistant C. Upon entering the Resident's room, Resident #18 was observed positioned on their back in bed. Nurse D began by removing the dressing from the Resident's right heel by saturating the dressing with spray wound cleaner. The prior dressing was noted to have a moderate amount of dark colored drainage. The wound was irregularly shaped and larger than a baseball in diameter. The wound encompassed all of the Resident's heel and the medial aspect of the heel. The wound bed was black in color with necrotic tissue. The wound borders were white and beefy red colored tissue. Wound measurements were requested but not obtained. Nurse B was observed cleansing the wound bed and then applied a dressing with a dark colored ointment already in place on the dressing. When queried what the ointment was, Nurse B indicated they had pre-prepared for the wound care treatment and stated, It's hydrogel (wound ointment) and santyl (wound [MEDICATION NAME] ointment). The santyl is first (closest to the wound bed). The dressing on Resident #18's left heel was then removed in the same manner using wound cleaner. The prior dressing was noted to have a small amount of dark yellow and brown colored drainage. The wound was irregularly shaped and located directly over the Resident's heel. The wound bed was observed to have an oblong shaped black colored center surrounded by white and yellow tissue. The open wound bed was surrounded by reddened tissue and with a dark purple area observed on the distal side of the wound. When queried regarding wound measurements, Wound Nurse B stated, I only measure the open part. When asked about the observed dark purple area, Nurse B stated, I didn't see that. With further inquiry Nurse B revealed the dark purple area was non-blanchable and would need to be included in the wound measurements. Nurse B obtained measurements of the wound at this time and stated, It's 3.5 cm (long) by 1.5 cm (wide). After application of a dressing, Resident #18 was repositioned on their right by Nursing Assistant C, Nurse B and Nurse D. A dark colored substance was observed on the outside of the Resident's brief. Upon removal of the brief to complete the dressing change, the current dressing in place over the Residents sacral pressure ulcer was observed to be completely saturated with dark colored drainage which was noted on the Resident's brief. After the dressing was removed by staff, the Resident's coccyx and sacrum were observed to have a large, irregular shaped ruddy red colored area which encompassed two visible open wounds. The area was larger in length and width than a dollar bill. The open wound on the Resident's left parasacral area, contained within the ruddy red area, was egg shaped with unattached edges and visible tunneling and undermining. The wound bed had white, yellow and red colored tissue. When queried regarding the wound depth, Wound Nurse B measured the depth of the wound and stated, 1.1 cm (deep). When asked about the visible tunneling, Nurse B measured wound tunneling and stated, 2.5 cm (deep- tunneling) at the 11 o'clock position. The second open wound, contained within the pressure injury area was distal to the left parasacral area. The open wound bed was approximately a quarter in size with yellow tissue covering 50 percent of the bed. After cleaning the wound beds, Nurse B applied a gauze dressing with an ointment over the pressure injury areas. When queried regarding the ointment, Nurse B indicated the wound treatment was [MEDICATION NAME]. After completion of wound care, Nurse B proceeded to pull the visibly soiled brief over the new dressing applied to the Resident's coccyx/sacral pressure ulcers. At this time, Nurse D stated, We need a new brief. During care and repositioning following wound care, Resident #18 was observed displaying facial grimacing and non-verbal signs and symptoms of pain. When asked if they were in pain, Resident's #18 indicated they were. Following care, Resident #18 was positioned on their back in bed by staff. Review of Resident #18's wound documentation on 9/25/19 revealed the following: -7/19/19: Weekly Skin Assessment . Right heel necrosis 85% of wound with yellow slough noted, moderate amount serosanguinous drainage noted. S/P (status [REDACTED]. Left heel Stage three 4 cm X 4 cm maroon in color pink periwound with small amount of yellow tissue noted, lateral side of left foot ecchymotic maroon in color. Bilateral buttocks/coccyx 4.5 (cm) X 5 cm with 2 wounds underneath left buttock measures 1.5 cm X 1 cm yellow slough in center pink periwound moderate drainage irregular edges . Low air loss mattress. Soft heel lit boots. Roho cushion while in chair turn/reposition q2h (every two hours)/prn (as needed). -8/2/19: Wound Care Nurse Practitioner Progress Note: Left heel is a Stage 3 Pressure Injury . measurements are 3 cm length X 2.7 cm width . small amount of serous drainage . Wound bed has pink [MEDICATION NAME] . Irregular edges . Right heel is a Stage 3 Pressure Injury . measurements are 4.2 cm length X 3.4 cm width X 0.3 depth . moderate amount of sero-sanguineous drainage noted. Wound bed has Necrotic base . Irregular edges . Left Parasacral is a Stage 3 Pressure Injury . measurements are 4.7 cm length X 4.1 cm width X 0.7 cm depth . moderate amount of serous drainage . yellow necrotic tissue . Irregular edges . Plan . Treatment Recommendations: [MEDICATION NAME] Gel Daily and PRN (as needed) to all open areas. Pressure Relief/Offloading: Low Air Loss Mattress . Frequently Reposition; Roho Cushion for wheelchair; Float Heels; Soft Heel Lift Boots . -8/16/19: Wound Care Nurse Practitioner Progress Note: Left heel is a Stage 3 Pressure Injury . measurements are 2.7 cm length X 1.7 cm width X 0.2 depth . small amount of serous drainage . Irregular edges . Right heel is a Stage 3 Pressure Injury . measurements are 5.1 cm length X 5 cm width X 0.3 depth . moderate amount of sero-sanguineous drainage noted. Wound bed has Necrotic base . Irregular edges . Coccyx/L (left) Parasacral is a Stage 3 Pressure Injury . measurements are 8.7 cm length X 5.1 cm width X 1.1 cm depth . moderate amount of sero-sanguineous drainage . Necrotic base . Irregular edges . Plan . Treatment Recommendations: [MEDICATION NAME] Gel Daily and PRN (as needed) to all open areas. Pressure Relief/Offloading: Low Air Loss Mattress . Frequently Reposition; Roho Cushion for wheelchair; Float Heels; Soft Heel Lift Boots . -8/23/19: Progress Note . Left heel is a Stage 3 Pressure Injury . measurements are 1.6 cm length X 1.1 cm width X 0.01 depth . moderate amount of serous drainage . Wound bed had Necrotic base . periwound skin texture is normal . Irregular edges . Right heel is a Stage 3 Pressure Injury . measurements are 5.3 cm length X 4.2 cm width X 0.01 depth . small amount of sero-sanguineous drainage noted. Wound bed has Necrotic base . Irregular edges . Coccyx/L (left) Parasacral is a Stage 3 Pressure Injury . measurements are 7.7 length X 4 cm width X 0.6 cm depth .large amount of sero-sanguineous drainage . Necrotic midcore, Irregular edges . -9/20/19: Wound Care Nurse Practitioner Progress Note: Left heel is a Stage 3 Pressure Injury . measurements are 0.8 cm length X 0.7 cm width X 0.3 depth . moderate amount of serous drainage . Necrotic Base . periwound skin texture is normal . periwound skin color is normal . Irregular edges Right heel is a Stage 3 Pressure Injury . measurements are 6.2 cm length X 5.3 cm width X 0.01 depth . moderate amount of sero-sanguineous drainage which has a strong odor. Wound bed has Necrotic base . Irregular edges . Coccyx/L (left) Parasacral is a Stage 3 Pressure Injury . measurements are 7.2 cm length X 5.2 cm width X 0.7 cm depth . moderate amount of sero-sanguineous drainage . Wound bed has pink base [MEDICATION NAME], Minimal Yellow Slough, Two wounds with a bridge granulation . Irregular edges . On 9/25/19 at 12:28 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding measurements of wounds obtained during wound care observation and last documented wound measurements on 9/20/19, the DON reviewed the medical records and stated, I will have to look into it. When queried regarding the frequency Resident's should be repositioned, the DON replied, Every two hours. When queried regarding observations of Resident #18's heels being positioned directly on the bed and not having heel boots in place, the DON indicated the Resident should have their heel boots on. An interview was conducted with the facility Administrator on 9/25/19 at 3:04 PM. When queried regarding the Turn/Reposition Record observed incomplete in Resident #18's closet. The Administrator indicated the form was not related to turning and repositioning Residents. When asked why the form was titled, Turn/Reposition Record, the Administrator indicated they were not using the forms. The Administrator further revealed no facility would ever use a form like that. No further explanation was provided. Review of Resident #14's (R#14) Electronic Health Record (EHR) revealed, R#14 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed R#14 was totally dependent on staff for Activities of Daily Living (ADLs) including bed mobility and had a severely impaired cognition. R#14's Treatment Administration Record (TAR) revealed no treatments ordered for wound care, turning and repositioning, or low air loss mattress settings. Interventions on R#14's care plan dated 1/9/19 included, APPROACH: Provide assist with repositioning at regular intervals Flowsheet: CNA (certified nursing assistant) Discipline: Nursing Frequency: Every 2 Hours; 12:00 AM, 02:00 AM, 04:00 AM, 06:00 AM, 08:00 AM, 10:00 AM, 12:00 PM, 02:00 PM, 04:00 PM, 06:00 PM, 08:00 PM, 10:00 PM. The care plan did not specify the method of repositioning. On 9/23/19 at 9:38 AM, R#14 was observed lying in bed and made eye contact but did not speak or move. R#14's bed was in semi-Fowler's position (on their back with the head and trunk raised 30 degrees), a low air loss mattress (for the prevention and/or treatment of [REDACTED]. On 9/24/19 at 5:23 AM, and 7:52 AM, R#14 was observed in the semi-Fowler's position. At 9:41 AM, Nurse D was asked about the low air loss mattress setting and stated, Nurse B sets them. This setting can be lowered. Nurse D then reduced the pressure setting after releasing the settings lock then re-locked it. R#14 remained in semi-Fowler's position, but now a pillow was observed under the resident's right arm. On 9/24/19 at 12:30 PM, R#14 was being examined by a Physician followed by care by nursing staff. At 1:00 PM, R#14 was observed flat in bed. On 9/25/19 at 9:33 AM, CNA I was asked about caring for dependent residents and stated, I check on them every two hours and change them if needed, and I turn them too. CNA I was asked how the positioning of a resident is maintained and stated, It depends on what kind of bed it is. On 9/25/19 at 11:30 AM, the Director of Nursing (DON) was asked about the policy and procedure regarding turning and repositioning dependent residents and stated, They are to be turned every two hours. The nurses and nurse managers should be checking to make sure the CNAs are doing their work. There will be more in-servicing. Review of facility policy entitled, Preventative Skin Program (Revised: 2/23/19) revealed, It is the policy of this facility to take steps to reduce the incident of pressure injury development . Licensed Nurse will complete skin assessments, no less than weekly . to identify any new wound concerns or changes with existing wounds . Skin care interventions will be implemented by the licensed Nurse upon identification of any new or worsening wound concern . Documentation of weekly skin observations shall be rendered in the clinical record . Routine off-loading shall be an [MEDICATION NAME] part of the preventative skin care program . The wound care team shall make weekly rounds on residents with identified wounds and routinely query staff to identify skin issues .

This citation refers in part to MI 196. Based on observation, interview, and record review the facility failed to ensure skin management interventions (skin assessments, repositioning, and treatments) were completed and or documented for one sampled resident (R904) of three residents reviewed for pressure ulcers in a total sample of six resulting in the worsening of a known skin condition/pressure sore. Findings include: On 02/19/19 and 02/20/19 the medical record for R904 was reviewed and revealed: R904 was admitted into the facility on [DATE]. R904 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with a 15/15 Brief Interview for Mental Status (BIMS) score, the need for extensive assistance of two persons for bed mobility, transfer, dressing, hygiene, and toilet needs. R904 was indicated in section M to be at risk for pressure ulcers and without a pressure ulcer. Interventions included a pressure reduction device for wheelchair and bed, and the application of a non-surgical dressing to an area other than the feet. The nursing care plans were reviewed and revealed: A Functional urinary incontinence R/T (related to) mobility limits (dated 9/29/17) with goal Resident will not develop skin breakdown related to incontinence and Approach Start Date: 07/19/2018 Weekly body audit. A Pressure Ulcer Risk for alteration in skin R/T: immobility. (R904) has mobility limits and is mostly bed and chair bound; is incontinent of (bowel and bladder) b/b, has multiple comorbidities that put at risk. Goal Patient will experience no skin breakdown, unless clinically unavoidable through the review date. Approach: encourage turning and repositioning as resident will refuse often, Treatment's as ordered, Frequent repositioning, Apply moisture barrier after incontinent episodes and as needed, Start Date: 10/03/2017 weekly skin assessments, Encourage /offer repositioning Q2 hrs (every two hours) & at regular intervals. An (activities of daily living) ADL Functional / Rehabilitation Potential Resident has a self care deficit R/T: (history) Hx of Left [MEDICAL CONDITION], and impaired mobility, and Hard of hearing (HOH); no stated goals; requires assist with all adls, Approach Start Date: 05/31/2018 Address resident clear, close and direct when speaking and clarify direction and needs with (R904) before leaving r/t HOH. A weekly skin assessment dated [DATE] indicated Reddened - bilat(eral) buttocks and coccyx (tailbone area). Additional weekly skin assessments were requested on 02/20/19 but not received prior to survey exit. The last wound consult was (MONTH) 11, (YEAR). The ADL, CNA (certified nursing assistant), General, Medication, Treatment and Order Flowsheets for (MONTH) and (MONTH) (YEAR) were reviewed for documentation of care and revealed: The ADL flowsheet did not document a shower was given nor the amount eaten at meals. The Medications Flowsheet did not document the intervention Alternating pressure low air loss mattress setting (dated) 11/25/17 and the Offer H.S.(hour of sleep) Snack At Bedtime 10/23/2017. The Treatment Flowsheet did not document the weekly skin assessment on Thursday and the apply [MEDICATION NAME] (foam type dressing) to coccyx area every other day for skin protection (dated) 06/01/18 were checked. Nursing progress notes were reviewed and revealed: On 02/10/2019 8:23 PM Resident daughter informed writer that (R904) had called her and stated that no one had changed (R904) all day. R904 last asked not to be repositioned on 02/07/19 at 10:39 AM. No additional refusals to turn and reposition were documented. A shower sheet dated 02/11/18 indicated redness to the coccyx area (circled on body diagram) but was not signed by a nurse. A shower sheet dated 02/14/17 which indicated redness (redness could indicate an increased potential for a worsening skin condition) to the coccyx was not signed by the CNA. A nurse signature noted the sheet as reviewed and a reddened area to the coccyx per a circled area on the body diagram and nothing warranted at this time. On 02/19/19 at 7:45 AM, 8:01 AM, 9:25 AM, 12:19 PM, 1:08 PM, 3:56 PM and on 02/20/19 at 7:41 AM, R904 was observed in bed on their back with one pillow under the torso on the left and right sides. The feet were elevated and a low air loss mattress was active. The head of the bed was elevated between zero and 45 degrees. On 02/20/19 at 10:42 AM, R904 was observed in bed with two pillows under the left side, positioned to face right, feet elevated above the level of the abdomen and the head of the bed elevated between zero and 45 degrees. On 02/20/19 at 12:35 PM, R904 was observed in bed with two pillows under the left side, positioned to face right, feet elevated above the level of the abdomen and the head of the bed elevated between zero and 45 degrees. R904 was down in the bed so the waist was past the break in the mattress. The lunch tray was on the left side of the bed on the over bed table. The table was pulled over the left side of the bed at an angle. R904 had to reach across their body to access items on the lunch tray. R904 attempted three times to open the twist off top of the nutrition supplement but was unsuccessful. R904 stated, I didn't want to push button because it is during lunch time and they probably wouldn't come. The side I'm laying on is hurting me. It may stop me from doing a lot of stuff. Everything's a struggle. R904 reached the glass of orange juice and when they attempted to drink the straw bent and kinked when trying to put the straw into their mouth. Nurse A came in to check on R904. R904 asked to be changed and reported the feet slide around in the boots and get twisted when staff move them up in the bed. It was noted that R904's feet while in boots were elevated on a foam wedge with no support under the knees, potentially placing pressure on the buttocks and lower back. R904 was then asked about wanting to get cleaned up or finishing lunch by Nurse A and chose to get cleaned up. An odor of stool had been noted. When turned onto the right side, a tennis ball diameter sized area of mottled, dark purple and red skin was observed around the coccyx. This appeared as a deep tissue injury (DTI-Persistent non-blanchable deep red, maroon or purple discoloration, results from intense or prolonged pressure or shear forces - National Pressure Ulcer Advisory Panel (NPUAP) definition). In the center of the area, an open slit like area 2 to 3 centimeters (cm) in length was noted (a stage two to three pressure ulcer (partial to full thickness skin loss per NPUAP)). Nurse A went out to get a treatment/dressing and was out twenty minutes before returning. One of the aides had gone out and looked for the nurse. Nurse A returned with a dressing and explained the treatment to R904 who then stated, I am not sure that is doing any good. CNA C attempted to raise the head of the bed higher for lunch but R904 reported increased pain and the bed was lowered past 45 degrees until R904 stated they were comfortable. On 02/20/19 at 4:50 PM, the Administrator was asked if weekly skin assessments should be completed and documented by the nurse and indicated, Yes. On 02/20/19 the facility Pressure Ulcers and Skin Breakdown revised 02/19/19 policy revealed, 2.the nurse shall assess and document/report the following: a. Vital signs b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (drainage) or necrotic (non-viable) tissue .

Based on observation, interview, and record review, the facility failed to consistently assess, offload pressure, monitor, and measure facility acquired pressure injury/ulcer(s) (a wound that occurs as a result of direct pressure to the skin) for one sampled resident (#12) of one resident reviewed for pressure injuries, resulting in the development and worsening of a pressure injury, pain, and the likelihood of the further development of wounds. Findings include: On 12/5/18 at 11:51 AM, Resident #12 was observed sitting up in their wheelchair in the activity room. Resident #12 was unable to communicate or answer questions appropriately. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #12 was admitted to the facility initially on 5/22/18 and then readmitted on [DATE] with the [DIAGNOSES REDACTED]. According to the MDS, Resident #12 was severely cognitively impaired and was dependent for transfers, eating, personal hygiene and bed mobility. On the skin section of the MDS, it revealed that Resident #12 had two stage 3 pressure ulcers, two stage 4 pressure ulcers, and one unstageable pressure ulcer. A record review of the Physician Orders for Resident #12 revealed the following in regards to the management of the wounds: 5/30/18-offload heels 6/19/18-Pressure Sore: Pressure reduction device to bed and/or chair. Place positioning wedge under calves to float heels. Use pillows to float heels while in bed. Every Shift . 6/19/18-Pressure Sore; Assess skin at least QD (every day) 8/3/18-Weekly Skin Assessment .Please complete an observation note . 9/12/18-per wound Dr. (physician) resident is to wear Profo boots when up on the chair 9/24/18-Pro-Stat .for wound healing 10/4/18- .low air loss mattress. Roho cushion to wheel chair. Elevate BLE (bilateral lower extremities). Float heels. 11/8/18-podiatry consult 11/9/18-air mattress . 11/9/18-BLE boots on while OOB (out of bed) 11/26/18-wound care consult 11/30/18-Soft heel lift boots to be worn while in bed. 11/30/18-Hydrogel .Clean right lateral lower leg . 11/30/18-Hydrogel .Clean right heel . A record review of the skin care plan (start date 5/24/18) for Resident #12 revealed the following: Problem-Risk for alteration in skin R/T (related to): Bed immobility; .has multiple comorbidities and .has a hx (history) of tissue injury's. Goal-Resident will be free of skin breakdown . Approach (started 6/29/18)-offload pressure to heels using a wedge when up to chair; pillows when in bed (5/24/18)-bi-weekly skin assessments with showers. On 12/06/18 at 11:33 AM, A wound observation was made with Licensed Practical Nurse (LPN) E of Resident #12's wounds and revealed the following: Right heel-foul odor noted from the wound. LPN E described the wound as a stage 4,(a full thickness wound or a wound that extends through the skin, fat tissue, muscle, and to the bone). There was yellow and black tissue observed along the lateral side of the foot and heel. A significant portion of the heel tissue was missing. There was moderate amount of clear, yellow drainage noted on the gauze in which the foot was resting. During the wound care, Resident #12 was wincing and grimacing with the movement of the right foot and with any contact to the wound. Right lateral lower leg-also described as a stage 4 by LPN E. The wound was a linear wound. The wound base was moist and red with a strip of yellow tissue in the middle of it. Buttocks-Small, pink and yellow wound, wound close to surface of skin. According to LPN E, the left heel wound was healed. A record review of the skin assessments and wound notes revealed the following for Resident #12: May (YEAR) 5/23/18 Admission skin assessment-no wounds 5/29/18 Weekly Skin Assessment-no wounds 5/30/18 Foot and Ankle Specialist- .Patient seen and evaluated, Podiatric visit w/ (with) lower extremity evaluation and assessment .Scabbing ulceration/pre blister left heel .consult wound care .elevate feet and offload heels .Daily inspect feet, I did inform the nurse about the above care since patient might not remember or unable to follow task . June (YEAR) 6/20/18 Wound Care Consult-Wound care consult requested Seen today for right and left heel deep tissue injury .Right heel deep tissue injury matches at 12(width)x 3.0(length)xUTD(unable to determine) (centimeters/cm) with blood blisters intact . Requested skin assessments and wound measurements for June, no other documentation provided by the end of the survey. July (YEAR) 7/4/18 Weekly Skin Assessment- .Dressings to heels .open areas without odor/drainage. 7/13/18 Wound Care Progress Note- .Right heel deep tissue injury with eschar (nonliving, black tissue) formation matches at 12x3xUTD (cm) .left heel deep tissue injury with eschar .Treatment as discussed above patient to continue to get foam boots in place all the time patient needs to be rotated frequently as possible, patient could benefit from high-protein low calorie diet. 7/19/18 Progress Note-Right heel deep tissue injury with eschar formation .left heel deep tissue injury . Requested skin assessments and wound measurements for July, no other documentation provided by the end of the survey. August (YEAR) Shower sheets 8/3/18, 8/6/18, 8/7/18, 8/10/18, 8/21/18, 8/24/18, 8/28/18 all revealed wounds present on both heels. 8/7/18 and 8/28/18 revealed a red buttocks. Wound measurements and notes were requested for the month of (MONTH) but not received by the end of the survey. September (YEAR) Shower sheets 9/7/18, 9/11/18, 9/17/18, 9/21/18 revealed previous concerns. Wound measurements and notes were requested for the month of (MONTH) but not provided by the end of the survey. October (YEAR) 10/18/18 Wound Care (Authored by Wound Care Nurse Practitioner/NP F)- .Multiple wounds .Vascular Ulcer, Pressure Ulcer,Blisters .Left Buttock is a Stage 3 Pressure Injury Pressure ulcer .Left heel is Vasculitic Ulcer .Right Bunion is a Vasculitic Ulcer .Right Heel is a Stage 4 Pressure Injury Pressure Ulcer .measurements are 6 cm length x7 cm width x1 cm depth .mild odor .wound bed has Pink Base .Right, Lateral Lower Leg is a Stage 3 Pressure Injury Pressure Ulcer . 10/23/18 Shower Sheet-New Open Areas, New Red Areas, New Bruising/Abrasions/Rashes/etc. with the right lower leg circled on the body sheet. 10/25/18 Wound Care -Left Buttock is a Stage 3 Pressure Injury Pressure Ulcer .Left, Posterior Heel is a Vasculitic Ulcer .Right Bunion is a Vasculitic Ulcer .Right Heel is a Stage 4 Pressure Injury Pressure Ulcer .measurements 6.5 cm length x 5 cm width x 0.6 cm depth .Right Lateral Lower Leg is a Stage 3 Pressure Injury Pressure ulcer .elevate BLE .Float heels .Soft heel lift boots. Requested skin assessments for the month of October, however, not received by the end of the survey. November (YEAR) 11/8/18 Wound Care (Authored by NP F)- .L (left) Buttock is a Stage 3 Pressure Injury Pressure Ulcer .Left Posterior Heel is a Vasculitic Ulcer .Right Bunion is a Vasculitic Ulcer .Right Heel is a Stage 4 Pressure Injury Pressure Ulcer Ulcer (8.5 cm x 9.6 cm x 2.5 cm) .Right Lateral Lower Leg is a Stage 4 Pressure Injury Pressure Right Buttock is a Deep Tissue Injury . 11/15/18 Wound Care (Authored by NP F)-Same as above assessment, with the addition of a Right Lateral Foot Deep tissue injury. 11/29/18 Wound Care (Authored by NP F)- Same wounds as above, with the exception of the Vascular ulcer of the Left Posterior Heel and Right Bunion as being resolved Requested Skin assessments for the month of November, however, none were provided by the end of the survey. On 12/6/18 at 12:38 PM, an interview was completed with the Director of Nursing (DON) in regards to the wounds that Resident #12 developed while at the facility. The DON was queried about whether Resident #12 had regular skin or body assessments since their original admission to the facility in May. The DON stated, One of the things I noticed when I came (in (MONTH) (YEAR)) here was that the skin assessments and the showers were not being done correctly .The nurse is supposed to go in during the shower and document (the skin assessment) on there. They are supposed to put it in the computer and then there is a paper they are supposed to sign off on. Now we put it in the MAR (Medication Administration Record), and then it prompts the nurse to do a skin assessment and then they have to create one (within the electronic medical record). I don't like that there was paper and computer assessments, it is done one way now (in the computer). On 12/6/18 at 1:39 PM, Resident #12 was observed on their right side in bed. No heel boots on. There was a blue foam heel boot on the chair in the room. On 12/6/18 at 2:00 PM, Corporate Consultant G and Unit Manager LPN C confirmed that if skin assessments were not in the computer or on paper, then it was not done. On 12/6/18 at 2:10 PM, Resident #12 was observed in bed on their right side. LPN B was present at the bedside. There were no heel boots on, nor were the feet/heels floated. LPN B who was in charge of the resident, was queried about the observation of the feet and heels resting directly on the mattress. LPN B stated, Yes, they are supposed to have something on (to protect the heels/feet). There was a blue foam heel boot on the chair in the room. On 12/6/18 at 2:27 PM, NP F was queried in regards to the wounds of Resident #12. NP F stated, I haven't seen them today, but with their comorbidities (Hypertension and Diabetes) you can't tell if they will get better. I would try to protect and treat them. (Resident #12) should have a heel boot and frequent repositioning. On 12/6/18 at 2:30 PM, The Administrator was queried about the acquired wounds of Resident #12 and not having regular body/skin assessments in the medical record. The Administrator stated, (Resident #12) was in and out of the hospital, so there will be some gaps in the documentation. A record review of the census of Resident #12 revealed that they had no discharges out of the facility in May, June, and September, but did leave the facility for less than 24 hours on 7/6/18, 8/10/18 and 10/28/18. Resident #12 had a hospital stay form 8/14/18-8/20/18, 10/6/18-10/12/18, and 10/30/18-11/7/18. On 12/6/18 at 3:45 PM, an interview was completed with Family Member D in regards to Resident #12's wounds. Family Member D stated, (Resident #12) did not have any wounds when they got to the facility. They (the facility) does not reposition them enough. They should be in there every hour checking on them and making sure they aren't dirty. There are times when I come in that (Resident #12) doesn't have any boots on their feet. I am trying to get some pictures of the right heel wound to send to my brother who is a doctor to see what can be done with it since it is getting worse. A record review of the facility policy titled, Pressure Ulcers/Skin Breakdown Revised 06/01/2016 stated the following: Assessment and Recognition-1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores .In addition, the nurse shall assess and document/report the following: a. Vital Signs b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue c. Pain assessment .

This citation pertains to intake MI 147. Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent elopement and ensure the safety for one sampled resident (701) who had impaired decision making and with a known elopement risk. Resulting in an Immediate Jeopardy (IJ) on Saturday 9/15/18 at 2:14 PM when, Resident #701 exited the facility from an unalarmed door to another door which was alarmed, but alarm was not audible. This elopement was unbeknown to facility staff, and the resident was returned to the facility by a visitor at 2:26 PM. This deficient practice had the likelihood of causing serious harm, injury, and/or death. Findings include: The IJ was started on 9/15/18 and identified on 10/3/18. The Administrator was notified of the Immediate Jeopardy on 10/3/18 at 2:30 p.m. The Administrator was asked for a plan to remove the immediacy. The IJ was removed on 9/17/18 based on the facility's implementation plan and verified onsite on 10/4/18. On 10/3/18 at 10:43 AM, during an interview, Nurse B was interviewed about the elopement of Resident #701. Nurse B stated, It was a Saturday, it had to happen between Noon-1:00 PM. I was looking for (R 701) to give medications. (R 701) is a very difficult person, (their) Dementia is really bad. I approached to give med's (R 701) said No in a very strong way and that I have to go to an appointment.' (R 701) kept walking around saying (they) had to go. I walked away and a little later I went to go re-approach and didn't see (them). I asked if anyone had saw (them), at the same time I was called to the front door. As I was walking to the door I saw (R 701) coming back in with a visitor (another resident's family member). I took (their) hand and walked (them) back to the unit and did a full assessment and assigned a one to one Certified Nursing Assistant (CNA). Nurse B was asked if this was Resident #701's first time getting out of the facility unsupervised. Nurse B stated, Yes. This was the first time. (They) would always say (they) had to go, or that (they) were leaving for an appointment. Nurse B was asked if Resident #701 was assessed as an elopement risk. Nurse B stated, Yes. (They) were set as an elopement risk from the onset. Nurse B was asked if she had taken a statement from Visitor E that found Resident #701 outside. Nurse B stated, No, because I didn't see (them) outside. I just told them thank you. On 10/3/18 at 10:08 AM, during an interview, the Director of Nursing (DON) was interviewed about the elopement of Resident #701. The DON stated, (R 701) was assigned to the South unit and exited out of the North door. The door alarms have been changed to a much louder sound since then. The DON was asked for the name for the CNA that was assigned to Resident #701. The DON explained that it was two agency CNA's that day and not facility staff. The DON was asked if Resident #701 was assessed for elopement. The DON stated, No. (R 701) was new to the building and had not been assessed. The DON was asked for the staff person that is responsible for elopement assessments. The DON stated, That would be the social worker. On 10/3/18 at 11:31 AM, during an interview, the Former Administrator (FA) was interviewed about the elopement of Resident #701. The FA stated, I viewed the camera and determined that (they) went to the door by the social worker's office at 2:14 PM. I don't know how long (they) were at the second door, there is no camera there. The next time (R 701) was in view of the camera was at 2:26 PM coming back into the facility with the a visitor. The FA was asked if they had interviewed the visitor. The FA stated, Yes. (They) said (they) were driving by and saw (R 701) walking on the side of the building . On 10/3/18 at 12:07 PM, during an interview, the Administrator was asked to explain the door alarm system. The Administrator stated, The resident exited out of the door in the hallway that did not have an alarm, that led to a vestibule door that had an alarm . The doors that Resident #701 exited out of was observed with the Administrator and Maintenance director. The door that lead to the outside alarm was observed with the hallway door closed. At that time the door that lead to the outside of the building was verified to be working but not audible when the first door was closed. On 10/4/18 at 8:25 AM, during an interview, the Social Worker SW was asked for the elopement and cognition assessment for Resident #701. The SW stated, I never got around to do my part. Every time I tried (they) would not be cooperative, so I would just say I will try another day. We were also looking for another placement for (them), so I also thought (they) were going to be discharged soon. Nursing would do the elopement assessment, I would keep track of them after the assessment. On 10/4/18 at 2:33 PM, during an interview, Visitor E was questioned about the elopement of Resident #701. Visitor E stated, I had saw (R 701) walking the halls before I left. As I was pulling out of the parking lot, I saw (R 701) walking on the road near the grass. I turned my car around, parked, and ran back into the building and told them, 'You guys have a resident out here.' I then went back outside (R 701) was walking on the grass up the hill to the parking lot. I walked with her into the building into the front door. Visitor E was asked did staff come outside at any point to assist with bringing Resident #701 back into the facility. Visitor E stated, No. Not outside, only when I got her back into the door. Facility provided the facility's Investigation: 9/15/18 at 6:31 PM Interview with (Receptionist). (Receptionist) states she was sitting at the front desk on 9/15/18 at approximately 2:20 PM. A family member came in the front door and said One of your patient's is outside (Receptionist) tried to call the nurses' station, no one answered, so she paged Nurses to the front (Receptionist) ran down the hall toward nurses station and told the agency nurse on the north wing - that a family member said there was a patient outside I think I ran down the hall and told (Nurse B) also, then agency nurse (Nurse H) and (Receptionist) came back up to the front lobby and she (Receptionist) didn't see anybody. Then as (Receptionist) and agency nurse (Nurse H) were standing in the front lobby. The family member walked through both sets of lobby doors into the lobby with the resident. Then the visitor exited the building to the parking lot. Receptionist, agency nurse (Nurse H) and resident walked her back to the nurses station - north side. As (Receptionist) got close to the exit door by social workers office she heard a beeping . (Receptionist) looked and saw (Nurse B) trying to reset the outside alarm . (Nurse B) said she was trying to make the alarm stop and (Receptionist) was able to stop the alarm and reset it. At this point (Receptionist) and (Nurse B) could not reenter the building from the vestibule, so they walked outside to the back of the building to get back in to the facility. (Nurse B) picked up residents tennis shoes that were outside the door and brought them inside. Visitor told (Receptionist) she found the resident outside; visitor had not gotten to car- resident in parking lot area. Review of clinical record revealed that the resident was, Possible elopement risk. continent, will continue to monitor. Record review revealed that on 09/14/18 at 10:12 PM, This resident was assessed for elopement potential and care plan generated, or updated as needed. On 09/15/18 at 8:46 AM Resident went to sleep around midnight. Kept pacing the floor, stating that (they) wanted to go home . On 09/15/18 (Recorded as Late Entry on 09/19/2018 11:11 AM) at 10:37 AM writer was called over head to come to the reception area. Upon arrival, saw resident with family member. Resident was escorted to the North unit where (they) was assessed from head to toe. No injury noted, Resident was loud stated she needs to go because (they) has an appointment. was encouraged to calm down and relax. (Patient) Pt. very difficult to redirect. Review of a care plan . Problem Start Date: 09/14/18, Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Intervention: Approach Start Date: 09/14/18 When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). Resident will be on individualized monitoring, with frequent documentation on an ancillary sheet . Review of Assessments. Admission Resident Elopement assessment: 9/14/18 Mobility: Ambulatory. Mental Status: Cognitively Impaired (Decreased safety awareness/ disturbance in judgement). Medications (including psychoactive): One or more. Total Score: Elopement Risk, Score: 20.0000, Level: At Risk. Review of the Psychosocial Well-Being Elopement Risk: 9/14/18. Cognitive Skills for Daily Decision Making (Made decision regarding tasks of daily life): 2. Moderately Impaired-decisions poor; cues/supervision required. How resident walks in corridor on unit: 0. Independent - No help or oversight needed - Help/oversight provided only 1-2 times in last 7 days. Indicate preventative action taken. Photograph Posted. Indicate Care Plan action taken. Elopement care plan to be initiated. Review of the face sheet noted that Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Admission Nursing assessment noted, Neurological: Alert, time, and person. Behaviors: . Wander . Continued record review of the facility's investigation revealed, an order for [REDACTED]. On 9/17/18 three alarms were added to the facility doors, with one being the door Resident #701 elopement from. On 9/20/18 the facility added a second alarm to all remaining doors in the facility. A review of the facility's undated policy, titled Elopements, noted, Policy Statement. Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing . The facility submitted a Plan of Correction: Element #1 Resident #701 left the faciity on [DATE] and has been returned but no longer a resident at this facility. Resident was brought back into the facility by a visitor and assessed by the charge nurse with no noted injuries and put on a 1:1 supervision. Care Plan was reviewed and revised. Physician and Emergency contact was notified. The visible door buzzer present at the time of this resident elopement was working but a second door alarm was added to all exit doors for a total of 8 exit doors. Completion dates was 9/20/18. Element # 2 All residents are at risk for leaving the building unattended. The facilities reviewed all facility residents' elopement assessment and have been updated. All residents' elopement risk assessments and care plans have been reviewed and/or updated. Elopement risk assessments will be done for every resident on admission, quarterly, annually and as needed. Elopement risk assessment will update and completed when any exit seeking behaviors occurs. Element # 3 Facility staff education was initiated on 9/15/18 and was completed on 9/19/18. All staff have been re-educated on residents at risk for elopement and code Pink. For any employee who was not present during this time in-services on elopement and code Pink will be arranged for them upon their return to work. The Director of nursing reviewed the current elopement risk assessment form that is in use at the facility with the Interdisciplinary Team (IDT) during the Quality Assurance Meeting held on Element # 3 9/27/18. An alternative Elopement risk assessment is being sought to replace the current assessment form that will include a numeric value, to improve accuracy of the assessment versus the current form in use. The elopement policy resident policy were reviewed and deemed appropriate. In order to ensure the safety and supervision of facility residents, the following interventions and systemic changes have been immediately put into place by the Quality Assurance Committee on (MONTH) 27, (YEAR). The front lobby door will be closed off at 11:00 pm to 7:00 am and a second door alarm was added to all exit doors. Any residents requiring access to the exit doors will be accompanied by a staff member. The Maintenance Director will check all the door alarms daily at the end of the shift to ensure the door alarms are working. All residents at risk for elopement have been moved close to the nurses' station. Staff will document hourly on each resident at risk for elopement daily for each shift X 4 weeks until sustained compliance. The nurses will chart in the MAR and the CENA will chart in the ADL on any residents determined to be at risk for elopement. Completion date 9/18/18. An elopement book was added at the front desk and each nurse's station on 9/15/18. Element # 4 The Administrator or DON will monitor the process and provide 1:1 education with repeat offenses and follow the disciplinary action process. Random door alarm drills will be conducted by the Administrator or designee weekly X 4 weeks. All results will be reviewed in the QA meetings for further recommendations. Element# 5 The Administrator will be responsible for sustained compliance Date of Completion: (MONTH) 23, (YEAR)

This Citation Pertains to Intake Number MI 965. Based on observation, interview and record review, the facility failed to ensure and update interventions, perform and document assessment and monitoring, and operationalize policies and procedures related to documentation and implementation of interventions for Residents requiring staff assistance to ensure safety for one (#703) of two Residents reviewed for appropriate interventions, of a total sample of three, resulting in lack of documentation, multiple falls with injuries, including a fall with fracture, unnecessary pain, and delay in treatment. Findings include: Record review on 10/31/17 at 10:30 AM revealed Resident #703 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform Activities of Daily Living (ADL's). A review of Resident #703's care plans at this time revealed the following care plans and interventions related to falls and ADL's: 1. Falls: Resident has history of falling . (Start Date: 10/1/17, Edited: 10/14/17). Care plan interventions included: -Offer to toilet resident before laying resident down at bedtime (Start Date: 10/14/17) -Room change closer to nurse station. (Start Date: 10/1/17, Edited: 10/2/17) 2. Falls: Resident at risk for falling . (Start Date: 7/15/17, Edited: 7/12/17) -Educate staff on transfer safety. (Start Date: 9/18/17, Created: 9/20/17) -Res to remain in areas of higher visibility while up in w/c (wheelchair) (Start Date: 7/25/17) -Bed alarm to bed/chair (Start Date: 7/17/17) -Give resident verbal reminders not to transfer without assistance. (Start Date: 7/15/17) -Offer to toilet resident before lunch (Start Date: 10/12/17) -Offer to toilet resident after breakfast. (Start Date: 8/28/17) -Offer to lay resident down after lunch (Start Date: 8/16/17) -Offer and assist resident up into w/c daily before breakfast and moved to an area of higher visibility (Start Date: 7/27/17) 3. ADL Functional / Rehabilitation Potential: Resident has a self care deficit . (Start Date: 7/15/17, Edited: 7/27/17) -BED MOBILITY: ext assist x 1 (Start Date: 7/15/17) -Resident to wear Left arm sling at all times as tolerated, may remove every shift to check skin, and ADL care. (Start Date: 7/27/17) -BATHING: 1-2 person assist as needed . (Start Date: 7/15/17) -DRESSING: 1 person assist (Start Date: 7/15/17) -HYGIENE / ORAL CARE: 1 person assist (Start Date: 7/15/17) -TOILETING: ext assist x 1 (Start Date: 7/15/17) -L(NAME)OMOTION: Wheel chair use with 1 person assist (Start Date: 7/15/17) -TRANSFER: ext assist x 1 (Start Date: 7/15/17, Edited: 7/27/17) On 10/31/17 at 11:30 AM, Resident #703's incident and accident reports were requested from the Director of Nursing (DON). An interview was completed with Confidential Witness I on 10/31/17 at 12:05 PM. When queried regarding Resident #703, Confidential Witness I stated, (Resident #703) fell and broke their arm (at the facility). They have an alarm now. With additional inquiry, Witness I stated, (Resident #703) has fallen quit a few times at (the facility). Witness I further indicated the Resident did not have an alarm prior to falling and breaking their arm. On 10/31/17 at 12:10 PM, Resident #703 was not in their room in the facility. The Resident's bed was unmade and their call light was on the floor. An enabler bar was observed to be raised an in place on the left side of the Resident's bed, towards the door to the room. A bed alarm was noted on the Resident's bed. The Resident's bed was not visible from the nurses station. Record review of Resident #703's facility provided incident reports, entitled Unusual Occurrence Report occurred on 10/31/17 at 12:30 PM. Review revealed six Unusual Occurrence Reports which indicated the Resident had fallen within the facility on 7/25/17, 8/16/17, 8/26/17, 8/30/17, 9/18/17, and 10/14/17. Review of reports revealed Resident #703 hit their head when they fell on [DATE] causing Skin tear, bruise/hematoma, head trauma and intervention which included, Cleansed area and treatment applied. The Unusual Occurrence Report for the fall dated, 8/30/17, indicated the Resident suffered an injury to the back of their head and on their right knee. Neurologic assessment documentation was not included with the reports and were not located in the medical record. Record review of Resident #703's medical record documentation at this time revealed progress note documentation indicating the Resident also feel within the facility on 7/13/17. The note, dated 7/14/17 at 8:09 AM, revealed, Late Entry for 1900 7-13-2017 to 0700 7-14-2017 shift. Resident in bed this PM, no C/O pain/discomfort. Found on floor by CENA at 2220. When asked by Nurse, stated they were trying to move around. When asked by CENA, Resident said that they were trying to take out the trash. Resident in bed, no noted/reported new marks/injuries to Resident. Call placed for attending (Physician) at 2239, no answer, NP (Nurse Practitioner) contacted at 0345 to inform, order for bed alarm and to ambulate prior to HS (bedtime) . On 10/31/17 at 12:55 PM, an interview was completed with the DON. When queried regarding neurologic assessments for Resident #703 after fall with head injuries, the DON replied, I will have to look for them. There are a bunch of places they could be. When queried why Resident medical records are not maintained together, the DON replied, We are working on that. When queried regarding why an incident report was not provided for the fall documented in Resident #703's medical record as occurring on 7/13/17, the DON replied, I will look for it. On 10/31/17 at 3:45 PM, Resident #703 was observed sitting in a common room within the facility. The Resident was sitting in a wheelchair. The wheelchair had with leg rests for both the Resident's legs. The Resident was observed moving their feet off of the foot rests and placing them on the floor under the wheelchair, behind the foot rests. Resident #703 was wearing regular socks and no shoes. The Resident had a half cast/immobilizer in place to their left lower arm. The room was not located or visible from the nurses station and there were no staff present in the room. The Resident did not have a call light and a chair alarm was not in place on the wheelchair. An interview was completed with Resident #703 at this time. When queried regarding their arm, Resident #703 stated, I fell and broke it about a month ago maybe. With further inquiry, Resident #703 stated, fell here and broke it. It hurts all the time. When asked what their current pain level was, Resident #703 replied, 8 (8/10). The Resident then stated, Would you please ask the Nurse if I can have something for the pain? On 10/31/17 at 3:55 PM, an interview was completed with the DON. When queried regarding the cast/immobilizer on Resident #703's arm and the Resident stating they fell at the facility, the DON stated, Yeah, it happened her but we didn't know about it because we sent (Resident #703) out (to the hospital) and they found it there. When queried why an incident report for the incident was not provided when requested, the DON stated, Oh, I didn't give you that. I will look for it. An interview was completed with Nurse C on 10/31/17 at 4:00 PM. When queried regarding Resident #703's pain level, Nurse C stated, (Resident #703) has a broken arm, I know it hurts. I try to make sure (the Resident) gets pain medication. Nurse C reviewed the Resident's medical record and stated, (The Resident) can have something (for pain) now. When queried regarding Resident #703 having a chair alarm, Nurse C stated, They don't have a chair alarm just a bed alarm. Resident #703's care plan was reviewed with Nurse C at this time. Review revealed the Resident had an intervention for a chair alarm in place. When queried again regarding the intervention, Nurse C stated, Oh, (the Resident) isn't supposed to have a chair alarm. Nurse C proceeded to edit Resident #701's care plan and remove the intervention. When queried regarding why the Resident was not wearing shoes and/or non-slip footwear, Nurse C replied, (The Resident) takes off their shoes. Nurse C then reviewed the Resident's care plan and stated, That isn't an intervention. When queried further regarding non -slip foot wear for fall prevention, Nurse C stated, You're right. Nurse C proceeded to edit and add the intervention to Resident #703's care plan at this time. On 10/31/17 at 4:25 PM, review of progress notes within the medical record revealed the following documentation: -10/1/17 at 6:32 AM: Writer was up checking on resident and was in the hallway, had just looked in room, resident was sleeping at this time. At 4:40 AM bed alarm was going off, went to check on resident, when I got close to the room heard a bang, and resident was on the floor. Resident stated they were going to restroom and fell . At this time noticed an small abrasion on left side of resident forehead . -10/1/17 at 10:10 AM: Left wrist [MEDICAL CONDITION] resident c/o pain x 1 [MEDICATION NAME] given but not too effective per resident, MD phoned made aware stat X-ray ordered . -10/1/17 at 10:57 AM: Noted left wrist wrapped with ace wrap for support for resident . awaiting stat X-ray to be done -10/1/17 at 12:41 PM: Stat X-ray completed per order . -10/1/17 at 3:27 PM: . Results for left wrist X-ray still pending -10/1/17 at 5:18 PM: X-ray results faxed in NP notified via phone findings vertical slightly displaced fracture with minimally sclerotic margins, new orders to send to ER . (Ambulance) notified for transfer to emergency room (ER) -10/1/17 at 5:35 PM: Transported via stretcher x 2 attendants . -10/2/17 at 9:17 AM: Per nurse, resident returned to facility via ambulance at about 3:40 AM this morning. Radiology documentation was not present within Resident #703's medical record. On 10/31/17 at 4:30 PM, the DON provided printed Post Fall Observation documentation for Resident #703. An interview and record review was completed at this time. When queried regarding why the documentation was not completed on a Unusual Occurrence Report form as the provided fall incidents were, the DON replied, It should have been. Review of Post Fall Observation documentation at this time indicated the Resident was going to use the restroom and fell within their room. The report further revealed Resident #703 was wearing socks-regular at the time of the fall and had a bed alarm in place. The report indicated the Resident had a small abrasion on left side of forehead as a result of fall. No documentation was included of neurological assessment and/or monitoring. When queried regarding Resident #703's care plan including an intervention for a chair alarm but not having an chair alarm in place, the DON stated, We decided to discontinue the alarms in an IDT meeting. There should be a note. Record review with the DON at this time revealed the following documentation dated 10/2/17 at 5:49 PM, IDT rounds s/p fall on 10/01/17 at about 4:40 AM. Resident fell trying to toilet himself. Call light was within reach but was not activated. IDT recommends to change resident's room close/across the nurse station. Alarm will also be discontinued. When queried what alarm was to be discontinued, the bed or the chair, the DON did not respond. When asked why the Resident's care plans were not updated, the DON did not provide an explanation. When queried regarding footwear to prevent falls and Resident #703 observed not wearing slip resistant footwear and slip resistant footwear being included on the Resident's care plan, the DON did not provide an explanation. When queried regarding the Resident falling on 10/1/17 and the timeline between the fall at approximately 4:40 AM and not being transferred to the hospital for treatment until 5:35 PM, the DON indicated the facility was waiting for the X-Ray results. When queried regarding the acceptable length of time to receive STAT results, the DON did not provide a response. When asked where the radiology report of the Resident's fractured arm, the DON replied, I can call the company and see if they could send it. When asked why the record was not present in the facility, the DON did not provide an explanation. When queried again regarding neurological assessment documentation for Resident #703, the DON stated, We haven't found anything. When queried if neurological assessments were not documented, the DON replied, We can't find any. No further explanation was provided. Record review of facility policy entitled, Change in a Resident's condition (Dated 6/1/16) on 10/31/17 at 5:35 PM revealed, The Nurse Supervisor/Charge Nurse will notify the Resident's Attending Physician or On-Call Physician when there has been: An accident or incident involving the Resident; . A significant change in the Resident's physical/emotional/mental condition; . A need to transfer the Resident to a hospital/treatment center . The policy further revealed, A significant change of condition is a decline or improvement in the Resident's status that: Will not normally resolve itself without intervention by staff . Impacts more than one area of the Resident's health status .The Nurse Supervisor/Charge Nurse will record in the Resident's medical record information relative to changes in the Resident's medical/mental condition or status. On 10/31/17 at 5:40 PM, record review of facility policy entitled, Neurological Assessment (Revised 8/1/16) revealed, 9. Perform neurological checks with the frequency as ordered or per falls protocol. 10. Determine Resident's orientation to time, place and person. 11. Observe Resident's patterns of speech and speech clarity . 13. Check pupil reaction . 14. Determine motor ability . 15. Determine sensation in extremities .16. Check gag reflex . 18. Check eye opening, verbal and motor response using the Glasgow Coma Scale. The policy further indicated, The following information should be recorded in the Resident's medical record: The date and time the procedure was performed . All assessment data obtained . Notify the physician of any change in a Resident's neurological status. Record review on 10/31/17 at 5:45 PM of facility policy entitled, Falls - Clinical Protocol (6/1/16) revealed, The nurse shall assess and document/report the following: vital signs, recent injury especially fracture or head injury, musculoskeletal function ., change in cognition ., neurological status, pain, frequency and number of falls since last physician visit, precipitating factors, details on how fall occurred . The policy further indicated, The staff and physician will continue to collect and escalate information until ether the cause of the falling is identified, or it is determined that the cause cannot be found . Based on the preceding assessment, the staff and physicians will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling . If an individual continues to fall, the staff and physician will reevaluate the situation and consider other possible reasons . and will reevaluate the continued relevance of current interventions.

This Citation Pertains to Intake Number MI 965. Based on observation, interview and record review, the facility failed to provide assessed levels of assistance, ensure application of interventions and monitoring, operationalize policies and procedures related to documentation and investigation for change in condition for one (# 701) of three Residents reviewed for appropriate care, assessment and monitoring, of a total sample of three, resulting in lack of monitoring, assessment, documentation, investigation, and delay in emergency treatment for [REDACTED]. Findings include: Record review on 10/31/17 at 9:10 AM revealed Resident #701 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform Activities of Daily Living (ADL's). On 10/31/17 at 9:20 AM, an interview was conducted with Resident #701. When queried if they had fallen at the facility, Resident #701 stated, Yes, my daughter thought it was a nurse that took me into the bathroom but I think it was an aide. I didn't even have a gait belt on. They (staff) told my daughter I didn't hit my head when I fell . Well I didn't hit the back of my head I hit the side of my head. Resident #701 then stated, They didn't call the hospital. When I did go to the hospital, they said I had a stroke. Record review of Resident #701's medical record on 10/31/17 at 10:15 AM revealed the following: -Nursing Progress Note by Nurse F, Dated 9/22/17 at 11:23 AM: Resident had a witnessed fall by (Nurse B) but could not get to (the Resident) fast enough. (Resident #701) was trying to get back to their chair after using the restroom. No injuries noted at this time. Resident denies being in any pain. ROM (Range of Motion) WNL (Within Normal Limits). Call light in reach. (Family member) and (Physician) called and notified of fall . -Nursing Progress Note by Nurse F, Dated 9/22/17 at 6:44 PM: Resident has a bruise to her left eye, no c/o pain noted. Neuro checks initiated. -Nursing Progress Note by Nurse E, Dated 9/23/17 at 3:02 AM: Resident had fall at 10:45 AM this morning. Resident has no c/o pain or discomfort. Neuro checks on-going WNL, VSS. Resident is alert and oriented and voiced she is fine. Resident used call bell for assistance toileting. Safety maintained, call light within reach. Wellness checks every hour this shift. -Nursing Progress Note by Nurse H, Dated 9/23/17 at 1:09 PM: Resident was receiving ADL care this morning (getting dressed) when resident c/o pain to left arm. Cena (Nursing Assistant) reported findings to writer. Writer immediately performed passive ROM to bilateral upper and lower extremities. No level of difficulty observed except when resident was asked to extend left arm up toward head. Resident stated arm was hurting from left shoulder down to left hand. Writer asked her pain level and (the Resident) stated it was 5.5/10. Writer also observed some swelling to residents left humerus region. Writer offered resident pain medication and ice/heat treatment but resident declined at the time. Writer also observed purplish bruising to residents left orbital region. Resident did not c/o pain to left eye at the time and denied blurry or double vision. Pupils were equal and reactive to light with neuro checks still in effect. No slurring or difficulty with speech observed during assessment . Writer contacted doctor to report residents condition. Doctor stated that since resident has known bleeding condition to send to (ER) . Ambulance arrived at approximately 12 PM . Neurological assessment documentation was not located within Resident #701's medical record. Review of Resident #701's care plans at this time revealed care plans entitled, Falls (Start Date: 7/1/17, Edited: 9/25/17) and ADL Functional / Rehabilitation Potential (Start Date: 7/1/17, Edited: 10/10/17). Fall care plan interventions included: -Keep call light in reach at all times. (Start Date: 7/1/17) -Provide toileting assistance x 1 assist, as needed. (Start Date: 7/1/17, Edited: 7/13/17) -Give resident verbal reminders not to transfer without assistance. (Start Date: 7/1/17) -Offer assistance to bathroom after breakfast. (Start Date: 9/22/17, Edited: 9/25/17) ADL Functional / Rehabilitation Potential care plan interventions included: -Ambulation: x 1 assist with walker. (Start Date: 7/13/17) -HYGIENE / ORAL CARE: 1 person assist (Start Date: 7/1/17) -DRESSING: 1 person assist (Start Date: 7/1/17) -TOILETING: x 1 assist (Start Date: 7/1/17, Edited: 7/13/17) -TRANSFER: x 1 assist. (Start Date: 7/1/17, Edited: 7/13/17) Record review of facility provided Incident Report authored by Nurse F entitled, Unusual Occurrence Report dated 9/22/17 at 10:45 AM revealed the following: -What was Resident doing before incident? Leaving the restroom - What preventative devices were in place prior to incident? N/A -Describe the incident based in Resident's own words or what the first responder observed: Trying to back to chair from wheelchair. -Nature of Occurrence: Fall -Intervention: Offer assistance to bathroom after meals. Documentation on the Unusual Occurrence Report stipulated, While walking past Resident's room. Resident was walking out restroom with walker. (Resident #701) began to stumble, I immediately rushed in, I could not catch her fall. (Resident #701) fell on her bottom. No injuries. The Unusual Occurrence Report revealed Resident #701's physician was notified of the Resident's fall on 9/22/17 at 11:06 AM. The provided Unusual Occurrence Report also included paper documentation of neurologic checks for Resident #701. The neurological check form indicated monitoring began on 9/22/17 and included assessment of pupil reaction and abnormal findings. The neurological assessment form indicated no abnormal findings were noted by nursing staff. Record review of facility provided Investigative Employee Interview Form, signed and dated by Nurse F on 9/30/17 occurred at this time. The Investigative Employee Interview Form revealed the following timeline for 9/22/17: -10:30 AM: (Nurse B) notified (Nurse F) that they observed (Resident #701) fall in their room . -10:45 AM: (Nurse F) rounded on Resident. Resident C/O (complain of) pain to LUE (Left Upper Extremity). Neuro checks started due to pain. Vital signs WNL (Within Normal Limits), Pupils equal * reactive, orientation A & O X 3 (person, place, and time), speech WNL. -11:06: (Physician) notified of fall and assessment. No new orders. -4:00 PM: Discoloration observed to outside of left eye. (Witness A) contacted (Nurse F) and stated they spoke to Resident on phone and thought Resident was slurring words . (Nurse F) went to check on Resident. Speech was normal . The Unusual Occurrence Report documentation also included a Conclusion statement, dated 9/27/17 and authored by the DON. Review of the conclusion statement at this time revealed, On 9/22/17, Resident has a fall at about 10:30 AM while returning from bathroom. Resident stated call light was within reach but they did not call for assistance because (the Resident) didn't think they need help to go to the bathroom. Resident was educated to always call for assistance even it means just a standby. Resident denied hitting their head initially after fall but on the 23rd per nurses notes, a discoloration was observed to Resident's left eye. Which was assessed and per nurses note, Resident denies blurred vision or double vision. Resident stated that they think they hit their face on their walker when they fell and that must be where the discoloration came from. Assessing neuro-checks, no changes were observed. (Resident family member) also stated they think Resident was having some slurred speech which all through, nurses assessed Resident and found no slurred speech. There was no acute change in condition until Resident stated they had left sided pain. (Physician) was noted about the discoloration to Resident's eye Resident should be sent to hospital because of know factor V history. New intervention in place to offer toilet to Resident after lunch to prevent further falls. Record review on 10/31/17 at 11:45 AM of Resident #701's hospital medical records revealed a CT scan of the brain, dated 9/23/17 at 1:14 PM that indicated the Resident suffered a Lacunar infarction right thalamus (Stroke in deep area of brain). An interview was completed with Nurse B on 10/31/17 at 12:00 PM. When queried regarding Resident #701's fall within the facility on 9/22/17, Nurse B stated, I was just walking by the room when I saw (the Resident) stumbling. They had their walker. With further inquiry, Nurse B stated, (Resident #701) fell to the left into the closet dresser. They went all the way down to the floor. When asked if there were any other staff present in the room or if the Resident's call light was on, Nurse B replied, There wasn't anyone in the room with (the Resident) and the call light wasn't on. When asked if they knew how the Resident got to the bathroom, Nurse B stated, I heard the aide (Nursing Assistant) put (the Resident) on the toilet. When queried what happened after the fall, Nurse B indicated they made sure the Resident was safe, obtained vital signs, and got assistance. Nurse B stated, I got (the Resident's) nurse. I was just walking past the room and went into help. (Resident #701) was not my assigned patient. On 10/31/17 at 1:30 PM, an interview was conducted with Nursing Assistant D. When asked if they provided care to Resident #701 on 9/22/17, Nursing Assistant D indicated they were unsure. Nursing Assistant D then reviewed facility provided Unusual Occurrence Report and stated, Yep, I remember. I was (Resident #701's) aide (Nursing Assistant). When asked how the Resident got to the bathroom, Nursing Assistant D stated, I helped (the Resident) to the bathroom. I got (Resident #701) set up to brush their teeth. (Resident #701) was pretty much done and I asked them if they were okay. (The Resident) said yes. I left to take out laundry. I had their wheelchair set up. When I came back, (Resident #701) was on the floor by the dresser/closet thing in their room. Nursing Assistant D then stated, Later that day, (Resident #701) had a bruise that showed up on their eye. When queried regarding the Resident's chair being set up, Nursing Assistant D stated, Yep, by (Resident #701's) bed so they could go back and sit down. It was locked and everything. (The Resident) had there walker. When queried further regarding Resident #701's location when they left the room, Nursing Assistant D replied, (Resident #701) was right by the sink standing with their walker. They were finishing up. I just left out of there. When asked if the Resident's call light was in reach, Nursing Assistant D stated, No. With further inquiry, Nursing Assistant D stated, The call lights in the bathrooms are on the other side of the toilet. They don't reach the sink. Nursing Assistant D then revealed, (Resident #701) said they felt dizzy all of a sudden (when they fell ). When asked what level of assistance Resident #701 required from staff, Nursing Assistant D replied, They did pretty good. On 10/31/17 at 1:45 PM, an interview was completed with the DON, when queried regarding documentation of neurological assessment in the Resident's medical record. The DON reviewed the medical record and stated, It is just the form. When queried regarding Resident #701's activity order and level of staff assistant required to perform ADL's, the DON replied, They did good. Didn't need much help. Resident #701's medical record including orders and fall care plan was reviewed with the DON at this time. An activity order was not noted within the medical record. When queried how staff are aware of the level of assistance required by Residents, the DON stated, It's on the report they (staff) get. I will get it for you. On 10/31/17 at 2:00 PM, observation occurred of Resident #701's bathroom within the facility. Observation revealed the call light was positioned near the toilet and unable to be reached when standing at the sink. On 10/31/17 at 2:30 PM, an interview was conducted with Family Member Witness A. When queried regarding Resident #701, Witness A stated, We got a call (Resident #701) fell on the 22nd (9/22/17) but they (facility staff) told me that (the Resident) didn't hit their head. I called (Resident #701) and they were slurring their words so I called the nurses stated and the nurse said they were going to evaluate (the Resident). I sent a friend up to the facility to check on (Resident #701) and the friend called me and said (the Resident) was slurring their words and that there was something wrong with (Resident #701's) left arm. So I called at 8:00 PM and talked to (Nurse E) who said 'I've done everything I need to do' and then told me they would call the Director of Nursing (DON). I said I wanted (Resident #701) to go to the hospital. Witness A proceeded to state, When I called the next day, (Resident #701) was still slurring their words. I insisted they send (the Resident) to the ER (emergency room ). I guess when they (facility staff) said they would be evaluating (the Resident), it didn't mean send them to the ER. I met the Resident at the ER and (the Resident) had a huge black eye and couldn't use their left arm. I was told (the Resident) didn't hit their head and I feel like they (facility) didn't do anything. I talked to the DON who said they were never notified. Then I talked to the Doctor and they said they didn't know either. The Doctor said they would have just said to send (the Resident) out if they would have known they hit their head especially since (Resident #701) has that clotting disorder. An interview and record review of Resident #701's Profile Care Plan Approaches was completed with the DON on 10/31/17 at 2:40 PM. Review of provided Profile Care Plan Approaches indicated the Resident required the assistance of one staff member with dressing, hygiene, oral care, toileting, transferring, and ambulation (7/1/17 was listed start date for interventions). When queried if level of care interventions were active on 9/22/17 when Resident #701 fell , the DON replied, Yes. When queried regarding interventions following the Resident's fall, the DON replied, We had an IDT meeting. There should be a note. Record review of the Resident's medical record at this time revealed a note dated 9/25/17 at 10:00 AM that stated, IDT rounds on 9/25/17 s/p (status [REDACTED]. Resident did not use call light for assistance to the bathroom and fell while returning. Call light was within reach. IDT recommends offer to toilet resident after breakfast. To implement on return from hospital with further assessment. When asked why Resident #701 was left alone in the bathroom standing at the sink with their walker, the DON stated, I don't recall that. With further inquiry regarding why the facility investigation did not include a statement from Nursing Assistant D, who was assigned to provide care to the Resident on the day of the fall, and why the investigation did not indicate the Resident was assisted to the bathroom by staff and left unattended, the DON stated, I don't think (Nursing Assistant D) knows what they are talking about. With inquiry pertaining to if the investigation included the events leading up to the fall, The DON replied, (The Resident) was coming out of the bathroom. It was never mentioned. When asked if the Resident should have been left alone in the bathroom, the DON stated, They would have had their call light. With inquiry regarding the call light not reaching the sink where the Resident was standing with their walker, the DON went to the Resident's bathroom, returned and stated, You're right. It won't reach. With further inquiry, the DON stated, No, (Resident #701) should not have been left alone in the bathroom. With additional inquiry regarding the intervention added to Resident #701's care plan on 9/22/17 to Offer assistance to bathroom after breakfast when the Resident had been assisted to the bathroom and the investigation completed by the facility, the DON stated, I'm flabbergasted. I did not know the CENA (Nursing Assistant) took (the Resident) to the bathroom. No further explanation was provided. At 2:45 PM on 10/31/17, a record review of facility provided Investigative Employee Interview Form, signed and dated by Nurse E on 9/23/17 was completed. The Investigative Employee Interview Form indicated an interview was completed by the facility Staff G on 9/23/17 at 4:45 PM and included a timeline for assigned shift on 9/22/17 (7P-7A shift). Documentation on the Investigative Employee Interview Form indicated Nurse E called the DON and left a voicemail regarding Resident #701 and Witness A concerns at 8:00 PM on 9/22/17. Investigative Employee Interview Form further revealed the DON did not return call. On 10/31/17 at 4:45 PM, an interview was completed with the DON. When queried regarding Resident #701's representative requesting the Resident be transferred, the DON stated, The family was saying there were issues and wanted (Resident #701) transferred if they were slurring their words. The family did not demand (the Resident) be transferred. The nursing staff did not see anything or any reason to transfer (the Resident). With further inquiry the Resident being transferred the following day, the Administrator stated, Better safe than sorry. When asked, the DON stated, I was in contact with the staff about the Resident and aware of the situation. When asked about documentation on the Investigative Employee Interview Form, signed and dated by Nurse E on 9/23/17, which indicated the Nurse left a voicemail for the DON at 8:00 PM and did not receive a return phone call, the DON stated, I don't know. When queried why Resident #701 was not transferred for evaluation and medical treatment when the Resident complained of pain in left arm at 9/22/17 at 10:45 AM and/or when a bruise was observed on the Resident's left eye on 9/22/17 at 4:00 PM, the DON stated, We (facility staff) did not feel it was necessary. With further inquiry regarding the Resident's known history of a clotting disorder causing excessive bleeding, the DON stated, That is why we decided to send (the Resident) the next day. With inquiry regarding documentation of neurological assessments and facility policy, the DON replied, That is the form we use. No further explanation was provided. Record review of facility policy entitled, Change in a Resident's condition (Dated 6/1/16) on 10/31/17 at 5:35 PM revealed, The Nurse Supervisor/Charge Nurse will notify the Resident's Attending Physician or On-Call Physician when there has been: An accident or incident involving the Resident; . A significant change in the Resident's physical/emotional/mental condition; . A need to transfer the Resident to a hospital/treatment center . The policy further revealed, A significant change of condition is a decline or improvement in the Resident's status that: Will not normally resolve itself without intervention by staff . Impacts more than one area of the Resident's health status .The Nurse Supervisor/Charge Nurse will record in the Resident's medical record informaiton relative to changes in the Resident's medical/mental condition or status. On 10/31/17 at 5:40 PM, record review of facility policy entitled, Neurological Assessment (Revised 8/1/16) revealed, 9. Perform neurological checks with the frequency as ordered or per falls protocol. 10. Determine Resident's orientation to time, place and person. 11. Observe Resident's patterns of speech and speech clarity . 13. Check pupil reaction . 14. Determine motor ability . 15. Determine sensation in extremities .16. Check gag reflex . 18. Check eye opening, verbal and motor response using the Glasgow Coma Scale. The policy further indicated, The following information should be recorded in the Resident's medical record: The date and time the procedure was performed . All assessment data obtained . Notify the physician of any change in a Resident's neurological status. Record review on 10/31/17 at 5:45 PM of facility policy entitled, Falls - Clinical Protocol (6/1/16) revealed, The nurse shall assess and document/report the following: vital signs, recent injury especially fracture or head injury, musculoskeletal function ., change in cognition ., neurological status, pain, frequency and number of falls since last physician visit, precipitating factors, details on how fall occurred . The policy further indicated, The staff and physician will continue to collect and escalate information until ether the cause of the falling is identified, or it is determined that the cause cannot be found . Based on the preceding assessment, the staff and physicians will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling . If an individual continues to fall, the staff and physician will reevaluate the situation and consider other possible reasons . and will reevaluate the continued relevance of current interventions.

Based on interview and record review, the facility failed to prevent the resident's head from being entrapped between the enabler bar and air mattress for 1 (#702) of 1 resident reviewed for accidents from a total sample of 10, resulting in strangulation, emergency hospitalization and an Immediate Jeopardy (IJ) to the health and safety of the resident. The IJ was identified on 9/2/17 at 1:10 a.m., per nurse's note when the resident was found on floor and head between assist bar and mattress, knees on floor. In the absence of the Administrator, the Director of Nursing (DON) was notified of the Immediate Jeopardy on 10/10/17 at 4:25 p.m. A plan of correction was requested to remove the immediacy. The IJ was removed on 10/11/17 at 11:41 a.m. based on the facility's implementation of the plan removal as verified onsite. Although the IJ was removed, the facility's deficient practice remains as isolated. Actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: On 10/9/17 at 10:00 a.m., during the initial tour, Resident #702 was observed lying in bed asleep in a low positioned bed. Bilateral fall mats were noted on the floor on both sides of the bed. On 10/10/17 at 12:45 p.m., Resident #702's nurses' notes were reviewed and revealed that two falls from the bed had occurred within 48 hours. The first fall occurred on 9/1/17 at 9:40 p.m. The nurse's note dated 9/2/17 at 12:39 a.m., authored by the assigned nurse (G), revealed the following documentation: At 9:40 p.m. Resident was observed on the floor via Certified Nursing Assistant ( CNA) K. CNA K came and informed me of resident on the floor. Resident stated he was rolling over in bed, and bumped his head on the assist (enabler) bar leading assist bar to fall down and pt sliding onto floor .No new skin and motor changes observed. Exchanged bed with working assist bar to prevent pt from sliding out of bed .No new orders at this time. The Unusual Occurrence Report, dated 9/1/17 at 9:40 p.m., revealed the following documentation: Resident stated he rolled over and assistant bar (enabler bar) fell down and he rolled out of bed. The form further revealed documentation that the bed was changed out - checked assist bars/in place. The second fall occurred on On 9/2/17 at 1:10 a.m., review of a nurse's note, dated 9/2/17 at 2:42 a.m., authored by Nurse G, for Resident #702 revealed the following documentation: At 1:10 a.m. CNA (certified nursing assistant J) went into room to check on resident and observed him on floor and head between assist bar and mattress. Knees on floor. Removed head and noticed welp (welt) on left cheek. Denies pain at this time .Resident stated mattress was slippery. At this time put foam wedge on both sides of resident . Per the Unusual Occurrence Report document, CNA J was identified as the witness or First Responder. The Interdisciplinary Post Fall Review Form, undated, document revealed, Rolled over, slid out of bed, Resident state mattress is slippery. Re-opened area on right arm, mark on left cheek. Conditions that may contribute: air mattress. Per a nurses note dated 9/2/17 at 10:04 a.m., Resident #702 was sent to the hospital hours later. The nurse's note revealed the following documentation: Transported at 8:35 a.m. via stretcher X 2 attendants to local hospital per order. On 9/3/17 Resident #702 returned from the hospital. The nurse's note dated 9/3/17 at 7:45 p.m., revealed the following documentation: Resident arrived at 7:25 p.m. via the ambulance with 2 EMTs (Emergency Medical Technicians), taken to room .Assessment done at this time. Multiple bruises noted on upper extremities . On 10/10/17 at 1:15 p.m., an attempt to contact the assigned midnight shift CNA (J) via phone was made. There was no answer. A message was left for a return phone call. On 10/10/17 at 1:25 p.m., Resident #702 was interviewed regarding the second fall. Resident #702 stated, I got trapped in there (pointing near the edge of the mattress). There were no enabler/assist bars attached to the bed at this time. Resident #702 further stated, There were bars there. My call button was on the floor. I could not get to it. A nurse came by and saw me. My head was jammed in there. My shoulders and leg were also jammed. I couldn't move or get out. I don't know how they got me out. They sent me to the hospital. My left hip now bothers me. My right side was trapped. I also have a sore jaw now. I could not get to the call button. On 10/10/17 at 1:40 p.m., record review revealed that Resident #702's was admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 9/15/17, indicated a moderately impaired cognition and the requirement of extensive assistance with ADLs with the assistance of two people. On 10/10/17 at 1:53 p.m., the Director of Nursing (DON) was queried regarding an investigation for Resident #702's second fall from the bed. The DON stated, There was no investigation. He was sent to the hospital. We took the bars off his bed. We are in the process of removing all of the bars from the beds. When asked if there were measurements done prior to the application of the bars, the DON reported not being sure. The DON stated, I am not sure of space measurements. When asked if an assessment and care plan were developed for the use of the bars, the DON replied, No. On 10/11/17 at 12:25 p.m., The DON was interviewed regarding the Quality Assurance (QA) process regarding the incident with the enabler bars and mattress. The DON stated, I switched the mattress. It was the air loss mattress. We did not identify it as a concern because we knew how it happened. It was the air mattress. The position of the mattress fluctuates when you change positions in bed. The air mattress is not stationary or still as it moves based on how a resident repositions. On 10/12/17 at 5:46 p.m., CNA J (witness/first responder) was interviewed regarding the second fall. CNA J stated, I was heading towards the front of the hall when I peeped into his room (#702). I peeped in because he had a fall earlier that night. When I looked into the room I did not see his legs. I saw his face positioned downward between the bar and mattress and he was on his knees. He was on the right side of the bed. The side closest to the door. His head was between the mattress and rail .face was head down. He said he yelled for someone. His right arm, the one that works, was on the mattress. His left side does not work because he had a stroke. He was just laying there. His left side was on the ground. He was on his knees. I thought he was dead. I yelled and said his head was stuck. His nurse (Nurse G) saw this. I could not get him alone. I thought he was dead, period. He (Resident #702) will tell you that incident really bothered me. He said I saved his life. He always says to me thanks for finding me. On 10/13/17 at 1:40 p.m., review of the facility's policy titled Bed Safety, dated 7/1/16, revealed the following documentation: Our facility will strive to provide a safe sleeping environment for the resident. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, and foot accessories), the facility will promote the following approaches: Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review will consider situations that could be caused by the resident's weight, movement or bed position). Copies of the inspection results and QA Committee recommendations will be maintained by the Administrator and/or Safety Committee. The staff will report to the DON and Administrator any deaths, serious illnesses and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The Administrator will ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. The facility submitted plan of correction: Resident #702 is a [AGE] year old gentleman admitted on [DATE] to Lakeside Manor for rehab. He has [DIAGNOSES REDACTED]. Dysphasia, chronic[DIAGNOSES REDACTED], [DIAGNOSES REDACTED], cardio [DIAGNOSES REDACTED], weakness and chronic kidney disease stage III. Resident is on enteral feeding for nutritional needs. Low air mattress was in place in place upon admission related to all the co morbidities and at risk for skin alterations per IDT teams recommendation. Resident #702 had an incident in which he was entrapped between the mobility bar and the air mattress on 09/02/17 as described by the charged nurse. The nurse and the CNA immediately removed him from harm. The resident was assessed for any physical injury and pain. The resident denied pain at that time. No injury was noted. The physician and family were notified. The physician ordered the nurse to send the resident to the hospital on [DATE] for further evaluation. The IDT team met and investigated the cause of the incident on 09/02/17. The resident was on a rental mattress since admitted d 06/03/17. Facility purchased a brand new air loss mattress on 09/02/17 as swapped it with the rental mattress. The inhouse new air loss mattress was determined to be faulty by the IDT team on 09/02/17. The new air loss mattress on the resident's bed was not fitting correctly on the bed frame causing him to slip out of the bed. The facility immediately removed the newly purchased air loss mattress for any further use and has placed it in the lock out. This was a single purchased mattress by this facility. The mobility bars were also removed per therapy screen for safety in bed. Resident # 702 returned to the facility from the hospital on [DATE]. He continues to reside in the facility and is safe. The IDT team determined the placement of the wedge mattress prevents sliding out of bed. On 10/10/17 all other residents in the facility with current mobility bars and mattresses were evaluated by the Nursing and Therapy team for risk of getting entrapped in the gap between assist bars and mattresses. All 66 mattresses were measured and were deemed appropriate for fitting in the bed frame on 10/10/17. Therapy team screened all resident with mobility bars for their appropriateness and use. All care plans of like residents were reviewed and updated. Policy for proper use of Mobility Bars as it relates to the mattresses were reviewed and deemed appropriate on 10/10/17. Facility staff was educated on 10/10/17 on this policy in particular, assessment, and mobility bar, mattress fitting to bed frame and entrapment to prevent any future incidents. All rental/purchased equipment will be assessed by the IDT team before issuing to a resident for use for safety, fitting and compatibility. Weekly audits for 4 weeks will be conducted by the DON/Designee for conformance to bed system entrapment zones. Results will be discussed in the QAPI monthly for 3 months. The Medical Director has been notified. QA is in progress. The Administrator will sustain compliance on 10/10/17.

Based on observation, interview and record review, the facility failed to perform/document weekly skin assessments, measurements and/or obtain a consult for a pressure ulcer (PU) in a timely manner, for two (#s 701 and 702) of three sampled residents reviewed for pressure ulcers, from a total sample of 12, resulting in the potential for untreated, worsening, and the potential development of additional facility acquired pressure ulcers. Findings include: On 10/9/17 at 11:40 a.m., the Director of Nursing (DON) was queried regarding the Weekly Skin Assessments for Resident #702. The DON reported the PU for Resident #702 as being Community Acquired. The Weekly Skin Assessments were requested at this time. On 10/9/17 at 1:20 p.m., a wound observations was conducted. Nurse I was observed treating Resident #702's coccyx PU. The wound bed was pink. Scant amounts of yellow slough was noted. The PU was cleansed with normal saline, santyl (wound debridement), and a dry dressing was applied. On 10/9/17 at 3:40 p.m., Resident #702's Weekly Skin Assessments were reviewed. The MDS Nurse provided a total of three Weekly Skin Assessments for the resident's entire stay at the facility. The Weekly Skin Assessments were dated for 8/18/17, 9/4/17, and 9/15/17. The Weekly Skin Assessment, dated for 8/18/17 indicated Redness on buttocks and scrotal area. The Weekly Skin Assessment, dated 9/4/17 (first day after re-admission), indicated Bruises to bilateral arms. There was no mention of a PU. Although, Nurse G authored a note on 9/3/17 at 9:59 p.m., that included the following documentation: Turning resident every two hours at this time due to coccyx ulcer . There were no measurements or description of the wound. The Weekly Skin Assessment, dated 9/15/17, indicated Pressure Ulcer - coccyx. There were no measurements or description of the PU in the nurses' note nor on the form. Review of the physician's orders [REDACTED]. Special Instructions: Open area to coccyx. The documentation is inconsistent with the Weekly Skin Assessment, dated 8/18/17, that only documented redness to Resident #702's buttocks and scrotal area. The wound consult was not done until 9/10/17. Per the wound consult: Pressure ulcer, stage II, coccyx, 1.3 centimeters (cm) x 0.7 cm x 0.4 cm in depth. Periwound borders are regular. 100% granulation tissue at the base .Scant amount of serosanguineous drainage. The second wound consult was not done until 9/24/17. The following documentation was noted: Pressure ulcer, stage II, coccyx, 0.9 cm x 0.6 cm x 0.3 . On 10/9/17 at 4:47 p.m., the DON was queried regarding documentation of wound notes that included the measurements and descriptions of the PU. The DON reported the wound consultation notes had the measurements and descriptions of the PU. The DON further stated, The Nurse Practioner is the only person that does measurements of the wound. They should be done weekly. The DON had no explanation as to why the coccyx wound was only measured two times. When asked when the PU developed, the DON reported not knowing. When asked if a system was in place for tracking PU, such as weekly updates, the DON stated, No. The DON confirmed the last wound measurements for Resident #702's coccyx PU was on 9/24/17. There was no explanation for the delay for the wound consult. On 10/10/17 at 9:15 a.m., the Director of Nurses (DON) was queried regarding the onset date of the Resident #702's PU. The DON presented a nurse's note with documentation of the pressure ulcer, dated 9/8/17 at 3:03 p.m., that read, Nsg notes still indicate open area to sacrum and orders remain. The DON reported that this was the first notation of the PU since Resident #702 was readmitted back to the facility on [DATE]. Review of the admission skin assessment, dated 9/3/17, did not indicated a PU. On 10/10/17 at 1:40 p.m., review of Resident #702's clinical record revealed the following: The face sheet revealed an admission into the facility on [DATE] and a re-admission on 9/3/17 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 9/15/17, indicated a moderately impaired cognition and the requirement of extensive assistance with ADLs with the assistance of two people. It also indicated that Resident #702 had a stage II pressure ulcer (PU). The measurements were not documented on the MDS. Resident #702's admission MDS assessment, dated 6/16/17, indicated there was no PU present at the time of admission into the facility. The current physician's orders [REDACTED]. Weekly Skin Assessment, once a day on Friday 07:00 a.m. - 07:00 p.m. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Special instructions. Cleanse open area to coccyx with saline solution, cover with 4 x 4 tape daily . A physician's orders [REDACTED]. An order was written on 10/1/17 for Santyl ([MEDICATION NAME] agent) ointment; 250 unit/gram; amount to administer: topical to coccyx; topical. On 10/11/17 at 12:20 p.m., during the Quality Assurance (QA) review with the DON, the lack of Weekly Skin Assessment and Weekly Skin Notes were mentioned. The DON reported there was a break in the facility's system for pressure ulcers and further stated, I decided we are not going to use that Nurse Practioner anymore. We wanted one person to do the measurements . On 10/9/17 at 10:30 AM a review of Resident #701's medical record revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment revealed intact cognition. Further review of the medical record revealed that the resident was admitted into the facility with a Stage II pressure ulcer on the left hip area. No documentation of the measurement of the pressure ulcer was found in the electronic medical record. A review of the Resident's care plan for Pressure Ulcer, dated 9/29/17, with an approach that stated, Assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization weekly. On 10/9/17 at 12:30 PM, the Director of Nursing was queried regarding the wound measurements for Resident #701 and the progression of the wound healing or worsening. The DON stated, The wound specialist would have that information and I am waiting for them to fax over that information. When queried if the Nursing staff measures the wound, the DON replied, The wound specialist would do that when they see the Resident. On 10/9/17 at 4:20 PM, the DON was queried again about the wound measurements for Resident #701 and stated, There is none. That is something that was missed. The Resident is not followed by wound care specialist. When queried if the Nursing staff had measured the wound, the DON stated, There is no measurements. On 10/10/17 at 8:30 AM, Nurse B, who was assigned to Resident #701 and had done dressing changes on the pressure wound to the Resident's left hip, was queried. When queried about the progression of the wound, Nurse B stated, It's doing fair. When queried about the need of doing measurements on a wound, Nurse B stated, I did not on (Resident #701). Usually we try to do measurements. I am not going to lie, we should be doing them but I did not do them on (Resident #701). On 10/10/17 at 11:05 AM, Nurse C was queried regarding the Resident #701's pressure wound to the left hip. Nurse C stated, I had measured it yesterday and called the Doctor. It is on the left hip, open and superficial. 8 cm (centimeters) by 1.6 cm and no depth that could be measured really. I changed the dressing yesterday to a duoderm (a [MEDICATION NAME] dressing to treat pressure sores) that needs to be changed every three days. It was silver and the Doctor said to change it to the duoderm. An observation was made of Resident #701's left buttock/hip pressure wound covered by a duoderm that was clean and intact and had a quarter sized whitened area where moisture from the wound bed was discoloring the dressing.