Every finding on record at Lakeview Manor Healthcare Center

Based on observation, interview and record review, the facility failed to ensure proper storage of respiratory equipment (BiPAP, nebulizer treatment mask and nasal cannula) for 3 residents (#14, #25, and #27) of 3 residents reviewed for respiratory equipment. Findings Include: Resident #25 On 5/11/26 at 11:37 AM, Resident #25 was observed in their room, sitting in a wheelchair. A nebulizer machine was present on the dresser beside the Resident's bed. The administration set of the nebulizer was connected and uncontained with visible fluid present in the medication chamber. An interview was completed at this time. When queried regarding the nebulizer machine and treatments, Resident #25 stated, Do daily in the morning. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), cerebral infarction (stroke) with resulting right sided hemiplegia and hemiparalysis (one-sided paralysis) and aphasia (difficulty communicating). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required set up to total assistance to complete Activities of Daily Living (ADLs). Resident #27 On 5/11/26 at 10:42 AM, Resident #27 was observed in their room in bed with their eyes closed. A nebulizer machine was sitting on the dresser next to their bed. The administration set of the nebulizer was connected and uncontained with visible fluid present in the medication chamber. While walking in the hallway on 5/11/26 at 2:55 PM, Resident #27 was heard yelling out that they wanted their nebulizer. From the hallway, Resident #27 was heard yelling, I use it when I need it and they took it away. Registered Nurse (RN) O entered Resident #27's room and told the Resident they could not have it (nebulizer treatment) because they just had it. RN O exited Resident #27's room and walked to the Nurses' station. An interview was completed with RN O and Licensed Practical Nurse (LPN) G at this time. When queried regarding Resident #27's nebulizer treatment, RN O stated, I'm helping out on the floor and (Resident #27) is not happy with me. When asked if they were the Resident's assigned nurse, RN O revealed they were now and LPN G stated, I had (Resident #27) this morning. When asked, LPN G stated, I gave (Resident #27) their breathing treatment. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses which included CODP, psychotic disturbance, depression, and anxiety. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required set up to moderate assistance to complete ADLs. On 5/13/26 at 10:24 AM, Resident #27's nebulizer administration set was observed sitting in a bag on the dresser next to their bed. The nebulizer administration set was connected with visible fluid present in the medication administration chamber. An interview was conducted with the facility Administrator on 5/13/26 at 10:16 AM. When queried regarding facility policy/procedure related to storage of nebulizer administration equipment, the Administrator stated, Rinse and leave out to dry. The Administrator was then informed of observations of Resident #25 and Resident #27's nebulizers having visible fluid in the administration chamber. The Administrator reiterated nebulizer administration equipment should be rinsed and left out to dry following each use. No further explanation was provided. Resident #14: Review of the Face Sheet, care plans dated 2/26 through 5/26, and physician orders dated 2/26, revealed Resident #14 was [AGE] years old, alert and his own person, admitted to the facility on [DATE], dependent on staff for Activities of Daily Living/ADl's, and extremely short of breath with any exertion or excess communication. The residents diagnosis included, acute respiratory failure, panic disorder, anxiety, chronic lung disease, respiratory disorders and shortness of breath with a history of respiratory infections. The resident had a BiPAP machine with connected air piece, Respiratory nebulizer treatment mask, and nasal cannula hook up to an E-tank next to his bed. Review of the residents physician orders dated 4/2/26, revealed orders for inhalation treatments, orders for BiPAP and Nasal Cannula oxygen as needed. Observations were made on 5/11/26 (at 11:14 a.m., 12:45 p.m., and 1:15 p.m.), and on 5/12/26 (at 7:00 a.m., 9:00a.m., and 12:00 p.m.), revealed his BiPAP air piece, nebulizer treatment mask, and nasal cannula/NC hook to the E-tank all were noted to not be in a clean bag for cleanliness and to prevent cross-contamination leading to lung infections. During an interview done on 5/12/26 at 3:00 p.m., the Director of Nursing said the residents BiPAP, nebulizer mask and NC should all be in a clean storage bag when not in use and immediately got them all put in a clean storage bag. Review of the facility Use of Oxygen policy dated 2/28/25, stated The O2 cannula or mask (including treatment masks and BiPAP), when not in use, should be stored in a clean bag, bag should be changed weekly.

Based on observation, interview and record review, the facility failed to ensure timely implementation of Transmission Based Precautions (TBP) and ensure appropriate hand hygiene for one resident (Resident #58) of two residents reviewed for Infection Control (IC) resulting in a lack of immediate implementation of TBP for a resident with known positive Clostridioides difficile (C. diff- highly contagious bacterium which effects the colon, can be life threatening, and becomes a spore when outside of the body). Findings include:Resident #58: On 5/11/26 at 10:59 AM, a contact isolation sign was observed on Resident #58's room door. Certified Nursing Assistant (CNA) S was observed approaching Resident #58's room and began donning Personal Protective Equipment (PPE) without performing hand hygiene first. Family Member T approached the room while CNA S was donning PPE and asked CNA S if they needed to wear PPE to go into the room. CNA S told Family Member T they were unsure and would need to ask other staff. CNA S left the area, and an interview was completed with Family Member T. When queried if this was the first time they visited Resident #58 at the facility, Family Member T responded it was not. Family Member T revealed the Resident had been in a local hospital prior to being transferred to the facility on Saturday (5/9/26). When asked why Resident #58 was in the hospital, Family Member T disclosed Resident #58 was having severe back pain and found out they had c-diff while in the hospital. Family Member T stated, I came yesterday (5/10/26) and they told them (facility staff) that Resident #58 was positive for C-diff. Family Member T stated revealed the staff at the facility were unaware. CNA S returned at this time and informed Family Member T that they did need to wear PPE to visit the Resident. CNA S entered the room wearing a gown and gloves at this time. Family Member T proceeded to don PPE including a gown and gloves without performing hand hygiene prior to donning PPE. Family Member T opened the Resident's room door while holding their coat and a purse. Staff were present in the room and Family Member T asked if they could bring their items (coat and purse) into the room. The staff in the room were overheard saying yes and Family Member T took the items in the room and shut the door. On 5/11/26 at 11:08 AM, CNA S was observed exiting Resident #58's room. CNA S walked directly into a different resident room (Resident #10) across the hallway from Resident #58 without performing hand hygiene prior to entering Resident #10's room. CNA S was asked what they were doing and stated, You can come in, I'm just going to do oral care. CNA S was asked to step into the hallway and an interview was completed. When queried where they removed their PPE in Resident #58's room, CNA S stated, Right inside the door. CNA S was then asked where they performed hand hygiene after removing their PPE and replied, Well there really isn't anywhere in (Resident #58's room) because the sink is too far. CNA S proceeded to explain the sink was on the opposite side of the room from the door and they would need to walk through the entire room after removing PPE in order to wash their hands and there was not a hand sanitizer dispenser in the room. When asked if they were going to provide oral care to another resident (Resident #10) without performing hand hygiene, CNA S responded that they should have washed their hands before entering (Resident #10's) room and then proceeded to use hand sanitizer. When queried if hand sanitizer was effective against C-diff, CNA S indicated they did not know. Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses which included C-diff infection and diabetes mellitus.An interview was completed with IC Registered Nurse (RN) O on 5/12/26 at 11:39 AM. RN O was asked when Resident #58 was placed on TBP due to C-diff infection and replied, I came in on Monday and reviewed the antibiotic listing and seen (Resident #58) was on antibiotics. RN O revealed the Resident was receiving oral Vancomycin (strong antibiotic commonly used to treat C-diff infection) for a Urinary Tract Infection (UTI) and stated, I knew that is not normal for I UTI so I went to look and see if there was a urine culture in the chart and saw the C-diff results. RN O stated, (Resident #58) wasn't on TBP so I put (the Resident) on right away. RN O was asked to clarify if they were saying the Resident was admitted on [DATE] with a positive C-diff culture and not placed in TBP until 5/11/26, RN O confirmed. When queried regarding facility policy/procedure related to implementation of TBP, RN O revealed the admitting nurse is able to implement TBP when appropriate. When queried if they spoke to the nurse who had admitted Resident #58, RN O responded that they had not. When asked if TBP are ordered as a order in the Electronic Medical Record (EMR), RN O stated, Yes. RN O was asked why Resident #58 did not have an order for TBP. RN O reviewed the Resident's EMR and confirmed there was not an order in place for TBP. RN O stated, I missed that. When asked what staff are supposed to tell Resident #58's visitors to do with their personal items, RN O did not provide an explanation. RN O was informed of observation of Family Member T taking their personal items into the Resident's room and stated, I have to find that out still. RN O then stated, The Resident is continent and is using the bathroom. When asked if C-diff is a spore, RN O confirmed it is. RN O was then asked where staff are supposed to wash their hands after providing care and removing PPE and stated, They can use the hand sanitizer to get out the room. They can use hand sanitizer and then go wash their hands. With further inquiry regarding hand sanitizer use following care of Resident #58, RN O stated, Can use hand sanitizer if your hands are not visibly soiled. When asked if hand sanitizer is effective with C-diff, RN O stated, No. RN O was informed of observation and interview with CNA S related to lack of hand hygiene after caring for Resident #58. RN O verbalized hand hygiene needs to be completed but did not provide further explanation. An interview was completed with the facility Administrator on 5/13/26 at 10:07 AM. The Administrator was informed Resident #58 was admitted to the facility with a positive culture for C-diff on 5/9/26 and was not placed on TBP until 5/11/26 as well as observation and interview pertaining to lack of hand hygiene. The Administrator verbalized understanding of concern and indicated the nurse who had admitted the Resident was an agency nurse and would no longer be coming to the facility. Review of facility policy/procedure entitled, Multi Route Transmission Based Precautions (Revised: 11/22/22) revealed, Policy: Transmission-based precautions are the second tier of basic infection control are to be used in addition to standard precautions for residents who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Contact Precautions: Use contact precautions for residents with known or suspected infections that represent an increased risk for contact transmission. This can include. C difficile. Use PPE appropriately, including gloves and gown for all interactions that may involve contact with the resident or the residents environment. Donning PPE prior to entering the room and Doffing and properly discarding before exiting the room.

Based on interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) submission assessment data for one resident (Resident #8) of one resident reviewed. Findings include:Resident #8:Review of the facility provided CMS-802 form indicated Resident #8 was receiving Hospice Services. Record review revealed Resident #8 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart failure, dementia, major depressive disorder, and generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment completed, dated 4/10/26, designated Resident #8 was not receiving Hospice services. Review of Resident #8's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #8) is at risk for decline in condition, pain, depression, weight loss and other symptoms R/T (related to) terminal prognosis. Receives Hospice services. The care plan was created, initiated, and revised on 10/23/25. An interview was completed with Registered Nurse (RN) O on 5/11/26 at 3:00 PM. When queried regarding Resident #8, RN O stated the Resident had been on Hospice since they were admitted in October of 2025. Review of prior MDS assessments in Resident #8's EMR revealed MDS assessments submitted on 10/27/25 and 1/23/26 both indicated the Resident was receiving Hospice Services. An interview was completed with MDS RN F on 5/12/26 at 2:16 PM. When queried, RN F revealed they recently began employment at the facility. RN F was asked if they had completed Resident #8's most recent MDS assessment and responded they had. When queried if Resident #8 was receiving Hospice Services, RN F confirmed they were. RN F was then asked if Resident #8 had been discharged and readmitted to Hospice and verbalized they had not. When asked why the MDS dated [DATE] detailed the Resident was not receiving Hospice Services, RN F reviewed the Resident's EMR documentation and stated the MDS said no Hospice and should have been on Hospice . RN F verbalized made an error. An interview was completed with the facility Administrator on 5/13/26 at 10:07 AM. The Administrator was informed of Resident #8's MDS assessment specifying the Resident was not receiving Hospice services when they had been receiving Hospice services since October 2025. The Administrator verbalized understanding of the concern and indicated RN F is new the facility and MDS RN role.

Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #19) of 16 residents reviewed for Activities of Daily Living/ADL care received daily oral care and was shaven as needed. Findings Include:Resident #19: Review of the Face Sheet, care plans dated 4/3/26 through 5/13/26, and nursing notes, dated 4/26 and 5/26, revealed Resident #19 was 62 years-old, alert, admitted to the facility on [DATE], and was totally dependent on staff for all Activities of Daily Living (ADL). The resident's diagnoses included, Cerebral Palsy, other symptoms involving the musculoskeletal system, spastic quadriplegic CP, and required assistance with personal care. Observations made during the survey, revealed Resident #19 had not had any oral care done or had been shaven on the following days and times: Observations made on 5/11/25: -At 9:00 a.m., the resident was in his bed awake and was waiting for his breakfast.-At 12:00 p.m., the resident was in his bed waiting for his noon meal.-At 3:00 p.m., the resident was in his bed wake.Observations made on 5/12/25: -At 7:15 a.m., the resident was awake in his bed.-At 10:00 a.m., the resident was awake in his bed. -At 11:00 a.m., the resident was awake in his bed waiting for his noon meal. During an interview done on 5/11/26 at 9:00 a.m., Family Member #1 M stated They (staff) usually shave him on Sunday's during his shower, but not this Sunday, I don't know why (Family member #1 M was also a resident in the adjoining room and she kept his door open so she could watch Resident #19). During an interview done on 5/12/26 at 11:00 a.m., Family Member M stated They still have not shaven him or brushed his teeth, I am just going to do it so it gets done. Review of the residents Functional Ability Deficit care Plan dated 4/14/26, revealed no documentation that Resident #19's Family Member did his daily oral care and staff needed to check daily to make sure it got done. During an interview done on 5/13/26 at 9:00 a.m., In Service RN, Nurse L stated There has been no in service on oral care since I came back (3 months from survey), they (CNA's still have to do it shave and oral care). During an interview done on 5/13/26 at 9:55 a.m., Nursing Assistant/CNA K who frequently care for the resident stated that she sometimes miss it (doing oral care and shaving if needed). During an interview done on 5/13/26 at 10:40 a.m., MDS Coordinator F reviewed the residents Functional Ability Deficit care plan dated 4/14/26, and stated The CNA's (Nursing Assistant's) still have to do the task (oral care daily, and shaving as needed), they need to check to see if (Family Member M) provided oral care and if not, provide it. Review of the residents Functional Ability Deficit care plan up-dated to 5/13/26, revealed MDS Coordinator F had add the intervention of checking daily to see if oral care had been given and if not, provide it to the resident.Review of the facility Routine Resident Care policy dated 3/12/25, stated Daily personal hygiene minimally includes washing their face and hands, shaving, nail care, combing their hair each morning, and brushing their teeth.

Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure coordination of care and communication with an external dialysis provider for one resident (Resident #7) of one resident reviewed. Findings include: Resident #7: On 5/11/26 at 3:20 PM, Resident #7 was not in their room. An interview was completed with Registered Nurse (RN) P on 5/11/26 at 3:23 PM. When queried regarding Resident #7's location, RN P responded that Resident #7 had recently returned from dialysis and went straight to the Activities Room when they got back. When asked, RN P revealed they were the Residents assigned nurse. When queried regarding the facility policy/procedure related to communication with the external dialysis provider, RN P responded the facility sends a form with the Resident when they leave, the dialysis nurse completes a portion and sends the form back with the Resident. RN P was asked if they had received a dialysis communication form following the Resident's dialysis treatment today and responded they had. RN P provided a Hemodialysis Communication Form dated 5/11/26. Review of the form section titled, Complete at the Dialysis Unit detailed the Resident weighed 55.6 kilograms (kg) pre-dialysis and 57.6 kg after dialysis. The only other documentation completed by the dialysis facility was vital signs. The forms included sections, Medications During Dialysis. Medication Changes Recommended. Diet Changes Needed. Complications During Dialysis. Pertinent Labs. Condition of Shunt. Addition Comments. were all blank. The bottom of the form included a section titled, Completed by the Facility upon Return which was blank. When queried why Resident #7 gained weight during dialysis (normally fluid is removed and weight decreases during dialysis), RN P stated, I'm not sure. Review of Resident #7's prior dialysis forms dated 5/1/26, 5/4/26, and 5/8/26 all showed the Resident had a weight loss during treatment. Review of the Dialysis Communication Form dated 4/27/26 revealed no documentation of a weight prior to dialysis but did include a post dialysis weight. Not all of the dialysis forms were signed by dialysis staff. The prior forms including consistent lower weight post dialysis were reviewed with RN P. When queried, RN P responded that the dialysis staff may have written the pre and post weights in the wrong area. RN P was asked to contact the dialysis center regarding Resident #7's treatment and post dialysis weight gain. RN P revealed the facility did not have a direct phone number to the local dialysis facility and indicated they would need to call the central number and try to be connected to the local facility. RN P was informed the dialysis center gave (Resident #7) a bolus (fluids) when they arrived for treatment and did not take hardly anything off because their blood pressure was in the 90's (low). RN P stated, They (dialysis center staff) don't fill it out (form) and that is why we think everything is going fine. On 5/11/26 at 3:38 PM, an interview was completed with the Director of Nursing (DON). When queried regarding communication with external dialysis facilities, the DON responded that a communication form is sent with the resident and a section is completed by the dialysis center staff. Resident #7's Dialysis Communication Form for 5/11/26 was reviewed with the DON at this time. When queried regarding Resident #7's post dialysis weight gain and the blank areas on the form, the DON confirmed the form was incomplete and stated they will need to address with the dialysis provider. The DON was then informed RN P was asked to contact the dialysis center and that the dialysis center had informed them that Resident #7 was hypotensive (low blood pressure) and had received fluids. The DON stated the lack of communication was not okay and indicated they would contact the dialysis center manager to address the concerns. An interview was attempted to be completed with Resident #7 on 5/11/26 at 3:58 PM in their room. When asked questions, Resident #7 responded but their speech was very garbled and was unable to be understood. A follow up interview was completed with RN P on 5/11/26. When queried regarding Resident #7's speech being garbled and not being able to understand them, RN P revealed they are a casual status employee and do not work often. RN P stated, (Resident #7) was like that a could days ago but I don't really know them though. An interview was conducted with Certified Nursing Assistant (CNA) R and CNA Q on 5/11/26 at 4:00 PM. When queried regarding Resident #7's garbled speech, CNA R stated, Been getting worse the past couple of weeks. CNA Q agreed with CNA R and added, Resident #7 was not like this when they first got here. Record review revealed Resident #7 was originally admitted to the facility on [DATE] with diagnoses which included heart disease, Congestive Heart Failure (CHF), hepatitis C, and End Stage Renal Disease (ESRD) with dialysis dependance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required set up to moderate assistance to complete Activities of Daily Living (ADLs). On 5/13/26 at 1:00 PM, Resident #7 was not in their room and review of the Electronic Medical Record (EMR) revealed the Resident had been discharged . An interview was completed with the DON on 5/13/26 at 1:21 PM. When queried regarding Resident #7, the DON stated, Went out due to fluid overload. With further inquiry, the DON stated, It was partially because of you. They (dialysis center) gave (Resident #7) 1.5 liters of fluid during the treatment on 5/11/26. When asked, the DON revealed facility staff were monitoring the Resident more closely due to the amount of fluid they had received. The DON disclosed Resident #7 was on dietary fluid restrictions at the facility as instructed by the dialysis center and the fluids they had received when at dialysis sent them into fluid overload. Review of facility policy/procedure entitled, Hemodialysis (Revised: 7/23/25) revealed, Residents receiving hemodialysis will be evaluated pre and post treatment and receive necessary interventions.

Based on interview and record review, 5 of 17 nursing staff (RN's & LPN's) and 5 Nursing Assistants/CNA's of 34 CNA staff failed to have up-to-date annual competency evaluations, resulting in the protentional for Nursing Assistants to not be able to re-certify certification, and improper nursing techniques and care for the facility's census of 54 residents. Findings Include:During an interview done on 5/13/26 at 11:25 a.m., In Service Nurse Director, RN I revealed she had been at the facility for 2 months, and the Nursing Assistant's/CNA's and Nurse's (Rn and LPN) annual competencies (facility competency check-off's) were not up-to-date, no one had done them for months prior to her. In Service Director I stated Before I came, no one did them; the last In Service Nurse did not keep them up-to-date. On 5/13/26 at 11:30 a.m., the In Service Director I and this surveyor went through all nursing and CNA's annual competencies for 2025 through 5/2026. There was a total of 5 Nurse's ana total of d 5 CNA's that were found to not be up-to-date with their facility annual competencies. Review of the facility Training for the Compliance Program policy dated 11/4/2024, stated The Compliance Program will be incorporated into on-boarding (video education) and annual education (facility annual competency check-off's) programs; the staff development (In Service Director) coordinator or designated staff member will be responsible for educating staff. Review of the State expenditures #483 for nurse aide training and competency evaluation dated 12/5/2016, revealed CNAs are required to have annual skill competency evaluations.

Based on observations, interviews, and record review, the facility failed to ensure a sanitary environment in the kitchen (Soiled equipment, rust on freezer shelves), water in clean and ready for use dishes, and no use-by dates on open and partly used foods, for a census of 57 residents who eat from the kitchen. Findings include:On 5/11/26 starting at 8:15 a.m., the initial kitchen walkthrough was done with Dietary Manager B on 5/11/26 at 8:15 a.m., and the following concerns were noted: -At 8:17 a.m., observation of x 6 clean and ready for use plastic cups with water inside of all of them were in the dry cup container and ready for use. During an interview done on 5/11/26 at 8:19 a.m., Dietary Manager B stated yes, they (cups) are dry. According to the FDA 2022 Food Code, clean equipment and utensils were to be air dried in a manner in which allows them to circulate air in order to dry; no water should be left inside. -At 8:20 a.m., 1 open and partly used bag of chips (Bangles), 1 open package of hamburger buns, 1 open half loaf of bread, and 1 package of hot dog buns, were all found to not have any use-by or expiration dates on them. During an interview done on 5/11/26 at 8:20 a.m., [NAME] C stated yes, they need an open and use-by date on them. Review of the facility Food Purchasing and Storage policy dated 12/10/2024, revealed all left over foods (including breads) were to be dated. 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 -At 8:25 a.m., the pureed machine (makes pureed foods) was found was clean with a top on it sitting on the shelf. This was found to have water inside with the top on it. -At 8:32 a.m., The Arctic Air Freezer bottom shelf was found to have an excessive amount of food and crumbs on the bottom shelf; all shelves had white paint/coating chipping off and rust exposed (from oxidation). During an interview done on 5/11/26 at 8:33 a.m., Dietary Manager B stated Every shift should clean it (the freezer). Review of the facility Food Purchasing and Storage policy dated 12/10/2024, stated Metal shelves will be stainless or coated (painted) to prevent oxidation (leading to rust build-up).According to the FDA 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensil's, 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 implement and operationalize an infection control program including ensuring safe and sanitary conditions in the beauty parlor, comprehensive outcome surveillance, evaluation and analysis of data for potential trends, and identification and monitoring of potential infections for all 57 residents residing in the facility. Findings include: An interview and review of facility Infection Control (IC) data was completed with IC Registered Nurse (RN) C on 3/27/25 at 2:09 PM. Upon request to review IC data for February 2025, RN C provided a written line listing tool, a typed line listing Surveillance Monthly Report, a mapping tool, and a summary form. When queried why there were both written and typed line listing forms, RN C revealed the written form is not an official tracking tool but stated they use it to make notes regarding infections when not in their office. RN C stated they enter the appropriate information into the system and the computer program generates the official typed Infection Surveillance Monthly Report form. Review of both the typed and handwritten forms revealed each resident listed on the form had received an antimicrobial treatment for infection. When asked how they identify and track residents who have potential infections to prevent spread, RN C revealed they track residents who are receiving treatment for infection. RN C was asked how they are able to quickly identify and prevent the potential spread of infection if they do not have a system in place to track residents who have signs and symptoms of potential infection, RN C verbalized understanding and indicated they were unaware they needed to have a system for monitoring and identifying potential signs/symptoms of infection and/or infections which do not receive antimicrobial treatment. When queried if antifungal medication are included on their surveillance tracking documentation, RN C revealed the primary antifungal treatments in the facility are topical. When queried if topical antifungal medications are used to treat fungal skin infections, RN C confirmed they are. When queried if fungal skin infections can be contagious, RN C verbalized they can be. RN C was then asked why topical skin infections are not included on the official typed IC line listing surveillance and revealed they had Review of the Summary form for February 2025 revealed no documentation of analysis for infection trends. Review of outcome surveillance data including the Infection Surveillance Monthly Report revealed the facility had a total of 13 infections which received antibiotic treatment during the month. Of the 13 infections, five were listed as pneumonia on the Infection Surveillance Monthly Report. The The Infection Summary detailed there were three Residents with pneumonia on the 100 hall and one Resident on the 200 hall. When queried why the summary only included four residents with pneumonia when the line listing detailed five, RN C revealed they must have made an error. When asked, RN C revealed three of the five residents with pneumonia were classified as facility acquired. When queried if they identified any trends in the pneumonia diagnoses, RN C stated, (Resident #32-200 hall) had aspiration pneumonia. When queried regarding the four other residents with pneumonia (#28, 211, 47, and 212) including dates of symptom onset, common caregivers, and areas/time outside of their room, RN C revealed they had not considered nor identified any potential trends previously but were able to see potential trends now. The outcome surveillance data for February 2025 further revealed the facility had four Urinary Tract Infections (UTI's), two on the 100 hall that were present on admission and two on the 400 hall that were facility acquired. When queried regarding the organisms causing the UTI's and if any trends were identified, RN C verbalized no trends were identified. Review of Culture and Sensitivity documentation for the residents listed as having UTI's revealed one resident was admitted with a UTI caused by Klebsiella Oxytoca (gram negative bacterium frequently associated with pneumonia infections) on 1/29/25 and another resident with a UTI had an infection onset date of 2/5/25 that was also caused Klebsiella Oxytoca. When asked if they considered and/or identified a potential trend, RN C stated, I do now. When queried what process surveillance was completed for the month, RN C revealed they did not know what process surveillance meant. RN C was then asked if they completed any IC audits and provided facility wide audit forms. When asked if any education was completed specific to potential IC concerns identified during process or outcome surveillance, RN C revealed no specific IC education was provided. When queried if they had previously identified an increase in infection and/or concern and completed education related to that incident, RN C revealed they had an increase in UTI's the prior year and education was completed by the previous education/staffing nurse. RN C did not have the education provided for review. Review of facility policy/procedure entitled, Infection Prevention Program Overview (Revised: 2/28/25) revealed, Policy: The infection prevention and control program (IPCP) must include, at a minimum, the following elements . investigates, identified, presents, reports and controls infection and communicable disease for all residents Infection Preventionist (IP) . serves as the coordinator of an Infection Control program . Responsibilities may include: Collecting, analyzing, and providing infection data and trends to nursing staff and healthcare practitioners. Consulting on infection risk assessment, prevention, and control strategies. Providing education and training; Implementing evidence based infection control practices including those mandated by regulatory and licensing agencies . 22347 Observation was made of the resident's beauty parlor on 3/26/25 at 3:35 p.m., during the environmental tour accompanied by Director of Maintenance and Housekeeping H, the Administrator and Infection Control Nurse C. The resident's beauty parlor was found to have the following: -At , in several (x 4 drawers) of the black plastic equipment drawers was observed an excessive amount of hair, dust, and pieces of paper. The drawers looked like they had not been cleaned for an extended amount of time. -In 2 of the black plastic drawers, a pile of used curlers was found with a lot of hair in them. -x 2 electric razors were found in the top left side drawer with skin and hair on both of the blades. -A black bin had small curlers sitting in it with hair, dust and pieces of paper in the bottom of the bin. During an interview done 3/27/25 at 1:12 p.m., Director of Maintenance and Housekeeper stated, They (housekeeping staff in the facility beauty parlor) are to clean the countertop sink and floor, they do not do the equipment. They are supposed to clean that (community equipment, including razors and curlers) that after every use. During an interview done on 3/26/25 at 3:30 PM, the Infection Control Nurse C was taken to the room upon her request and shown the condition of the beauty parlor. Infection Control Nurse C stated It's discussing, gross. I do come in here every once on a while. Review of the Infection Control environmental walk-through dated 2/25, revealed 3 thing to observe in the beauty parlor (hygiene, equipment disinfected and chemicals stored properly).

Based on observation, interview and record review, the facility failed to: 1) Ensure proper labeling of open dates and expiration dates of multi-dose medications in 2 of 2 medication carts and 2) Ensure proper labeling of glucose monitor strips for expiration date after opening, resulting in the opened and undated medications and inaccurate blood glucose monitoring. Findings include: Observation and interview on 03/25/25 at 09:28 AM with Registered Nurse (RN) D of the 200/400 medication cart revealed that she was a unit manager and staff education director, but was working the 200/300 hallway medication cart because of a staff nurse call-in. RN D unlocked the medication cart to review with the state surveyor: Resident #41's had Lantus insulin pen open date with no expiration date, and Novolog insulin pen with open date, with no expiration date. Resident #28 had Humulin 70/30 insulin pen with open date and no expiration date. Novolin 70/30 insulin pen with an open date with no expiration date. Resident #17 had Lantus insulin 100unit/ml bottle with an open date that was unreadable smudged and there was no expiration date. The bottle was not in a box with pharmacy label. Resident #4 had Aspart 70/30 insulin pen was used with no open date and with No expiration date noted. RN D reviewed all medications for proper labeling and open and expiration dates and found none on the insulin pen. Resident #35 had: Latanoprost 0.005% eye drops multi-dose bottle with no open date, and no expiration date. Resident #27 had Polymyxin/trimethoprim 0.1% (antibiotic) opened with on open date and no expiration date. Observation of the medication cart stock glucose blood sugar sticks container was opened with sticks missing with no date opened or when expected to expire. Resident #32 had (Breo) Fluticasone/vilanterol 100/25 mcg dated 2/28/25 and 3/8/2025. Resident #32 had Incruse Ellipta dated 3/8/2025 opened and used with no expiration date. Resident #49 had Advair diskus Fluticasone/Salmeterol dated 2/14/2025 with no expiration date. Interview and record review with RN D reviewed all the medication containers for open dates and expiration dates. Record review of the clear medication cart overlay revealed a medication list of insulins with expiration recommendations for dating opened insulin pen and other medications. Record review of the 'Medications with Shortened Expiration Dates' form located under a clear protectant sheet on the top of the medication cart revealed: Once these products are opened, they must be used within a specific timeframe to avoid reduced stability and sterility and potentially, reduced efficacy. These medications should be labeled in such a way that the Beyond Use Date is securely attached to a part of the package and will not be discarded . Aspart, Humalog, and Humulin insulin pens were stable, in use at room temperature for 10 days. Lantus insulin bottle/pen were stable, in use at room temperature for 28 days. Glucose test strips were noted to be good for 3-6 months after opening. Record review of the facility 'Medication Administration' policy 5.3.9 injectable medications dated 6/21/20217 revealed multi-dose vials: a.) After initial use are to be labeled with the date opened and initials of healthcare professional. Open vials are to be discarded within twenty-eight (28) days . Record review of the facility 'Medication Administration' policy 5.3.9A Insulin Administration dated 6/21/20217 revealed insulin is a high-risk drug and warrants additional precautions for the safe and effective administration . (7.) Check the expiration date prior to administration to ensure it is within the usage date. Expired insulin should be immediately discarded. Vials and pens without an open date recorded should be discarded. Observation and interview on 03/25/25 at 09:48 AM with Registered Nurse (RN) P of the 100/400 hallways medication cart. RN P stated that she was working the 100/400 hallways as the floor nurse passing medications revealed: On 03/25/25 at 09:58 AM that Resident #45 had Albuterol sulfate Nebulizer inhalation ampules, with the foil packet opened with missing ampules with no date when opened. Resident #45 had Breyna (Symbicort inhaler) inhalation inhaler 160mcq/4.5 mcg had an open date, with no expiration date, and an Incruse Ellipta 62.5mcg with open date of 3/25/25 with no expiration date noted. RN P stated that she did not date the inhaler. Resident #164 who was Out to hospital had Albuterol sulfate nebulizer ampules with opened foil packet with 2 ampules loose in the box with no dates, and a Trelegy Ellipta inhaler 200mcg with an open date, but no expiration date noted. RN P had no idea about an expiration date for the medications. Resident #5 had Fluticasone Propionate inhaler 55mcg/14 mcg opened and used with no open date and No expiration date. Resident #13 had Fluticasone vilanterol Ellipta 200mcg/25mcg opened and used with no expiration date. Resident #12 had Trelegy Ellipta 100mcg opened and used with no expiration date. Resident #10 had Ipratropium/Albuterol nebulizer ampules with opened foil packet with no open date and loose ampules out of the foil packet lying in the box. Resident #14 had Fluticasone Vilanterol Ellipta opened and used with no open date and No expiration date. Registered Nurse (RN) P reviewed all containers for open and expiration dates as surveyor requested. In an interview on 03/25/25 at 11:30 AM with Registered Nurse D came to the state surveyor to report that the blood sugar test strips are good for 6 months after opening per the medication shortened expiration sheets. RN D stated that she did throw out the other strips after the surveyor brought it to her attention. Record review of the facility pharmacy 'Medications with Shortened Expiration Dates' list dated 2024, revealed 4 sheets. The medication shortened list identified: Insulins- Aspart pen, Humalog mix pen and Humulin 70/30 pen had stability in use at room temperature was good for only 10 days. Lantus pen/bottle insulin had stability in use at room temperature was good for only 28 days. Albuterol nebulizer solution should be stored in foil pouch and was good for only 7 days once removed from pack. Breo or Incruse Ellipta expiration 6 weeks after removal from foil tray packaging. Latanoprost eye drops once opened may be stored at room temperature for up to 6 weeks. Record review of the facility 'Medication Disposal and Returns' policy 6.2 Dating and Discarding of Multidose Parenteral Vials' dated 6/17/2017 revealed nursing staff will date multidose vials and discard opened vials as outlined to decrease the risk of contamination and bacterial or fungal growth from multidose vials. (2.) Nursing staff is responsible for inspecting medications and their expiration date on a regular basis. Expired drugs should be discarded per policy and procedure .

Based on observation, interview and record review, the facility failed to ensure that weights were done accurately for two residents (Resident #11 & Resident #16). Findings include: Resident #11: Observation on 03/25/25 at 10:38 AM during the survey screening process the surveyor observed Resident #11 to be lying in bed and thin in appearance. Observation and interview on 03/25/25 at 01:06 PM with Resident #11 revealed that she did get lunch (while still lying in bed), she had Lost some weight, but that she was not hungry. Observation on 03/25/25 at 01:08 PM of Resident #11's meal tray in the meal tray brown box revealed 3/4 of tray was eaten. Record review of Resident #11's documented weights revealed that on 2/10/2025 at 12:49 PM weight was 129.0. Weight on 2/25/2025 at 3:09 PM was 123.5. The weight loss of 5.5 pounds was not reweighed again until 3/4/2025 at 2;01 PM of 123.5. Record review on 03/25/25 at 02:47 PM of Resident #11's weight log documentation revealed: On 1/21/2025 resident #11's weight was 136.2 pounds and on 2/25/2025 weight of 123.5 equaled a 12.7-pound weight loss in 35 days of 9.32% loss. In an interview and record review on 03/26/25 at 12:37 PM with Certified Dietary Manager (CDM) O reviewed the electronic medical record with the surveyor of Resident #11's documented weights. CDM O revealed that the facility weight policy was upon admission, and once a week for four (4) weeks, and then if stable the resident is changed to monthly, if not resident was kept on weekly weights. CDM O stated that Nutritional assessments must be done within 7 days of admission, nutritional risk screen was done at 5 days of admission. When there was a Change in residents' weight, the Minimum Data Set (MDS) nurse tells me there is a significant weight change. A Significant weight is 5 pounds or more in a week. Record review of Resident #11's nutritional progress notes revealed only one note dated 2/12/2025 at 1:20 PM by the Registered Dietitian was the only note that referred the resident to the Interdisciplinary for weight loss. Record review of Resident #11's care plans pages 1-56 revealed alteration for nutrition initiated 11/27/2024. Revision of nutritional alteration care plan dated 2/12/2025 revealed 120ml Med Pass 2.0 twice daily was added. On 3/6/2025 the Certified Dietary Manager (CDM) revision but made no changes to the interventions even with additional 12.7-pound weight loss noted on 2/25/2025. Record review of the facility 'Weight Management' policy dated 9/22/2023 revealed residents will be monitored for significant weight changes on a regular basis . Anticipated Outcome: any resident with unintended weight loss/gain will be evaluated by the interdisciplinary team and interventions will be implemented to prevent further wight loss/gain. Practice guidelines: (3.) Re-weights are initiated for five-pound variance if the resident is greater than 100 pounds and three-pound variance if less than 100 pounds. If a resident's weight is less than 200 pounds a re-weight will be done for a weight loss or gain of 3% or consult with the dietary manager or Registered Dietitian/designee. Re-weights will be done within 48-72 hours. Resident #16: Observation on 03/25/25 at 08:57 AM Resident #16 was seated up in wheelchair in her room and was thin in appearance. Observation and interview on 03/25/25 at 01:12 PM with Resident #16 revealed that she went to the dining room in via self-propel in wheelchair. Resident #16 was observed getting herself back to her room. Record review on 03/25/25 at 02:40 PM of Resident #16's electronic medical Record review of resident documented weight log revealed: On 1/21/2025 resident #16 weight was 189.5 pounds and on 3/24/2025 residents' weight was 178.0 pounds that is a 11.5-pound loss or 6.07% loss in 60 days. Interview and record review on 03/26/25 at 12:51 PM with Certified Dietary Manager (CDM) O reviewed the electronic medical record with the surveyor of Resident #16's documented weights revealed that the resident weight on 2/17/2025 of 186.6 pounds and then in 24 days and documented weight of 176.2 pounds on 3/13/2025 was noted. That was a weight loss of 10.4 pounds. The CDM O was asked about nutritional notes dated 3/24/2025 with no new interventions added to care plan. The CDM O stated that would be the Registered Dietitian consultants note. Record review of Resident #16's care plans pages 1- 63 with revision date 3/9/2025. Record review of the dietary interventions revealed: Provide diet as ordered: Consistent Carbohydrate diet, puree texture, pudding thickened fluids. Enriched/fortified foods, revision by CMD O revision date of 2/20/2025. There were no other interventions since the 2/20/2025 revision date for the 10.4-pound weight loss. 37668

Based on interview and record review, the facility failed to ensure informed consent including risks and benefits of psychotropic medications were provided for one resident (Resident #44) of five residents reviewed for unnecessary medications. Findings include: Resident #44: On 3/25/25 at 11:05 AM, Resident #44 was observed in their room. The Resident was in bed wearing a hospital style gown. An interview was completed at this time. When asked how they were feeling, Resident #44 stated, I'm real depressed. When asked if they were taking any medications for depression, Resident #44 replied, They keep switching my meds around without telling me and it makes me feel like I don't matter. Record review revealed Resident #44 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included bladder cancer, depression, bipolar disorder, adjustment disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to total assistance for toileting, transferring, and hygiene. The MDS further detailed the Resident displayed no behaviors and was receiving antipsychotic and antianxiety medications. Resident #44's Census documentation revealed the Resident was admitted to Hospice services on 12/2/24. Review of Resident #44's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident) is at risk for adverse reactions and side effects r/t (related to) receiving multiple psychotropic medications. Resident takes: Antianxiety and Antipsychotic . management of Bi-polar disorder, anxiety . (Initiated: 7/11/22; Revised: 3/7/25). Review of Resident #44's Medication Administration Record (MAR) and Health Care Provider (HCP) orders revealed the Resident was currently receiving the following psychotropic medications: - Rexulti (Brexpiprazole- antipsychotic medication used to treat major depression disorder, Schizophrenia, and agitation associated with dementia due to Alzheimer's disease) Oral Tablet 1.5 milligrams (mg) daily at bedtime for bipolar disorder (Start Date: 12/18/24) - Citalopram Hydrobromide (Celexa- antidepressant) 40 mg daily Note: Citalopram 40 mg daily was originally ordered on 7/8/22 and discontinued on 12/13/24. The medication was reordered on 3/26/25. - Xanax (Alprazolam- anti-anxiety medication) 0.5 mg two times a day for Anxiety Note: Xanax was originally ordered on 11/13/24 as needed (PRN) twice a day and renewed every 14 days. The medication order was changed on 2/27/25 from PRN to scheduled twice a day. Resident #44's EMR contained scanned documentation from a Behavioral Health Service provider. The Behavioral Health Provider visit notes were revealed and detailed: - 12/4/24: Complaint . Urgent consult: depression/tearfulness, bipolar disorder and medication review . seen previously . for ongoing psychiatric care. At last visit medication changes were not recommended . case discussed with facility staff. Staff report that patient's psychiatric condition has worsened- increased depression and anxiety. Consult today to review patient's mood, sleep, and manage psychotropic medication use . a change in medication was considered but will not be implemented/recommended as current plan is most effective at present time . Any type of dose reduction at this time would likely impair resident function and cause psychiatric instability by exacerbation of underlying symptoms . The note detailed Resident #44 was receiving the following psychotropic medications: - Citalopram 40 mg . 1 time per day - Klonopin (medication used to treat seizures and anxiety) 0.5 mg . 1 time per day (Start date: 2/23/23) - Duloxetine (Cymbalta- antidepressant medication) 30 mg, delayed release . 30 mg during the day and 60 mg before bed (Start Date: 12/1/22) - Rexulti 1.5 mg at bedtime - 3/20/25: Complaint: Urgent consult increased c/o (complaint of) anxiety and depression; previous dc (discontinue) of psych meds . seen previously for mood/insomnia. No medication changes were recommended at that time . Since previous visit chart notes patient developed difficulty with swallowing. Celexa, Klonopin, and Cymbalta were discontinued. No changes to Rexulti noted . Xanax was changed from PRN (as needed) to scheduled BID (twice a day). Bo other concerns noted. Consult today to review patients mood and manage psych med use . Assessment and Plan . Patient with increased anxiety and depression which is most likely due to recent dc of psych meds . Recommend resuming Celexa 40 mg (every day)- use liquid if necessary . Unsure of reason that Xanax was started instead of previous Klonopin order . Informed consent to provide the service via telehealth was obtained prior to the encounter beginning . Discussed case with nursing staff . Collaborated with social worker . The note detailed Resident #44 was receiving the following psychotropic medications: - Rexulti 1.5 mg at bedtime - Xanax 0.5 mg twice a day A review of Resident #44's EMR revealed no documentation of consent for psychotropic medications were noted in the Resident's EMR. On 3/26/25 at 3:45 PM, Resident #44 was observed lying in bed in their room. The room was dark with the window shades down and the lights off. The Resident was wearing a hospital style gown, and their eyes were open. When asked, Resident #44 they primarily stayed in their room in bed. When queried if they wanted to get out of bed, Resident #44 did not respond. On 3/26/25 at 3:48 PM, an interview was completed with Certified Nursing Assistant (CNA) R and CNA S. When queried regarding observations of Resident #44 in in bed, wearing a hospital gown, both CNA's verbalized the Resident chooses to not get up. With further inquiry regarding the Resident's normal routines and behavior, CNA S stated, (Resident #44) doesn't say to much and CNA R confirmed. When asked if the Resident had told them they were depressed, both CNA S and CNA R replied, No. An interview was completed with Licensed Practical Nurse (LPN) Social Services (SS) E on 3/27/25 at 9:37 AM. When queried regarding Resident #44, LPN SS E replied, (Resident #44) is seen by behavioral health and is on hospice. When queried regarding Resident #44 stating they were depressed and their medications were being switched around without their knowledge, LPN SS E stated, (Resident #44) wasn't able to swallow and meds were discontinued. (The Resident) has made a turn around and we have been adding (medications) back in. Resident #44's psychotropic medications were reviewed with LPN SS E at this time. When queried regarding consent for Resident #44's psychotropic medications, LPN SS E indicated they maintain the consents provided a signed informed consent form for Rexulti. When queried regarding consent for Celexa and Xanax, LPN SS E revealed they only get consent for antipsychotic medications and stated, Do not get consents for antidepressants and antianxiety meds. When queried if documentation of education related to the reason for medication use, effects of the medication, risk/benefit of the medications, and intended duration of use was documented elsewhere, LPN SS EE reviewed Resident #44's EMR and behavior healthcare provider documentation and confirmed there was no documentation of consent in Resident #44's EMR. LPN SS E stated they were not aware informed consent was needed for psychotropic medications. An interview was completed with the facility Administrator on 3/27/25 at 1:58 PM. The Administrator was informed of the lack of consents for all psychotropic medications for Resident #44 and interview with LPN SS E. An explanation was not provided.

Based on observation, interview and record review, the facility failed to timely update/revise individualized, person-centered care plans to reflect changing care needs for 3 residents (Residents #11, Resident #16 and Resident #111). Findings include: Resident #11: Observation on 03/25/25 at 10:38 AM during the survey screening process the surveyor observed Resident #11 to be lying in bed and thin in appearance. Observation and interview on 03/25/25 at 01:06 PM with Resident #11 revealed that she did get lunch (while still lying in bed), she had Lost some weight, but that she was not hungry. Observation on 03/25/25 at 01:08 PM of Resident #11's meal tray in the meal tray brown box revealed 3/4 of tray was eaten. Record review on 03/25/25 at 02:47 PM of Resident #11's weight log documentation revealed: On 1/21/2025 resident #11's weight was 136.2 pounds and on 2/25/2025 weight of 123.5 equaled a 12.7-pound weight loss in 35 days of 9.32% loss. Record review of Resident #11's care plans pages 1-56 revealed alteration for nutrition initiated 11/27/2024. Revision of nutritional alteration care plan dated 2/12/2025 revealed 120 ml Med Pass 2.0 twice daily was added. On 3/6/2025 the Certified Dietary Manager (CDM) revision but made no changes to the interventions even with additional 12.7-pound weight loss noted on 2/25/2025. Resident #16: Observation on 03/25/25 at 08:57 AM Resident #16 was seated up in wheelchair in her room and was thin in appearance. Observation and interview on 03/25/25 at 01:12 PM with Resident #16 revealed that she went to the dining room in via self-propel in wheelchair. Resident #16 was observed getting herself back to her room. Record review on 03/25/25 at 02:40 PM of Resident #16's electronic medical Record review of resident documented weight log revealed: On 1/21/2025 resident #16 weight was 189.5 pounds and on 3/24/2025 residents' weight was 178.0 pounds that is a 11.5-pound loss or 6.07% loss in 60 days. Record review of Resident #16's care plans pages 1- 63 with revision date 3/9/2025. Record review of the dietary interventions revealed: Provide diet as ordered: Consistent Carbohydrate diet, puree texture, pudding thickened fluids. Enriched/fortified foods, revision by CMD O revision date of 2/20/2025. There were no other interventions since the 2/20/2025 revision date for the 10.4-pound weight loss. Review of the facility Care Planning policy dated 3/3/25, revealed person centered care plans are to be prepared (done) by the interdisciplinary team (all members of the team, including nurse responsible for the resident). Resident care plans are triggered based on the needs and/or potential needs. 22347 Resident #111: Review of the Face Sheet, physician, nurses progress notes, physician orders and care plans dated 6/23 to 3/25, revealed Resident #111 was [AGE] years old, alert, admitted to the facility on [DATE], and required assistance with all Activities of Daily Living. The resident's diagnosis included, Bipolar Disorder, anemia, cognitive impairment, Anxiety Disorder, heart failure, Atrial Fibrillation, muscle weakness, Dysphagia, chronic lung disease, diabetes and chronic kidney disease. The resident had a history of loose stools and incontinence. Review of the residents facility Skin assessment dated [DATE], stated small area of excoriation/red area left gluteal fold/crease. Observation done on 3/26/25 accompanied by MDS Nurse at 9:10 am of residents coccyx area, revealed skin intact, with no signs of pressure ulcers. The residents peri area was red, excoriated and tender with complaints of pain and discomfort. Review of all the residents facility care plans with MDS Nurse, LPN F on 3/26/25 at 9:00 a.m., revealed no documentation of an actual skin impairment care plan; only an at risk for skin impairment care dated 6/21/23. The resident did have actual skin impairment and redness; no up-date to the at risk for skin impairment or actual skin impairment care plan was found. During an interview done on 3/26/25 at 9:20 a.m., the Director of Nursing stated The nurses (floor nurses) would do the care plans. During an interview done on 3/26/25 at 9:51 a.m., Education Nurse, RN D stated During orientation I do educate them on care plans. They don't up-date them, we (managers) usually do it. They are supposed to be up-dating care plans. Review of the facility nursing orientation sheet (un-dated) revealed documentation of education on care plans. Review of the facility Care Planning policy dated 3/3/25, revealed person centered care plans are to be prepared (done) by the interdisciplinary team (all members of the team, including nurse responsible for the resident). Resident care plans are triggered based on the needs and/or potential needs. Review of the facility Skin Management policy dated 9/14/24, revealed the licensed nurse will document preventive measures on the care plan/Kardex; the DON (Director of Nursing)/designee will document any changes in the care plan/Kardex at the meeting (Resident at Risk Meeting).

Based on observation, interview and record review, the facility failed to implement a care plan related to supplemental oxygen use for one resident (Resident #44) of two residents reviewed for respiratory care. Findings include: Resident #44: On 3/25/25 at 11:06 AM, Resident #44 was observed in their room in bed. The Resident was receiving supplement oxygen via Nasal Cannula (NC) at a rate of 2 liters (L) per minute. At 3:42 PM on 3/26/25, Resident #44 was observed in their room. The Resident was in bed and receiving supplemental oxygen at 2L/minute via NC. Record review revealed Resident #44 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included bladder cancer, depression, bipolar disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to total assistance for toileting, transferring, and hygiene. The MDS further detailed the Resident was receiving oxygen therapy. Review of Resident #44's care plans revealed the Resident did not have an active and/or discontinued care plan pertaining to oxygen therapy and/or respiratory care. Review of Resident #44's Health Care Provider (HCP) orders revealed the order, Oxygen 2L via nasal cannula. as needed for SOB (Shortness of Breath) dated 1/25/25. An interview was completed with the facility Administrator on 3/27/25 at 1:58 PM. When queried if Residents receiving oxygen therapy should have a care plan in place, the Administrator verbalized they should. When asked if Resident #44 had a care plan related to oxygen therapy, the Administrator reviewed Resident #44's EMR and confirmed the Resident did not have a care plan pertaining to oxygen therapy. The Administrator indicated they would discuss with the MDS nurse to ensure a care plan was implemented.

Based on observation, interview and record review, the facility failed to 1) Maintain food kitchen equipment in a sanitary and good working condition, and 2) Date prepared foods with made date and use-by date, resulting in an increased likelihood for food borne illness with hospitalization , and cross contamination affecting 57 residents who consumed oral nutrition from the facility kitchen of a total census of 57 residents. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. On 3/25/25 at 9:50 a.m., during the tour of the kitchen accompanied by Dietary Manager G the following concerns were observed: -At 9:51 a.m., observation of the food processor that was cleaned and ready for use was found to have a thin layer of dark brown dried on food particles near the blade. -At 10:00 a.m., there was 1 clean silver metal pan (1/3rd size) found with dried on food particles inside. -At 10:01 a.m., a clean and ready for use sliver metal pan stacked inside another clean pan was found to have water inside. -At 10:05 a.m., on the far right side spigot of the coffee pot was found dark colored sticky substance (a build-up of coffee substance). Review of the facility Weekly Cleaning Assignment (un-dated), revealed all kitchen jobs including the proper cleaning of kitchen equipment was broken down into specific day's of the week and assigned to staff to clean. -At 10:08 a.m., the refrigerator fan covers (x 2) were observed to have an excessive amount of dust that was blowing directly on bread sticks that were sitting on the top shelf. The bread sticks had a sheet of parchment paper on top of them, however the fans were blowing the paper up on the sides. -At 10:11 a.m., in the freezer was found open and partly used bags of blue berries and rolls with no use-by dates on them. During an interview done on 3/27/25 at approximately 12:55 p.m., Dietary Aide M stated We put a use-by date on things open, usually it's about 3 days. Review of the facility Food Purchasing and Storage policy dated 12/10/2024, revealed all opened food items required dating of made by, opened, and use-by dates.

Based on observation, interview and record review, the facility failed to ensure to complete urinary catheter care per professional standards of practice for one resident (Resident #41). Findings include: Resident #41: Record review of Resident #41's Minimum Data Set (MDS) dated [DATE] revealed a male resident with Brief Interview of Mental Status (BIMS) score of 15 out of 15, cognitively intact. Medical diagnosis included anemia, coronary artery disease, hypertension, neurogenic bladder, diabetes and depression. Section H: Bladder & Bowel identified indwelling urinary catheter. Observation made on 03/25/25 at 09:24 AM of Resident #41, who was lying in bed with the room door open to the hallway. State surveyor observed urine catheter bag off the floor hanging out of a blue bag with the spout hanging down on the floor visible from the doorway. Observation of Resident #41's wound vac and tubing visible from doorway with dark fluid noted in tubing hanging down from the bed frame railing. Resident #41 stated that 'they (staff) hang it on the side by the door because it's easier to empty for them'. Observations and interview on 03/25/25 at 11:32 AM of Resident room with room door is open to the hallway. Housekeeper Q was cleaning rooms on 200 hallways. and stated that she already had cleaned Resident #41's room. Interview and Observation on 03/25/25 at 11:35 AM with Resident #41 stated that he got the (Urinary) catheter a while ago, and did not know when it was changed last. Observation of Resident #41's urinary catheter had the spout laying on the floor and estimated 300 clear yellow solution noted in the catheter bag and tubing. Observation and interview on 03/25/25 at 11:38 AM with Registered Nurse (RN) D the state surveyor requested nurse go to Resident #41's room with surveyor to observe the urinary catheter was hanging out from under the privacy bag and the surveyor pointed it out. RN D stated that should not be that way (hanging down out of the bag). In an interview with Resident #41 on 03/25/25 at 11:39 AM stated when asked about his catheter that he did not want everyone to know that he had it, but that he did feel better in the blabber area with it in place. Record review of the facility 'Catheter Associated Urinary Tract Infection Prevention' policy dated 2/28/2025 revealed the policy was to ensure appropriate technique in the care and maintenance of indwelling catheters. (9.) Keep the collection bag and tubing off the floor. (11.) Empty the collecting bag regularly using separate, clean container for each guest/resident. Avoid splashing, and ensure the drainage spigot does not contact the non-sterile collecting container .

Based on observation, interview and record review, the facility failed to implement planned interventions for pressure ulcer (wounds caused by pressure) prevention for one resident (Resident #23) of six residents reviewed. Findings include: Resident #23: On 3/25/25 at 9:52 AM, Resident #23 was observed in their room in bed. The Resident was in bed, positioned on their back and covered in a blue blanket. The blue blanket was visibly soiled with scattered areas of an unknown brown colored substance. Their left knee was bent, and their right leg was straight. A heel boot (soft boot to refuse pressure) was in place on the Resident's right lower extremity only. When spoke to, Resident #23 made eye contact but did not provide meaningful, verbal responses. A second heel boot was observed on the top and back corner of the Resident's armoire/closet behind their room door. Record review revealed Resident #23 Electronic Medical Record (EMR) revealed the Resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, depression, anxiety, bipolar disorder, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required maximum to total assistance to complete Activities of Daily Living (ADL's) with the exception of eating. The MDS further detailed the Resident was at risk for pressure ulcer development and was receiving Hospice services. Further review of Resident #23's EMR revealed the Resident had developed a pressure ulcer at the facility which had healed. Review of Resident #23's EMR revealed a care plan entitled, (Resident #23) is at risk for impaired skin integrity/pressure injury R/T (related to): mobility deficit, Alzheimer's disease, bowel and bladder incontinence, and weakness . unable to verbalize or sense need for toileting (Initiated: 5/24/24; Revised: 6/8/24). The care plan included the intervention, Encourage to wear soft Prafo (heel) boots on in bed and in chair. (Resident #23) will refuse at times (Initiated: 6/12/24; Revised: 3/20/25). On 3/27/25 at 8:31 AM, Resident #23 was observed in their room. The Resident was in bed, positioned on their back with their eyes closed and mouth open. The room lights were off, the window shades were down, and the TV on. The Resident's right leg was straight, and their left leg was bent at the knee at approximately a 140-degree angle. The Resident had a heel boot in place on their right foot but not on their left. A second heel boot remained in the same place on top of the Resident's armoire/closet in the back behind their room door. An interview was completed with Registered Nurse (RN) N on 3/27/25 at 8:55 AM. When asked if Resident #23 should have heel boots in place for pressure prevention, RN N stated, I'm not sure and indicated they thought Resident #23 only had one heel boot due to contractures. An observation of Resident #23 and their room was completed with RN N at this time. RN N confirmed the Resident only had one heel boot in place. RN N began looking in the Resident's room including in the armoire/closet and verbalized they did not see a second heel boot in the room. The second heel boot on the top of the armoire/closet in the back was pointed out to RN N. RN N attempted to get the heel boot from the top of the armoire/closet but was unable to reach the item. Upon exiting Resident #23's room with RN N at 8:59 AM on 3/27/25, Wound Care Licensed Practical Nurse (LPN) B was observed in the hallway and an interview was completed. When asked if Resident #23 is supposed to have heel boots in place on one or both lower extremities, LPN B stated, Supposed to have both boots on. An observation of Resident #23's room was completed with LPN B at this time. LPN B confirmed Resident #23 only had one heel boot in place on their right lower extremity. When asked if the heel boots were termed Prafo boots in the Resident's care plan, LPN B verbalized they were. The second heel boot, on the top in the back of the armoire/closet was pointed out to LPN B. When asked about the location of the heel boot on the armoire/closet, LPN B attempted to reach to heel boot and confirmed it was not within reach. LPN B indicated it appeared as if the staff threw the heel boot on top of the armoire/closet. LPN B was observed attempting to get the heel boot down and was unable to reach the device. LPN B stated, I have other ones. When queried regarding other observation of the Resident only wearing one heel boot and the second heel boot location on the top and back of armoire/closet in the room, LPN B stated, Does have a care plan that will refuse to wear the heel boots. When asked how staff are attempting to place both heel boots on the Resident when the heel boot has been in the same place on the top and back of the armoire/closet on more than one day/observation, LPN B was unable to provide an explanation. An interview was completed with the facility Administrator on 3/27/25 at 1:58 PM. When queried regarding observations of Resident #23 only having one heel boot in place, staff interviews, and the location of the heel boot in the room, the Administrator did not provide further explanation.

Based on observation, interview and record review, the facility failed to implement timely interventions to prevent the development of a Stage 3 pressure ulcer for one resident (Resident #18) and an unstageble pressure ulcer for another resident (Resident #30), follow interventions, ensure that physician's treatment orders were followed and documented and prevent the worsening of the Stage 3 pressure ulcer for Resident #18 of three residents reviewed for pressure ulcers, resulting in Resident #18's development and worsening of a Stage 3 pressure ulcer and Resident #30's development of a left heel unstageble pressure ulcer with the likelihood of pain and infection. Findings include: Resident #18: On 4/02/2024, at 2:30 PM, a record review of Resident #18's electronic medical record revealed a readmission on 07/27/2023 after a short hospital stay with diagnoses that included Diabetes, weakness and Dementia. Resident #18 required extensive assistance with Activities of Daily Living (ADL) and had severely impaired cognition. According to the admission Minimum Data set Assessment (MDS) dated [DATE] . Section M . M0150. Risk of Pressure Ulcers. Is this resident at risk of developing pressure ulcers? The box 1. Yes. Was check marked. M0210. Unhealed Pressure Ulcer (s) Does this resident have one or more unhealed pressure ulcer (s) at Stage 1 or higher? The box 0. No was check marked. A review of the Skin & Wound Evaluation . Date: 3/26/2024 . Type: . Pressure . Stage: Stage 3: Full-thickness skin loss . Location Right Lateral Foot . In-House Acquired . Exact Date 11/3/2023 . Wound Measures 1.58 x 0.78 cm . A review of the care plan (the resident) had a stage 3 on right lateral foot . Pressure ulcer will show improvement through next review. Date Initiated: 11/09/2023 . Air mattress on bed and extender Date Initiated: 11/09/2023 . Low profile cushion to Broda chair Date Initiated: 11/09/2023 . Observe for sliding down in the chair and assist to reposition in chair as needed. Date Initiated: 11/22/2023 . Prafo boots on at all times off for showers Date Initiated: 11/09/2023 . Treatment to pressure ulcer, right lateral foot per physicians order. Date Initiated: 11/22/2023 . A review of the (the resident) has a functional ability deficit and requires assistance with self care/mobility R/T (related to): Impaired Balance and Impaired Cognition Date Initiated: 10/04/2023 . Goal Mobility Will maintain current level of function in Roll left and right . Chair/bed to chair transfer . Interventions . AMBULATION: (the resident) is unable to ambulate and requires a Broda chair with right side lateral support. Bolster attached to right chair handle for positioning. Blue padded foot buddy on Broda chair. BED MOBILITY: (the resident) requires 2 assist to reposition and turn in bed. Date Initiated: 04/03/2024 . TRANSFER: (the resident) requires 2 assist Hoyer lift with transfers Date Initiated: 04/03/2024 . A review of the Physician's orders revealed an order for Enhanced Barrier Precautions Start Date: 03/26/2024. A review of the care plan (the resident) is on Enhanced Barrier Precautions related to: chronic wound Date Initiated: 03/29/204 . Prophylactic prevention of spreading an infection to the wound: Enhanced Barrier Precautions . Interventions Gloves, gown, alcohol-based sanitizer (masks and face shields if needed), readily available for high-contact resident care Date Initiated: 03/29/2024 . On 4/03/24, at 10:00 AM, Upon entering Resident #18's room, there was still no isolation caddy, gowns or sign on the doorway. Resident #18 was assisted to their reclining Broda chair with the assistance of CNA C and CNA D. Resident #18 did not have a dressing to their right foot and their pressure ulcer was exposed. CNA C offered that they had just assisted with a shower and that the nurse was headed in to put the dressing back on. CNA C positioned Resident #18's right foot for observation. There was an open wound to outside lateral right foot measuring approximately 1 centimeter (cm) wide by 1.5 cm long. The edges surrounding the ulcer appeared dried, yellow with a callus like appearance. There was an approximate depth of 0.5 cm to the center of the wound. On 4/03/24, at 10:13 AM, Therapy Staff (TS) E entered Resident #18's room and was asked if the resident was receiving therapy services and TS E stated, for maintenance on positioning and that they observe weekly to ensure proper positioning. TS E stated, that they ordered a full cushion inlay about two months back and were waiting on it. On 4/03/24, at 10:27 AM, Nurse A entered Resident #18's room with wound care supplies. Nurse A was concerned that it was a new wound as the CNA had reported it was the toe. Nurse A cleansed and treated the existing pressure ulcer to the right lateral foot per the physician's order. Nurse A was wearing gloves and no gown. On 4/03/24, at 1:00 PM, the facility was asked to provide a list of all residents in enhanced barrier precautions. On 4/03/24, at 1:05 PM, Resident #18 remained positioned in their reclining Broda chair. On 4/03/24, at 1:37 PM, Resident #18 was lying in their bed on their back. On 4/03/24, at 3:44 PM, Resident #18 remains in the same position on their back in bed. On 4/04/24, at 9:08 AM, Resident #18 was on lying on their back in bed. There was an isolation caddy to the doorway filled with PPE including gowns. On 4/04/24, at 10:00 AM, Nurse K was interviewed regarding Resident #18's facility-acquired pressure ulcer. Nurse K was asked if the resident was at risk for pressure ulcers and Nurse K stated, yes. A record review along with Nurse K of Resident #18's pressure ulcer treatment orders, measurements and skin evaluations/ulcer pictures revealed on 1/9/2024 the pressure ulcer was nearly healed; there was no depth to the wound the skin was closed. The 2/7/2024 picture revealed moderate amount of yellow slough to center of ulcer with an open area of 3 cm by 3 cm. The depth of the wound was immeasurable due to the moderate amount of yellow slough. Nurse K stated, that they had the wound almost healed but then was off sick and when they came back it had worsened. A record review of the TREATMENT ADMINISTRATION RECORD 2/1/2024 - 2/29/2024 . along with Nurse K revealed the following missed treatments: Tue 14 Sat 24 Sun 25 Wed 28 Thu 29 A review of the TREATMENT ADMINISTRATION RECORD 3/1/2024 - 3/31/2024 along with Nurse K revealed the following missed treatments: Sat 10 Sun 11. Nurse K was asked who completes wound measurements and care while they were not working and Nurse K stated, the scheduled nurses working the halls. On 4/04/24, at 10:10 AM, the Director of Nursing (DON) was interviewed regarding Resident #18's facility-acquired pressure ulcer and the DON offered that because the resident had contractures the ulcer was unavoidable and that therapy is now working with her. A review of the facility provided Skin Management Last Revised 7/14/2021 Policy revealed Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes . Upon admission/re-admission all guests/resident are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record . Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan . Resident #30: On 4/2/2024 at 12:42 PM, Resident #30 was observed finishing his lunch and watching television. This writer observed Prafo boots in the room and asked the resident about them. he explained he wears them only when he is in the bed as a wound developed on his heel at the facility. Resident #30 stated during his shower an aide noticed it and retrieved the nurse for further assessment. The wound is on the bottom of his left heel, but it has not caused him any discomfort. On 4/3/2024 at 10:00 AM, this writer observed Unit Manager B perform wound care on Resident #30's pressure ulcer. The wound was located on the side of the left heel, 100% eschar covered, circular and not able to be staged. On 4/3/2024 at approximately 11:00 AM, a review was conducted of Resident #30 medical records, and it indicated he admitted to the facility on [DATE] with diagnoses that included Acute Posthemorrhagic Anemia, Atrial Fibrillation, Acute Kidney Failure, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting left non-dominant side. Resident #30 is cognitively intact and able to make his needs known to facility staff. Resident #30 utilized a motorized wheelchair, required substantial assistance for lower body dressing/rolling left and right/putting on/taking off footwear. Further review of Resident #30's medical records yielded the following: Admission Assessment 2/16/2024: Per the skin assessment section there was bruising noted on his bilateral upper extremities, blanchable area on buttocks/coccyx, open area on distal left buttock and open area on proximal left buttocks. There was no open area on Resident #30's left heel upon admission the facility. Practitioner Notes: There were no practitioner notes that indicated the physician or designee assessed or were aware of Resident #30's facility acquired pressure ulcer. Progress Notes: 3/8/2024 at 14:43: .Unstageable blister to left heal (CVA side) measuring 3.83 x 3.4 cm (centimeters). Resident with inability to move left side of body due to CVA. Left hand is contracted 3/2/2024 at 21:58: Skin Turgor: Good Elasticity . Number of new skin conditions: 0. 2/24/2024 at 23:51: Skin Turgor: Good Elasticity .Number of new skin conditions: 0. Care Plan: (Resident #30) has unstageable pressure ulcer on left heel. He is at risk for additional impaired skin integrity/pressure injury R/T (related to): mobility deficit, weakness . Skin and Wound Evaluation: 3/6/2024: -Facility acquired unstageable pressure ulcer on left heel. Found on 3/6/2024 with measurements of 9.4 cm x 3.8 cm x 3.4 cm. Wound is 100% eschar and it indicated facility practitioner was notified of the wound. Cleanse wound with normal saline/wound cleanser, pat dry with 4x4's, apply skin prep and leave open to air daily. 3/13/2024: -8.2 cm x 3.8 cm x 3.0 cm, 100% eschar, unstageable with same treatment in place 3/20/2024: -8.2 cm x 3.8 cm x 3.1 cm, 100% eschar, unstageable with same treatment in place 3/28/204: -8.1 cm x 3.3 cm x 3.3 cm, 100% eschar, unstageable with same treatment in place On 4/4/2024 at 12:10 PM, an interview was conducted with the DON (Director of Nursing) and Wound Nurse K regarding Resident #30's facility-acquired pressure ulcer. Wound Nurse K shared that Certified Nursing Assistant (CNA) alerted her on 3/6/2024 to the new development and she assessed and took pictures. The resident had no pain or discomfort and upon discovery they initiated the Prafo boot while in bed. They were asked how the wound developed and it was explained the wound is on his stroke-affected side, which has poor circulation. When he lays in bed, his feet turn outward and that is where the wound developed. Prior to discovery there were no interventions in place while in bed to prevent development of the wound. 39059

Based on observation, interview, and record review the facility failed to administer one resident's (Resident #57) morning medications on their scheduled dialysis days, resulting in Resident #57 not being administered approximately 62 doses of scheduled medication on the days that the resident received dialysis. Findings Include: Resident ##57: On 4/2/2024 at 12:47 PM, Resident #57 was observed in his room after finishing lunch. He reported he is currently on restrictions for food and liquids. He has dialysis three times a week on Monday, Wednesday and Friday and the facility transport him to/from about 6:30 AM for his 7:00 AM chair time. On 4/3/2023 at approximately 10:30 AM, a review was completed of Resident #57's medical records and it indicated he was admitted the facility on 3/11/2024 with diagnoses that included, End Stage Renal Disease, Atrial Fibrillation, Acute Cholecystitis, Heart Failure and Anxiety. Further review of Resident #57's records revealed the following: Care Plan: Administer medications as ordered. Observe for side effects and ineffectiveness, report abnormal findings to the physician .For Hemodialysis: Facility will utilize the Dialysis Communication form to communicate with the dialysis center. Send the dialysis communication book to the dialysis center with each appointment. Upon return from the dialysis center review the communication book including any progress notes. Provide an update to the physician and any staff member/disciplines as needed . MAR (Medication Administration Record): Medications ordered for administration at 8:00 AM and Noon were not provided to Resident #57 over 60 times as he was at dialysis. There was no documentation found that indicated it was provided upon his return from dialysis, communication with the physician regarding missed doses or a plan to ensure administration of medications either prior to or upon return from dialysis. March 2024 MAR (Medication Administration Record): Midodrine HCL 5 MG (milligram)- two missed doses Renal Oral capsule 1 MG - five missed doses Pantoprazole Sodium Oral Tablet 40 MG- five missed doses Apixaban Oral Tablet 2.5 MG- five missed doses Doxycycline Hydrate oral capsule 100 MG- one missed dose Metoprolol Tartrate oral tablet 25 MG- nine missed doses Sennosides tablet 8.6 MG-six missed doses Polyethylene Glycol Powder- seven missed doses Sevelamer HCI tablet 800 MG- six missed doses Ipratropium-Albuterol inhalation Solution- eight missed doses April 2024 MAR: Polyethylene Glycol Powder- one missed dose Sennosides Tablet 8.6 MG- one missed dose Renal Oral Capsule 40 MG- one missed dose Sevelamer Carb 800 MG- two missed doses Ipratropium-Albuterol inhalation- one missed dose Apixaban oral tablet 2.5 MG- one missed dose Metoprolol Tartrate oral tablet 25 MG- one missed dose Progress Notes: 3/20/2024 at 07:23: eMar (electronic medical record) - Medication Administration Note Note Text: Unable to administer due to Res is on LOA at dialysis: DOXYCYCLINE MONO 100 MG CAP {50 EA} Give 1 capsule by mouth two times a day for pneumonia for 7 Days take for 7 days. 3/20/2024 at 07:24: eMar - Medication Administration Note Note Text: Unable to administer due to Res is on LOA at dialysis: Renal Oral Capsule 1 MG. 3/20/2024 at 07:25: eMar - Medication Administration Note Note Text: Unable to administer due to Res is on LOA at dialysis: Metoprolol Tartrate Oral Tablet 25 MG Give 25 mg by mouth two times a day for HTN. 3/20/2024 at 07:25: eMar - Medication Administration Note Note Text: Unable to administer due to Res is on LOA at dialysis: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML. 3/20/2024 at 07:25: eMar - Medication Administration Note Note Text: Unable to administer due to Res is on LOA at dialysis: Apixaban Oral Tablet 2.5 MG Give 2.5 mg by mouth two times a day for A-fib. 3/20/2024 at 07:26:eMar - Medication Administration Note Note Text: Unable to administer due to Res is on LOA at dialysis: Midodrine HCl Oral Tablet 5 MG Give 5 mg by mouth one time a day every Mon, Wed, Fri for Hypotension. 3/20/2024 at 07:27: eMar - Medication Administration Note Note Text: Unable to administer due to Res is on LOA at dialysis: Polyethylene Glycol Powder. Give 17 gram by mouth two times a day for Constipation. 3/20/2024 at 07:27: eMar - Medication Administration Note Note Text: Unable to administer due to Res is on LOA at dialysis: Sennosides Tablet 8.6 MG. Give 2 tablet by mouth two times a day for constipation. 3/20/2024 at 11:00: eMar - Medication Administration Note Note Text: Unable to administer due to Res is on LOA at dialysis: HCl Oral Tablet 800 MG Give 2 tablet by mouth with meals for Kidney failure. 3/20/2024 at 11:00: eMar - Medication Administration Note Note Text: Unable to complete the following treatment due to Res is on LOA at dialysis: Empty and measure JP drain TID right side three times a day for JP drain. 3/20/2024 at 12:00: eMar - Medication Administration Note Note Text: Unable to administer due to Res is on LOA at dialysis: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligram) /3ML (milliliter). 3/20/2024 at 12:26: eMar - Medication Administration Note Note Text: Unable to administer due to Res is on LOA at dialysis: Pantoprazole Sodium Oral Tablet Delayed Release 40 MG. 3/27/2024 at 09:14 AM, 09:15, 09:16, 09:17, 09:18, 09:18: eMar-Medication Administration Note: at dialysis. 3/29/2024 at 07:42: unable to administer due to Res is on LOA at dialysis: Apixban Oral tablet 2.5 mg. 3/29/2024 at 07:43: Unable to administer due to Res is on LOA at dialysis: Metoprolol Tartrate oral tablet 25 MG. 3/29/2024 at 07:43: Unable to administer due to Res is on LOA at dialysis: Ipratropium-Albuterol Inhalation . 3/29/2024 at 07:43: Unable to administer due to Res is on LOA at dialysis. Pantoprazole Sodium oral . 3/29/2024 at 07:44: Unable to administer due to Res is on LOA at dialysis. Polyethylene Glycol Powder. 3/29/2024 at 07:44: Unable to administer due to Res is on LOA at dialysis. Sennosides Tablet. 3/29/2024 at 07:44: Unable to administer due to Res is on LOA at dialysis. Sevelamer Carb. 3/29/2024 at 07:45: Unable to administer due to Res is on LOA at dialysis. Renal oral capsule. 04/04/24 at 01:23: Issues with medications being ordered and not given before. notes say not able to administer due to res on LOA at dialysis and holes on Wednesday. On 4/4/2024 at 3:45 PM, an interview was held with Nurse K regarding Resident #57's medications. Nurse K explained after review of the resident's chart, they were not able to locate any documentation that indicated the medications he missed while at dialysis were administered upon his return. Nurse K explained his March/April 2024 MARs were inconsistent on if he was administered the medications on dialysis days. Review was completed of facility policy entitled, Hemodialysis, effective 9/23/2023. The policy did not address medication administration on scheduled dialysis days. Review was completed of facility policy entitled, Medication Administration, revised 10/17/2023. The policy stated, .Medication administered in accordance with written orders of the attending physician .Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to established medication administration schedule for the facility .

Based on interview and record review, the facility failed to ensure a that Pharmacy Regimen Review was acted upon for one resident (Resident #15), resulting in a delay of the pharmacy recommendation of a fasting (nothing to eat or drink for 8 to 12 hours beforehand) lab test with the likelihood of unwanted side effects and/or ineffectiveness of the medication going unmonitored. Findings include: Resident #15: On 4/02/24, at 11:35 AM, a record review of Resident #15's electronic medical record revealed an admission on 2/26/2016 with diagnoses that included Chronic Pulmonary Obstructive Disease, Hypertension and Anxiety. A review of the Medication Regimen Review - Pharmacy Date: 2/5/2024 revealed the box was check marked for See report for noted irregularities and/or recommendations. A review of the Consultation Report . Recommendation date: 02/05/2024 . Comment: (Resident #15) receives Atorvastatin Calcium and does not have a fasting lipid panel documented in the medical record in the previous 12 months. Periodic lipid monitoring is recommended to evaluate effectiveness and to assist in adjusting medication therapy to the individual treatment plan. Recommendation: Please monitor a fasting lipid panel on the next convenient lab day and every 12 months thereafter . The line with the physician name had a signature and was dated 2/6/24. A review of the Consultation Report . Recommendation date: 03/11/2024 . Comment: (Resident #15's) prescriber accepted a pharmacy recommendation to draw lipid panel on 2/6/24, but the order has not yet been processed. (no order or lab result in (PCC) Recommendation: Please process the accepted pharmacy recommendation and update the medical record accordingly. A review of the third Consultation Report . Date: 04/02/2024 . Comment: (Resident #15) prescriber accepted a pharmacy recommendation to draw lipid panel on 2/6/24, but the order has not yet been processed . Recommendation: Please process the accepted pharmacy recommendation and update the medical record accordingly. There was a written message Lab ordered 4-3-24. A review of the facility provided lab result BLOOD Collected 03/18/2024 14:55 (2:55 PM) revealed the lab was drawn in the middle of the afternoon and was not a fasting lipid panel blood test.

Based on record review, the facility failed to provide timely physician's visits for one resident (Resident #15), resulting in a lack of a physician's 60-day follow-up visit, with the likelihood of decreased quality of care and missed assessments of health changes. Findings include: Resident #15: On 4/02/24, at 11:35 AM, a record review of Resident #15's electronic medical record revealed an admission on 2/26/2016 with diagnoses that included Chronic Pulmonary Obstructive Disease, Hypertension and Anxiety. A review of the physician visits revealed the last visit was documented on Date of Service: 1/19/24 Visit Type: Acute'. There were no documented physician visits from 1/19/2024 thru survey exit 4/4/24. A review of the facility provided Physician Services Last Revised 2/22/2022 Policy revealed . Each guest/resident must be seen by their physician at least every 30 days for the first 90 days after admission, and then every 60 days thereafter . A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required .

This Citation Pertains to Intake Numbers MI 477, MI 118, MI 060, MI 132, MI 310, and MI 636 Based on observation, interview and record review, the facility failed to institute and operationalize policies and procedures to ensure adequate supervision and implementation of planned, appropriate, and meaningful interventions to prevent falls in a timely manner for four residents (Resident #8, Resident #158, Resident #159, and Resident #160) of six residents reviewed for falls. This deficient practice resulted in multiple major injuries resulting from falls within the facility including Resident #8 suffering a femur fracture requiring surgical intervention, Resident #158 suffering a fractured femur with essential surgical intervention, Resident #159 fracturing both their sacrum (triangular bone at the bottom of the spine which connects the pelvis to the spine) and their right sided superior and inferior pubic rami (pelvis), and Resident #160 enduring a traumatic subdural hemorrhage (bleeding between the brain and the skull and puts pressure on the brain) and nasal bone fractures, unnecessary pain, and the likelihood for decline in overall health status. Findings include: Resident #8: Review of Intake documentation revealed Resident #8 had an unwitnessed fall in their room on 6/20/21 at 6:45 PM and sustained a left femur fracture. Intake documentation detailed, (Resident #8) was observed on the floor . curled up and holding their left side. (The Resident) verbally complained of left hip pain upon assessment . Staff asked resident what had happened and (Resident #8) stated 'I went around the walker to reach those slippers and fell ' . Resident was transferred to the local hospital for an x-ray of left hip . (Resident #8) sustained a left femur fracture and remained at the hospital for surgical repair . Resident has a history of falls and does not use the call light for assistance with transfers . At 9:45 AM on 12/14/21, Resident #8's room was observed. The room was not visible from the nurses' station. On 12/14/21 at 9:50 AM, Resident #8 was observed self-propelling in a wheelchair in their room. The Resident's bed was positioned with one side of the bed directly against the wall. The call light was observed hooked to the top of a cord, near the end of the bed, on the same wall the bed was positioned against. The call light was not within reach of the Resident and was unable to be easily accessed when standing. A rug was present on the floor in front of a recliner in the Resident's room. An interview was conducted with the Resident at this time. When asked if they had fell at the facility, Resident #8 replied, Yes, I broke this (touched left) hip and hit my head. Resident #8 continued, I still have lapses in memory. When asked what happened when they fell , Resident #8 stated, I don't remember. All I remember is waking up and they told me I fell . With further inquiry, Resident #8 stated, I don't remember the time at the hospital and revealed they had been transferred to the hospital following the fall and had surgery. When asked if they were having pain, Resident #8 stated, My hip is sore right now, but it really hurts when I get up. Resident #8 revealed they are not able to ambulate as well as they did prior to the fall due to pain. When queried regarding pain management, Resident #8 revealed they do not like to complain or take pain medications because I don't want to get addicted to it. Resident #8 was queried if they had received education related to pain management and healing and indicated they did not recall receiving education from staff at the facility. When queried if they had other falls in the facility, Resident #8 revealed they had. Record review revealed Resident #8 was originally admitted to the facility on [DATE] with diagnosis which included Alzheimer's disease, dementia, [CONDITION(S)] disease (disease which causes inflammation in the digestive tract, gastrointestinal discomfort, and diarrhea), weakness, diabetes mellitus, depression, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required limited, one-person assistance for transferring, walking, locomotion, and dressing and extensive one-person assistance with toileting and personal hygiene. The MDS further indicated the Resident had a history of falls. Review of facility provided investigation documentation pertaining to Resident #8's fall with fracture on 6/20/21 revealed the following: - Incident and Accident (I and A) Report . 6/20/21 . Location: Resident Room . Observed on floor . Type of Injury: Fracture . Left hip . Heard yelling. Opened bedroom door and observed laying on floor. (Resident #8) was curled up and c/o (complain of) left hip pain . Interventions implemented: Reminded resident to use call light for assistance (line drawn through intervention); PT (Physical Therapy)/OT (Occupational Therapy) to eval upon return from hospital (line drawn through intervention); Med review upon return from hospital, PRN (as needed) pain medication scheduled and PRN anti-anxiety meds ordered . Mental Status Prior to fall: A & O (Alert and Orientated) X 2 with confusion . Footwear at time of fall: Slippers . Gait Assist devices at time of fall . not in use . Time last toileted or changed . 5:30 PM . Medications . New medications/changed dose within last 30 days . Last time of guest/resident observation: 6:00 PM . Initial intervention to prevent further falls: Reeducated to call for assistance with transfers . - Incident and Accident Investigation Form . 6/20/21 . 6:45 PM . Description: Resident observed on the floor in room by direct care staff. After evaluation, Resident was transferred to the local hospital for a suspected fx (fracture). Hospital reports resident sustained a fx of the left femur Investigation . other documentation reviewed: Plan of care, medication list, progress notes . Additional interviews: (Certified Nursing Assistant [CNA] Q) . Date: 6/21/21 . Signature of Interviewee indicated that he/she has been interviewed, reviewed the interview summary and did not give a written statement: (BLANK) . (CNA S) . Date: 6/21/21 . Signature of Interviewee indicated that he/she has been interviewed, reviewed the interview summary and did not give a written statement: (BLANK) . (Licensed Practical Nurse [LPN O]) . Date: 6/21/21 . Signature of Interviewee indicated that he/she has been interviewed, reviewed the interview summary and did not give a written statement: (BLANK) . LPN P Date: 6/20/21 . Signature of Interviewee indicated that he/she has been interviewed, reviewed the interview summary and did not give a written statement: (BLANK) . Conclusion: Resident was ambulating in room with walker attempting to pack bags and in doing so lost balance and sustaining a fall resulting in a fracture to the left hip . - Typed, unsigned, and undated Witness Statements . (CNA Q): I was walking up 400-hall around 6:45 PM. (LPN P) said they though they heard someone calling for help so I went down 300-hall to find out who. When I got to (Resident #8's) room, the door was partially closed and when I entered, I seen (the Resident) laying on the floor on left side. Their walker was in the upright position in front of them . I last observed resident around 5:15 PM when I picked up their dinner tray . (LPN P): I had just finished taking report . when I heard someone yelling for help . I sent (CNA Q) to find out who it was . informed me (Resident #8) was on the floor . (Resident #8) was lying on the floor on left side . (CNA Q) stayed in room with (Resident #8) until EMT's arrived . (LPN O): I walked by Resident room around 5:30 PM . Resident was up walking around room without walker. I assisted . to and from the bathroom and make sure walker was within reach as (Resident #8) frequently self-transfers in room and forgets to use walker . At the time of the incident, I had just finished giving report to the oncoming nurse (LPN P) . (CNA Q) observed (Resident #8) on the floor. I went in to check on (Resident #8) . - Hospital CT (Computerized Tomography- diagnostic test) of the pelvis . Findings . nondisplaced seventh capitellum fracture of left femur . Impression: Subcapital incomplete fracture of the left femur without any dislocation of any displacement of the fracture fragments . Upon request for all Incident and Accident documentation for Resident #8, the following was provided and reviewed: - 6/4/21: I and A Report . 1700 (5:00 PM) . Location: Resident BR (Bathroom) . Observed on floor . Injury: Abrasion . Left Shoulder . Resident found on floor- sitting, legs crossed under them, arms folded . stated struck head on door . Physician Statement: No new orders . continue to monitor . Interventions implemented: Direct Resident to use call light . Move to room closer to nursing station . Post Fall Evaluation: 6/4/21 . trying to do just before they fell : Toilet self . Unwitnessed . Mental Status: Confused . Last time of guest/resident observation? 1700 in bed . Recreation of last 3 hours before fall . Resident in bed at 1700, found in bathroom at 1715 (5:15 PM) . Resident is weak and unstable when ambulatory . Initial intervention: Use call light . - 7/3/21: I and A Report . 1850 (6:50 PM) . Location: Resident Room . Fall . Observed on floor . Type of Injury: Bump, bruise . Back of head bump 1.5 cm (centimeter), bruise 2 cm (right) hip . Resident had incontinent of bowel . (Resident #8) stated slipped. There was bowel on floor and (Resident) . trying to clean self-up . observed lying on right hip, feet by the bathroom and head by hall door . Interventions Implemented: Assessed for injuries, sent to ER for eval, gripper socks on in bed, PRN antidiarrheal medication ordered (different handwriting and pen) . Post Fall Evaluation: 7/3/21 . Description: Incontinent of bowel, tried to clean self, slipped and fell . BM (Bowel Movement) on floor . Unwitnessed . Lying on right hip, feet near bathroom door. Head located near hall door. BM on floor. Bare feet. Legs bend at knees and hip. Resident had taken off gown and pull up and was naked on floor . unwitnessed . mental status: confused . baseline . Intervention to prevent further falls: Gripper socks while in bed . An interview was conducted with Certified Nursing Assistant (CNA) S on 12/14/21 at 1:26 PM. When queried if they were familiar with Resident #8, CNA S revealed they were. CNA S was then asked if they were working when Resident #8 had fell in the facility, CNA S replied, Which time? (Resident #8) fell quite a bit when they first got here. When asked about the fall where Resident #8 broke their femur, CNA S revealed they were working but they were not the Resident's assigned CNA and stated, (CNA Q) was. CNA S continued, I helped get (Resident #8) up with EMS (Emergency Medical Services). Apparently (the Resident) was trying to go the bathroom. (Resident #8) has [CONDITION(S)]. When asked if the Resident had been incontinent of stool, CNA S indicated they were. With further inquiry regarding the fall, CNA S revealed they went into the Resident's room to ask (CNA Q) if they needed help and stated, (Licensed Practical Nurse [LPN] P) and (CNA Q) were in there (Resident #8's) room. (Resident #8) was on a blanket and had a pillow under them. CNA S continued, You could tell (Resident #8) was in pain. CNA S was then queried regarding Resident #8's other falls in the facility and revealed they had been assigned to care for the Resident another day when they fell . When asked about the fall, CNA S stated, (Resident #8) was on the floor in the bathroom. (The Resident) said they slipped. Their walker was in the doorway. When queried if the Resident was incontinent when they found them, CNA S replied, Already went to the bathroom. (Resident #8) was sitting Indian style looking at the toilet. CNA S was asked what level of care and assistance Resident #8 required and stated, Needed help to go to the bathroom. CNA S was then queried regarding facility policy/procedure pertaining to investigations following a fall and revealed CNA staff write down observations for past three hours when there is a fall. When asked about Resident #8's interventions to prevent falls, CNA S revealed the Resident did not have any specific interventions in place. On 12/14/21 at 1:50 PM, an interview was completed with LPN O. When queried if they were working and/or recalled Resident #8's fall with fracture in the facility on 6/20/21, LPN O indicated they did. When asked what had transpired, LPN O stated, Pretty sure (Resident #8) was going to the bathroom and slipped because there was stool everywhere. LPN O continued, Found (Resident #8) two to three feet away from the bathroom door in the room. When asked who found the Resident, LPN O replied, One of the Aides (CNAs) and revealed the fall had occurred at nurse shift charge. When asked about facility process/procedure for investigations following falls and incidents in the facility, LPN O stated, We just write on the I and A (Incident and Accident form) and I (nursing staff) interview the aide. When asked about interventions in place to prevent falls and injury for Resident #8 when they fell and fractured their femur, LPN O revealed they did not recall any specific or additional interventions. With further inquiry regarding the Resident's falls, LPN O indicated the Resident had multiple falls and each fall had been related to the Resident having to use the restroom. LPN O stated, (Resident #8) has IBS (irritable bowel syndrome) and when they have to go, they can't wait. They had loose stools all the time. When asked if Resident #8 had interventions in place related to their bowels such as a toileting schedule and/or frequent monitoring, LPN O revealed the Resident did not have interventions in place related to toileting. LPN O was queried why an intervention was not in place related to toileting if staff were aware Resident #8 would get up and go the bathroom due to urgency, LPN O was unable to provide an explanation. An interview was completed with CNA Q on 12/14/21 at 2:25 PM. When queried if they recalled Resident #8's falling in the facility, CNA Q revealed they did. CNA Q stated, (Resident #8) fell on me like twice almost the same week. With further inquiry, CNA Q stated, (Resident #8) was super disorientated. We told them to use the walker and the call light, but they never did. When asked about the fall on 6/20/21 where Resident #8 suffered a fractured femur, CNA Q revealed they found the Resident following the fall. CNA Q stated, (Resident #8) was on their side. Their walker was tipped over in front (of them). CNA Q then stated, (Resident #8) was incontinent of stool. It (stool) was out of the brief. We got (Resident #8) cleaned up before the ambulance arrived. When asked if Resident #8 was incontinent for the second fall they had mentioned, CNA Q indicated all of Resident #8's falls which they were aware of were related to the Resident trying to go to the bathroom due to urgency. CAN Q revealed the Resident had IBS. CNA Q then stated, It's weird because the falls were all around the same time. When queried regarding Resident #8's care and fall prevention interventions and if the Resident had a toileting schedule due to their IBS, CNA Q revealed they were not aware of Resident #8 having interventions related to their IBS, self-transferring, and subsequent falls. Review of Resident #8's care plans revealed a care plan entitled, (Resident #8) is at risk for fall related injury and falls R/T (related to): antidepressant usage, history of falls, bowel and bladder incontinence . dementia and has poor safety awareness . (Created and Initiated: 6/3/21; Revised: 7/6/21). The Goal of the care plan detailed, Will be free from injury related to falls through the review date (Created and Initiated: 6/3/21; Revised: 6/23/21) and included the interventions: - Anticipate and meet needs PRN (as needed) (Created and Initiated: 6/3/21) - Complete fall risk per protocol (Created and Initiated: 6/3/21) - Encourage . to rest in recliner and chair when they appear fatigued (Created and Initiated: 6/3/21) - Follow facility fall protocol (Created and Initiated: 6/3/21) - Observe for fatigue and/or unsteadiness and encourage rest periods as needed - Put . call light within reach and encourage . to use it for assistance as needed (Created/Initiated: 6/3/21; Revised: 6/23/21) - PRN anti-diarrhea medications ordered (Created and Initiated: 7/6/21) - Anti-anxiety medication ordered PRN x 3 days to manage anxious behavior that may lead to falls (Created: 6/30/21; Initiated: 6/25/21) - Gripper socks applied and rechecked for placement post fall on 7/3/21 (Created: 7/6/21; Initiated: 7/3/21) - Room moved closer to nurses' station (Created: 6/30/21; Initiated: 6/4/21) Review of Resident #8's progress note documentation in the Electronic Medical Record (EMR) revealed the following: - 6/4/21 at 5:46 PM: Nurses Notes . resident found on floor in bathroom, sitting on buttocks . Small abrasion noted left shoulder, cleansed with soap and water, resident denies pain, states struck head, no abrasions or hematoma's noted . - 6/5/21 at 3:27 PM: Nurses Notes .s/p (status post) fall 06/04/2021 patient c/o (complain of) generalized pain . - 6/20/21 at 8:00 PM: Nurses Notes . Resident noted to have fallen in room . Telemed visit performed and . gave me an order to send to (Hospital) for further eval and treatment . - 6/20/21 at 12:00 AM: Progress Notes . Telehealth . Chief Complaint: Left hip pain, decreased ROM (Range of Motion) following a fall . Patient is complaining of 10/10 left hip pain and is unable to straighten left leg. Patient has prior injury to this hip as well . Musculoskeletal: Left hip is significantly tender to palpation. Patient unable to straighten left leg . + deformity noted . Xray not available STAT by mobile (provider) therefore patient sent out to the ER for likely left hip fracture . - 6/23/21 at 5:14 PM: Nursing Summary Note . patient readmission . patient A (alert) &O (orientated) X 1 (self) . surgical incision to left hip . -7/4/21 at 2:20 AM: Nurses Notes . 1850 (6:50 PM) resident observed on the floor . had been incontinent of bowel. Brief was by bed . lying by the bathroom with feet by bathroom door and head toward the hall door. Resident had taken gown and brief off . lying on left side. Resident was complaining of left hip hurting . surgical hip . unable to straighten left leg and yelled out in pain with attempted ROM to assess that hip. On call was contacted and ordered to send to ER for eval and treatment. resident has a 2 cm bruise to right hip . has 1.5 cm bump to the back of head . 1950 (7:50 PM) ambulance left with resident . 2250 (10:50 PM) Resident arrived back at facility. Neuro checks started r/t (related to) hitting head . Review of Resident #8's census data revealed the Resident was moved rooms within the facility on 6/7/21. An interview was conducted with the Director of Nursing (DON) on 12/14/21 at 3:15 PM. The DON was asked if resident call lights should be hung on the wall and not within the Resident's reach and revealed call lights should be accessible to residents. When asked why Resident #8's call light was hung on the same wall which the bed is positioned against and not within reach of the Resident, the DON was unable to provide an explanation. When queried regarding Resident #8's fall in the facility on 6/20/21 with resulting femur fracture and if the Resident's call light was in reach at the time of the fall, the DON reviewed the I and A documentation for the fall and revealed the call light was not on and indicated the Resident did not use their call light. When asked if the call light was in reach and accessible at the time of the fall, the DON did not provide a response. When asked about the I and A documentation for Resident #8's fall on 6/20/21 indicating the Resident was last observed at 6:00 PM when the provided statements detailed the Resident had been last observed at 5:30 PM, the DON was unable to explain the discrepancy. The DON was then queried regarding the staff witness statements not being signed by staff and replied, They were verbal. That is how I do it. When queried regarding facility policy/procedure related to investigations of occurrences and staff statements including written vs. verbal statements and signatures, the DON indicated they would need to review the policy. Resident #8's care plan was reviewed with the DON at this time. When queried regarding each of Resident #8's falls being related to the Resident using the bathroom without assistance, the DON indicated they were aware of the Resident's activities at the time of the falls. When queried regarding interventions in place pertaining to their diagnosis of [CONDITION(S)] disease as well as interventions to ensure adequate supervision and assistance to prevent falls when the Resident fell on [DATE], the DON indicated the Resident's room had been moved closer to the nurses' station following their fall on 6/4/21. When asked if the Resident's room was visible from the nurses' station, the DON revealed it was not. When asked, the DON revealed Resident #8 had been a high fall risk. The DON was then queried what the care plan intervention, Follow facility fall protocol entailed and replied, That is just what we do if someone falls. When queried why the Resident did not have interventions such as a toileting schedule and/or scheduled/frequent monitoring, the DON indicated they did not and would not implement a toileting schedule for Resident #8. The DON continued, I don't put that on a care plan. It's common sense. When asked how staff know what care and monitoring residents require if not care planned, the DON replied, It's common sense and reiterated they do not put everything on the care plan. The DON was queried if the Resident's footwear (slippers) at the time of the fall were assessed to ensure proper fit. The DON was unable to demonstrate that Resident #8's footwear was assessed but denoted the Resident did have their slippers in place. When queried regarding standard interventions to prevent falls and injury, such as low bed height, trip hazard removal, appropriate fitting, non-slip footwear, and increased monitoring frequency, the DON reaffirmed their previous response indicating those interventions were common sense. When queried regarding staff statements of Resident #8's known bowel urgency and bowel incontinent when they fell on [DATE], the DON replied, How do staff remember that? The DON indicated they were not aware the Resident was incontinent when they fell on [DATE]. The DON was then asked if they had asked staff about the Resident's continence as part of the investigation and replied, No. When queried how they were able to determine the root cause of the fall and implement appropriate interventions to prevent further falls if they did not complete a thorough investigation to determine the cause of the fall, the DON did not respond. The DON was then queried regarding the dates for Resident #8's care plan intervention, Room moved closer to nurses' station including the reason the intervention created date was after the initiated date and why neither date correlated with information in the census documentation. The DON stated they would guess it wasn't added so I added it later. When asked why the intervention of moving the room closer to the nurses' station did not occur until 6/7/21, three days after the Resident's fall on 6/4/21, the DON revealed they would need to review facility census data. When asked why there were no progress notes and/or assessment documentation related to the room change in the Resident's medical record, an explanation was not offered. With further inquiry regarding resident specific interventions implemented to prevent falls, as the Resident was assessed to be a high fall risk, no further explanation was provided. The DON was then queried regarding Resident #8's door being partially closed when they fell on [DATE] and if the door should have been opened or closed due to the Resident's risk of falls. The DON revealed the door should have been open and stated, (Resident #8) probably closed it. When asked how long the door was closed without staff being aware, the DON was unable to provide a response. The DON was then queried regarding facility policy/procedure related to rugs in resident rooms and if rugs increase the risks for falls and stated, Yes. When asked about Resident #8 having a rug in their room, Resident #8 replied, Shouldn't. The DON was then queried why the Resident had a rug if they should not, the DON did not provide an explanation. The DON then stated, Well, it is not on the care plan that they can't have a rug. An interview was completed with CNA J on 12/16/21 at 12:36 PM. When queried if they were working when Resident #8 fell in the facility, CNA J stated, I can't actually remember. (Resident #8) fell quite a bit for a while. When asked for clarification of falling quite a bit, CNA J was indicated the Resident fell frequently but was unable to provide a specific number of falls. CNA J was then asked about fall prevention interventions in place for Resident #8 including any specific interventions and replied, I don't remember anything specific for (Resident #8). An interview was conducted with Registered Nurse (RN) I on 12/20/21 at 3:33 PM. When queried if they were familiar with Resident #8, RN I indicated they were. When asked about Resident #8 fall risk and falls in the facility, RN I revealed the Resident had fallen and fractured their hip. RN I stated, (Resident #8) was really crazy after they came back from the hospital. We (staff) put (the Resident) in the Geri Chair and they would throw things. RN I divulged staff would put the Geri Chair at the desk due to their behaviors. RN I was asked if Resident #8 fell in the facility after the fall with fracture, RN I indicated they had. When queried regarding fall prevention interventions implemented to ensure Resident #8's safety, RN I revealed they did not recall any specific interventions. When queried regarding facility staffing levels, RN I revealed core staffing on night shift is two nurses and four CNAs. RN I disclosed the facility has four halls and each nurse has two halls and one CNA per hall. When queried if the staffing levels were sufficient to provide adequate supervision to residents, RN I stated, There are some nights that are short (staffed). RN I was asked the frequency in which they are short staffed on night shift and replied, I don't keep track. RN I revealed they Just have to go with it in regard to staffing levels. With further inquiry regarding staffing and the provision of assistance to residents who require two assistance, RN I indicated the CNAs assist each other with Residents who require two-assist on their respective assigned halls. RN I was asked if facility halls were left without staff supervision while staff were providing assistance to the Resident's who required two-assist and replied, Yes. When queried if Residents had fell while staff were on other halls providing care, RN I replied, Yes. RN I was asked how many residents required two-assist and replied, On the 200 and 300 halls, I would guess around 10. RN I was unaware of the number of residents who required two-person assistance on the other two halls of the facility. On 12/20/21 at 3:59 PM, an interview was conducted with Licensed Practical Nurse (LPN) P. When queried regarding Resident #8's fall on 6/20/21, LPN P stated, I just came on shift and heard (Resident #8) screaming. I sent a CNA down to check. When queried regarding Resident #8's fall risk, LPN P stated, (Resident #8) was definitely a high fall risk. (The Resident) would shut the door and walk around by themselves. LPN P further indicated the Resident was confused. LPN P was queried if the Resident was incontinent, LPN P replied, Yes. LPN P then stated, (Resident #8) has IBS or [CONDITION(S)]. They need to get to the bathroom right away. When queried if Resident #8 was on a toileting schedule and/or frequent monitoring related to their fall risk, history of falls, and confusion, LPN P revealed the Resident did not have those interventions in place. LPN P was then asked about facility policy/procedure following a fall in the facility and the involvement of nursing staff in development and implementation of interventions to prevent falls. LPN P stated, We update the care plan immediately or we are supposed to. When queried regarding the types of interventions nurses were able to implement following a fall, LPN P revealed nursing staff are supposed to implement an immediate intervention following falls but indicated there are no defined interventions. When asked if nursing staff were able to implement fall mats as intervention, as an example, LPN P replied, We used to. I don't know why we don't. An interview was completed with Nurse T on 12/20/21 at 4:15 PM. When queried regarding staffing in the facility, Nurse T stated, It's tough. When asked if there were enough staff to provide adequate supervision to Residents, Nurse T replied, Some nights there are multiple residents who need close supervision, and we don't have enough (staff). Nurse T continued, There have been multiple times when I have had to take residents on med pass with me. When queried, Nurse T revealed two nurses and four CNAs were supposed to be scheduled to work each night shift. Nurse T elaborated that the facility census was around 60 residents, so each nurse was assigned to 30 residents and each CNA was assigned to approximately 15 residents. When queried regarding the number of residents who required the assistance of two staff for care, Nurse T revealed they were unable to provide a specific number but indicated there were many residents. Nurse T was then asked if halls were left without staff supervision when CNAs were providing care to residents who required two assist and stated, Yes there would be no supervision. When queried if they had noted resident falls on halls where there was no staff supervision, Nurse T indicated they had. On 12/21/21 at 12:35 PM, Resident #8's call light was observed hanging on the wall in the same place/position as on 12/14/21 and not within reach of the Resident. Resident #158: Review of intake documentation for Resident #158 revealed the Resident fell in the facility on 5/5/21 at 4:35 AM and suffered a subcapital fracture of the right femur necessitating emergency medical care and treatment. Record review revealed Resident #158 was originally admitted to the facility on [DATE] on Hospice services in place and diagnoses which included Alzheimer's disease, dementia, anxiety, difficulty walking, restlessness, and agitation. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive to total assistance to complete ADLs. The MDS further revealed the Resident had a history of falls. Resident #158 was readmitted from the hospital on 5/7/21 without Hospice services and passed away in the facility on 6/4/21. Review of Resident #158's medical record revealed the following progress note documentation: - 4/27/21 at 3:40 PM: Nursing Summary . patient arrived . via family car. patient is hospice care . patient confused .Patient one assist . - 5/4/21 at 2:44 PM: Nurses Notes . This nurse made aware of resident being observed on the floor at 1420 (2:20 PM) in their room sitting on buttocks next to bed with legs extended. Upon further review it is noted that resident has [CONDITION(S)] (decrea [TRUNCATED]

This citation pertains to the facility reported incident Intake Number MI 260. Based on observation, interview, and record review, 1. the facility failed to provide adequate supervision to prevent a second degree burn from a coffee spill and 2. failed to notify a nurse of the burn in a timely manner to prevent skin damage from the coffee spill for one supervised resident (Resident #43) of one resident reviewed for accidents, resulting in a second-degree burn (Involves the first two layers of skin. Second-[MEDICAL CONDITION] present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin) and pain. Findings include: Review of Resident #43's most recent Minimum Data Set (MDS), prior to the 11/13/18 coffee spill incident-dated 9/13/18, indicated her eating level was supervision and, at times, required one-person physical assist. Resident #43's Brief Interview for Mental Status (BIMS) score was two, which reflected severe cognitive impairment. Resident #43's nutrition care plan, initiated 9/26/16, stated (Resident #43) dines in the supervised dining area. Provide verbal encouragement and assist with meals as needed. Resident #43's skin care plan, created 9/21/16, stated (Resident #43) has potential/actual impairment to skin integrity r/t (related to) fragile skin . Review of the facility's Incident and Accident Report for Resident #43's left upper leg burn resulting from spilling hot coffee in her lap, dated 11/13/18, indicated: - Resident removed lid from coffee cup during breakfast meal. Spilled coffee on Left upper leg. - Interventions Implemented - EXPLAIN (Corrective Measures Taken to Reduce Repetition of Accident or Incident) Supervised area for meals. Therapy to eval (evaluate) for appropriate device to use for hot liquids. Conclusion - CP updated for 2 handle sippy cup for hot liquids. The facility implemented. Supervised area for meals on 11/13/18, after this was already an intervention on the care plan since 9/21/16. - Brief Description of the Incident: Resident in main DR (dining room) for AM (morning) meal where she normally sits per her routine and plan of care. Resident served coffee .removed lid (Resident #43 removed lid) from coffee it spilled coffee on her left leg .and had coffee cup with lid in place. - Conclusion .Res (Resident) in main DR (dining room) for breakfast meal. Resident served coffee per her preference with lid on coffee per plan of care .Res removed lid from coffee and spilled coffee on her left leg .Upon re-interview by DON (Director of Nursing) with Res, resident still able to state she spilled coffee. - Provide a brief description of the plan to avoid this situation in the future .Resident care plan updated .for resident to sit in supervised area. No hot liquids until eval complete by therapy. The facility's plan to avoid this situation involved for resident to sit in supervised area, however as per the nutrition care plan, initiated 9/21/16 (implemented approximately two years before this burn incident), stated (Resident #43) dines in the supervised dining area. Provide verbal encouragement and assist with meals as needed. The intervention of supervision had been started in (YEAR), however the burn occurred under the care-planned intervention of supervision which remained in place at the time, and remained a post-burn intervention. Supervision was insufficient at the time of the incident to prevent the coffee spill and burn. - While nurse was observing leg/injury Resident stated I spilled my coffee . - CNA H stated on 11/13/18, Summary of Statement/Interview: Resident (#43) was being taken out of dining room by another staff member .She (CNA H) took resident into dining (room) for breakfast .She denies getting any beverages for the resident at that time (06:15). - CNA D stated on 11/13/18, Summary of Statement/Interview: Resident (#43) in dining room at approximately 06:20, resident at the table drinking her fluids, coffee cup on the table .noticed wet area on pant leg, staff (CNA D) wiped pant leg off with clothing protector .staff (CNA D) wheeled resident to activity room . - CNA C stated on 11/13/18, Summary of Statement/Interview: Staff member (CNA C) toileted resident and noticed red area on left leg .Staff member (CNA C) asked resident what happened, resident replied I spilled coffee on my leg at breakfast it hurts .This was at 07:25. - Licensed Practical Nurse G stated on 11/13/18, Summary of Statement/Interview: At 7:25 AM I was notified that res (resident) had a red blistered area on her left upper leg by CNA .I applied Aloe to the area per orders due to no silvadine available . - Physician Findings:, from Nurse Practitioner I at 12:30 PM, was a second degree burn with small blister. - Physician Statement: included physician orders, Physician J, Apply silvadine cream to left upper thigh BID (twice a day) and cover with (manufacturer brand's gauze wrap). Schedule (Manufacturer's Name Brand pain reliever) ([MEDICATION NAME]; pain reliever) BID and PRN (as needed) q (every) 6 hours. One time dose ordered at 11:30 AM- may apply Aloe vera until Silvadine available. Review of the facility's SBAR Communication Form (Situation, Background, Appearance, and Review and Notify), dated 11/13/18 at 11:00 AM, stated the following: - Other change in condition: 2nd degree burn to left upper leg - Things that make the condition or symptom worse are: Touch to site - Things that make the condition or symptom better are: (Manufacturer's Name Brand pain reliever) ([MEDICATION NAME]; pain reliever) - Skin Evaluation . Burn - Pain Evaluation . Does the resident have pain? Yes (describe below) .Is the pain? New (selected with check mark) Description/location of pain: Pain at site of burn/Left Thigh (front) .Intensity of Pain (rate on scale of 1-10, with 10 being the worst): (area was left blank) .Does the resident show non-verbal signs of pain (for residents with dementia)? Yes (describe) Occasional moan or groan. Low-level of speech with a negative or disapproving quality., Sad, frightened, frown, Tense, Distressed pacing. Fidgeting,. - .Area is painful to touch when Aloe was applied to site. Blisters intact to site. Review of the Wound/Skin Healing Record, dated 11/17/18, indicated that the date of onset was 11/13/18 for the burn area to the Left thigh (front) and measured 8 centimeters in length by 15 centimeters in width. The record also stated, Exudate Type Serous (thin fluid), Wound Bed Pink/Beefy Red, Surrounding Skin Color Bright Red, Pain r/t (related to) Wound .Is the resident experiencing Pain related to the wound? . Yes .Non-verbals demonstrated .Grimacing. Review of the Wound/Skin Healing Records for the burn site, dated 11/19/18 and 11/27/18, stated Pain r/t Wound . Is the resident experiencing pain related to the wound? .Yes. During meal observations on 04/02/19 at 12:14 PM and on 04/03/19 at 11:38 AM, Resident #43 was seated at the back left assist table in the main dining room, with staff seated across the table from her. Resident #43 was eating independently and drinking at a slower pace, each hand/arm movement presented in a slow methodical fashion. During an interview on 04/03/19 at 01:10 PM, in the confidential resident council group meeting an anonymous resident reported They (the facility) could use more service help in the dining room and reported sometimes there have been three to four hands raised (three to four residents requesting assistance) for help and no staff was in the room. During an interview on 04/03/19 at 02:59 PM, Certified Nursing Assistant (CNA) C reported on the day of the burn incident, 11/13/18, at approximately 7 AM CNA D was at the back left assist table seated directly next to Resident #43 and was providing verbal cueing with the meal. CNA C reported around 7:25 AM, as reported in the investigation interview, he took Resident #43 from the activity room to the bathroom and this is when he found the burned area on the left upper thigh and stated it was a big red spot, not quite a blister yet, skin was ripply, and it was huge. CNA C stated that Resident #43 reported she spilled coffee on herself and they (staff) pushed her into activities and left her (after the spill with no assessment of the burned area). CNA C reported it was CNA D who pushed Resident #43 from the dining room into the activity room with the wet spot, left Resident #43 in the activity room, and, as stated by CNA D, Didn't tell anybody about the wet spot. CNA C reported that once he told Nurse G about the burn, a cream was applied to the area and the resident was assessed at that time. CNA C was asked, with a CNA seated at the table next to Resident #43 in the assisted dining area, would the staff have been able to see and prevent the resident from removing the coffee lid. CNA C reported the CNA seated next to Resident #43 should've been able to stop the resident from removing the lid. Review of an email, 04/03/2019 2:55 PM, from the Director of Nursing stated Per the CDM (Certified Dietary Manager) and CNA (Certified Nursing Assistant) reports, resident (#43) was sitting in the assist area at the time of incident. Contact with CNA D was attempted 04/04/19 at 11:28 AM, but no response was obtained. On 04/03/2019 at 4:16 PM, policies [MEDICAL CONDITION] requested. The Director of Nursing provided the Skin Management policy, revised 5/2010. The policy didn't [MEDICAL CONDITION] rather addressed skin issues from pressure. During an interview on 04/04/19 at 09:23 AM, in discussing the burn incident for Resident #43 on 11/13/18, the Director of Nursing (DON) stated I determined she (CNA D) was at the assist table. CNA D's location to Resident #43, at the time of the spill and subsequent burn, was questioned and the DON stated, I don't have exactly where she (CNA D) was sitting.

This pertains to Intake #MI 838. Based on interview and record review, the facility failed to assess ROM (range of motion) after a resident had a fall for one Resident (#155) of 15 sampled residents, resulting in a fracture to the hip to go unrecognized and untreated and the Resident experiencing pain and immobility. Findings include: On 5/1/18 at 9:00 AM, a review of Resident #155 medical record revealed an admission into the facility on [DATE] and a discharge to the hospital on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognition and needed extensive assistance with two person physical assist for bed mobility, transfers and toilet use. Review of the Nurses Noted dated 12/3/17 at 18:28 (6:28 PM) revealed, Resident had fall at 13:05 (1:05 PM), wife tried to transfer resident to bathroom. No injury noted. Education provided to wife to call for help, not to transfer him herself. Review of the Resident at Risk note dated 12/6/17 at 12:48 PM, revealed, Resident is at risk for falls and has a history of falling both in the facility and prior to admission. resident sustained [REDACTED]. Per nurse report, resident refused pain medication and had no noted injuries at that time. Therapy reports that resident has had increased pain and difficulty during treatment on the Tuesday (12/5/17) following the fall. Action taken: Resident started on [MEDICATION NAME] on 12/4/17 to assist with managing pain as resident had frequent refusals of pain medication and on 12/5/17 an xray was ordered of bilateral hips which indicated a fracture to the right femoral neck. Resident sent to ED (Emergency Department) for evaluation and treatment . Further review of Resident #155's chart revealed no documented assessment of ROM to the right or left leg and hip from the time of the fall on 12/3/17 to the transfer to the ED. Review of the Physicians Order dated 12/4/17 at 12:41 PM, revealed, Physician in to see resident today; new orders: start [MEDICATION NAME] 25 mcg (micrograms) patch [MEDICATION NAME] qHS (every bedtime) every 3 days r/t (related to) refusal of PO (oral) pain medications. ([MEDICATION NAME] is a pain medication that can be given as a patch that is applied to and absorbed through the skin.) Review of the medical record failed to reveal that Resident #155 was assessed by a physician, prior to starting of the [MEDICATION NAME] Patch. No documented physician notes were obtained from the medical record. The facility was asked for the physician notes but were not received prior to exit of the survey. Review of the Nurses Note dated 12/5/17 at 17:20 (5:20 PM), revealed, resident sustained [REDACTED]. Today, therapy reports that resident is having increased pain to the right hip which is opposite of the affected hip .Xray ordered for bilateral hips. Review of the Nurses Note dated 12/5/17 at 19:19 (7:19 PM), revealed, Obtain X-Ray of right hip, 2 views, due to Res (Resident) c/o (complaints of) pain in right hip. Further review of Resident #155's medical chart revealed an x-ray was ordered on [DATE] (2 days after Resident #155 sustained the fall), the X-Ray company came in to do the x-ray on 12/6/17 for bilateral hips. The results stated: Acute right femoral neck impaction fracture without significant displacement or angulation .Conclusion: Acute [MEDICAL CONDITION] femoral neck. Examination date on 12/6/17 at 11:35 AM and the results reported to the facility on [DATE] at 11:53 AM. On 5/1/18 at 5:15 PM, an interview was conducted, with the Director of Nursing (DON) B, regarding Resident #155's fall on 12/3/17 with no documented assessment of the ROM to the Resident's legs and hips, documented complaints of pain on 12/5/17 with no documented assessment of ROM and x-rays ordered on [DATE] that were done on 12/6/17. The DON stated, The reason why we didn't suspect an injury is that he was refusing pain medication. Right after the fall he wasn't complaining of pain. Therapy stated he complained of pain and we started a [MEDICATION NAME]. He wasn't progressing with therapy. We started [MEDICATION NAME] on 12/4. Therapies noted he was going opposite and we got the x-ray and then sent him out . X-rays, they don't make special trips. They came in the morning. When queried regarding sending him to the ED after the complaint of pain in the right hip, the DON replied, We were not 100% convinced that he had a fracture at that point . It was an 'oh crap' moment when we found out he broke the other hip. A review of the Incident and Accident Report was reviewed with the DON. There was no assessment on the documentation that the ROM was performed at the time of the incident. When queried regarding an assessment of ROM at the time of the incident or with complaints of pain, the DON stated, There wasn't a noted documentation of the ROM. ROM should be checked. When I reviewed that I noticed it. I did education with the nurses on that . When queried regarding the Resident's complaints of pain the DON indicated the Resident would not acknowledge pain with the Nurses and would refuse to take the pain medication, when Therapy worked with him, he did not want to do the therapy due to c/o pain, therefore the Fentynal patch was started. On 5/2/18 at 3:10 PM, an interview was conducted, with Occupational Therapist W, regarding Resident #155's therapy prior to transfer to the ED. Therapist W stated, I came to do therapy on this day (12/5/17) and he had pain in the other hip (right hip). We decided to make him a hoyer (mechanical lift used to transfer a resident) because the pain was so bad. Therapy only did 15 minutes (12/4/17), he was not doing the greatest. Tuesday (12/5/17) he was seen and there was still an issue with his pain and he continued with pain in the right hip. The Therapist had documentation of the therapy session of the 15 minutes on 12/4/17 and 12/5/17. No time was indicated for when the therapy took place. When queried regarding what time therapy is accomplished, the Therapist stated, Between 7:30 and 4:00. We tried to do him before lunch time. When queried regarding the Resident's mobility the Therapist stated that the Resident did not move much after that (after the fall) and she thought they had changed his transfer level to a hoyer lift. When queried about the documentation to change him to a hoyer lift, the verification was not obtained prior to the exit of the survey. A review of the facility policy entitled, Change in status, identifying and communicating, long-term care, stated, . Particular changes to note include a decline in functional status, new or increasing confusion, incontinence, weight gain or loss in excess of 5% of body weight, deteriorating mobility, falls and behavior changes . Implementation. Perform a complete physical assessment, focusing on the identified change in status.

Based on observation, interview and record review, the facility failed to follow or develop comprehensive care plans for 2 (#13, #31) of 15 residents reviewed for care plans, resulting in Resident #13 sustaining a fall while wearing fuzzy socks while having norovirus (frequent stools) resulting in [MEDICAL CONDITION] and Resident #31 sustaining a significant weight loss of 8.1% over 90 days with no care plan revisions to the nutrition care plan. Findings include: Record review of facility 'Care planning' policy dated 11/2017 revealed every resident in the facility will have a person-centered plan of care developed and implemented that is consistent with the residents rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical. nursing, and mental and psychological needs identified in the comprehensive assessments and prepared by an interdisciplinary team who includes .additional resources will also be utilized to ensure that any additional needs of risk areas are identified. Resident #13: Record review of Resident #13's Minimum Data Set ((MDS) dated [DATE] the 30 day assessment revealed a [AGE] year old female with Brief Interview of Mental status (BIMs) score of 3 out of 15, severe cognitive impairment. Section G of the MDS noted Resident #13 to be two person assist with toileting, transfers. Occasional urinary incontinence was noted. Active [DIAGNOSES REDACTED]. Record review of resident #13's care plans prior to her fall, page 1 through 25, revealed care plans related to decreased mobility and incontinence, pain related to fracture pelvis, decline in cognition and had impaired cognitive function/impaired thought processes related to dementia, at risk for fall related to confusion, poor safety awareness, history of falls in facility and at home, pain, medication side effects. Intervention noted was Ensure the resident is wearing appropriate footwear dated 10/23/17. Goal to be free of falls target date of 1/18/18. Review of the facility's Incident/Accident form revealed that on 1/12/18 at 11:15 PM Resident #13 was observed on floor (unwitnessed) laying on her right side on the floor in front of the closed bathroom door. Resident was noted to be complaining of right hip pain. Resident was sent to the hospital for evaluation. (Fractured right hip). Review of the POS [REDACTED]. Resident was noted to say that she was 'going to the bathroom'. Resident was noted to not be using her walker, with fuzzy socks with no grippers on bottom as foot wear. Mental status prior to fall was noted as alert with confusion. Changes in residents normal routine were identified as not able to leave her room due to sickness in facility. Resident was noted to have recent GI (gastro-intestinal) upset with N/V/D (Nausea/Vomiting/Diarrhea) in the last 24 hours. Post fall huddle/evaluation noted resident was wearing fuzzy socks without grippers on bottom, walker was by recliner with a change of clothes hanging over it, shoes were at the foot of the bed on the floor. Record review of Resident #13's lab collection report dated 1/11/18 qt 2:45 PM revealed Resident #13 was being tested for Norovirus (severe vomiting and diarrhea) which came back positive. There was no care plan found for increased toileting frequency or increased supervision while resident was in room. In an interview on 5/1/18 at 4:54 PM via phone with Certified Nurse Assistant (CNA) Y revealed that she was at the nursing station when she heard a thump of the fall in the 100 hallway. The CNA Y stated that she went to the room and saw the resident against the bathroom door. CNA Y stated that the Resident was known to jump up and go, but did not have any fall alarms in place. In an interview on 5/1/18 at 4:49 PM via phone with Licensed Practical Nurse (LPN) Z revealed that she was working another hall when Resident #13 was found on the floor. LPN Z stated that she went to the room to help and stated that Resident #13 had tried to go to the bathroom. LPN Z stated that Resident #13 does not remember to use the call-light system and tries to do for herself. LPN Z stated that the Resident #13 would self transfer, but that there was no alarm care planned or in place at the time of the fall. LPN Z stated that the Resident #13 is impulsive and string minded and becomes upset if staff are not moving. Resident #31 Record review of Resident #31's physician orders [REDACTED]. Diet order of small portions with puree texture with thin liquids. During an observation on 4/30/18 at the noon meal Resident #31 was noted to attempt to feed herself. Little food intake was noted. During an observation on 05/01/18 at 07:12 AM Resident #31 was noted to be in dining room seated at a table slumped over to the left with a spoon in right hand with food substance on spoon. The Resident #31 held spoon for length of time and did not eat it. There was no staff at table to assist resident. Record review of Resident #31's weight log for six months revealed that on 2/1/18 a weight of 152.5 pounds was recorded. On 3/2/18 a weight of 149.2 was recorded. The next weight done on 4/2/18 was 144.8 pounds. That is a 7.7 pound or 5.05% weight loss in three months. Record review of resident #31's care plans page 1 through 35, revealed that the 'Gastro-[MEDICAL CONDITION]/[MEDICAL CONDITION]/[MEDICAL CONDITION] and is on a pureed diet, has poor dentition' care plan was last updated on 12/7/2017. Goal included: Resident will maintain weight of 150 pounds plus or minus 5 pounds target date 3/8/2018. The last intervention update was on 9/11/17 of small portions, puree texture with thin liquids. There were no interventions added to the care plan after Resident #31's documented 7.7 pound weight loss. On 5/2/18 at 7:15 AM the state surveyor asked if the staff could weigh Resident #31 for a monthly weight to compare weights. On 5/2/18 Resident #31 weight was 140.2 pounds. That is an 8.1% weight loss in 90 days which would trigger a significant weight loss. On 05/02/18 at 10:13 AM an interview was done with the Certified Dietary Manager (CDM) R revealed that Resident #31's weight today decreased to 140.2 that's a significant loss of 8.1% in 90 days. The CDM stated that she would implement interventions effective 5/2/18.

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO COMPREHENSIVELY ASSESS AND PROVIDE APPROPRIATE PAIN RELIEF TREATMENT FOR ONE (#13) OF FOUR RESIDENTS REVIEWED FOR QUALITY OF CARE, OUT OF A TOTAL POPULATION OF 60 RESIDENTS. THIS FACILITY DEFICIENT PRACTICE RESULTED IN RESIDENT #13 RECEIVING A TYPE OF MEDICATION (NARCOTIC) SHE WAS KNOWN TO HAVE AN ADVERSE REACTION TO, RESULTING IN A DECLINE IN HER MENTAL STATUS AND SUBSEQUENT FALL WITH FURTHER DECLINE IN HER OVERALL FUNCTION. FINDINGS INCLUDE: AN ABBREVIATED SURVEY TOOK PLACE AT THE FACILITY ON 3/19/12 THROUGH 3/20/12. ACCORDING TO THE FACE SHEET, RESIDENT #13 WAS admitted to the facility on [DATE]. THE HOSPITAL ADMISSION HISTORY AND PHYSICAL (H&P) DATED 1/17/12, RECEIVED BY THE FACILITY, READS IN PART, "...SHE IS A [AGE] year-old PATIENT OF MINE admitted TO THE HOSPITAL... WITH INCREASING CONFUSION OVER THE PAST FOUR TO FIVE DAYS... SHE HAD FALLEN AT HOME... FRACTURED HER PELVIS...". THIS H&P LISTS RESIDENT #13'S PAST MEDICAL HISTORY TO INCLUDE, PAI[DIAGNOSES REDACTED] SECONDARY TO A RECENT PELVIC FRACTURE WHICH IS ONGOING, PREVIOUS [MEDICAL CONDITION] WITH RESULTANT LEFT-SIDED WEAKNESS, AND CHRONIC [MEDICAL CONDITION] FIBRILLATION. THE ASSESSMENT AND PLAN RECORDED ON THIS H&P READS IN PART, "...ALTERED MENTAL STATUS MOST LIKELY SECONDARY TO NARCOTIC PAIN MEDICATIONS, I.E. [MEDICATION NAME]. I SUSPECT THAT HER ANOREXIA AND GASTROINTESTINAL UPSET IS MOST LIKELY THE RESULT OF THE SAME MEDICATION...WE WILL DISCHARGE HER BACK TO THE EXTENDED CARE FACILITY. I AM GOING TO DISCONTINUE HER [MEDICATION NAME] THERAPY. SHE WILL BE GIVEN TYLENOL... PRIOR TO HER PHYSICAL THERAPY OR... AS NECESSARY FOR PAIN. IF TYLENOL IS NOT EFFECTIVE FOR PAIN, SHE MAY NEED TO USE [MEDICATION NAME] AS NECESSARY FOR PAIN." A REVIEW OF THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., 5:00 P.M. AND AT 10:00 P.M. RESPECTIVELY, FOR A PAIN RATING OF "5" ON A 0-10 SCALE (0-1 MEANING NO PAIN TO 10 BEING EXCRUCIATING PAIN) WITH POST ADMINISTRATION RATING OF 0-1. RESIDENT #13 DID RECEIVE [MEDICATION NAME] 50 MG (1) ORALLY FOR THREE DAYS (1/20/12, 1/21/12 AND 1/22/12) AT 5A (5:00 A.M.) BEFORE GETTING UP IN A.M. RESIDENT #13 DID RECEIVE ONE ADDITIONAL DOSE OF [MEDICATION NAME] 50 MG TABLET ON 1/18/12 FOR A PAIN RATING OF "5" AND POST ADMINISTRATION OF "0", REVEALING THE TYLENOL AND [MEDICATION NAME] WERE EFFECTIVE IN RELIEVING RESIDENT #13'S PAIN WHEN THE MEDICATION WAS ADMINISTERED TO HER. A REVIEW OF THE NURSES NOTES FOR THE ENTIRE STAY (1/19/12 THROUGH 1/28/12) FOR RESIDENT #13 WAS CONDUCTED. OF THE TWENTY NURSING SHIFTS RECORDED, RESIDENT #13 WAS RECORDED AS HAVING "PAIN" FOUR TIMES. "IT HURTS WHEN I MOVE." HOWEVER, THE DOCUMENTATION IN THE MEDICAL RECORD REFLECTING EFFECTIVE PAIN MANAGEMENT IS CONTRADICTORY TO THE INFORMATION PROVIDED BY STAFF INTERVIEW DURING THE ABBREVIATED SURVEY. AN INTERVIEW WAS CONDUCTED WITH CNA "A" ON 3/20/12 AT 10:25 A.M. CNA "A" STATED SHE WAS A PRIMARY CARE GIVER FOR RESIDENT #13 AND THAT "SHE (RESIDENT #13) WAS A TOTAL LIFT, SHE DIDN'T LIKE ROLLING TO HER LEFT SIDE BECAUSE OF THE PAIN, BUT WE HAD TO IN ORDER TO CHANGE HER AND GET HER INTO THE SLING TO BE MOVED... SHE WOULD CRY OUT IN PAIN AT TIMES, BUT IF SHE WAS SITTING OR LYING IN BED SHE SEEMED COMFORTABLE... BUT ANY KIND OF MOVEMENT SHE HAD INCREASED THE PAIN... IF (RESIDENT #13) WAS ASKED IF SHE WANTED ANYTHING FOR PAIN, SHE WOULD SAY 'YES'." DURING AN INTERVIEW WITH LICENSED PRACTICAL NURSE (LPN) "B" ON 3/19/12 AT 4:09 P.M., SHE STATED RESIDENT #13 "SCREAMED A LOT BECAUSE HER BUTT HURT". A physician's orders [REDACTED]. RESIDENT #13 RECEIVED 3 TOTAL DOSES OF THE NARCOTIC [MEDICATION NAME] 1/25/12, AT 6:00 A.M. AND 8:00 P.M. AND A DOSE AT 6:00 A.M. ON 1/26/12. LPN "B" NOTIFIED THE PHYSICIAN ON 1/26/12 (ENTRY NOT TIMED) "RES VERY SLEEPY TODAY, DOES OPEN EYES NOT PARTICIPATING VERY WELL WITH CARES OR PT (PHYSICAL THERAPY) ...N.O. (NEW ORDER) TO D/C (DISCONTINUE) [MEDICATION NAME] START [MEDICATION NAME] 12 MCG PATCH (NARCOTIC PATCH 12 MICROGRAMS) DAUGHTER (FM #2) NOTIFIED." ACCORDING TO THE WEBSITE http://www.DRUGS.com, [MEDICATION NAME] ALSO KNOWN AS [MEDICATION NAME]; AN OPIOID PAIN MEDICATION. AN OPIOID IS SOMETIMES CALLED A NARCOTIC. THE MOST FREQUENTLY OBSERVED ADVERSE REACTIONS CAUSED BY [MEDICATION NAME] INCLUDE CONSTIPATION, LIGHTHEADEDNESS, DIZZINESS, SEDATION, NAUSEA AND VOMITING. [MEDICATION NAME] IS A SKIN PATCH CONTAINING [MEDICATION NAME], AN OPIOID PAIN MEDICATION. A REVIEW OF AN INCIDENT/ACCIDENT REPORT DATED 1/25/12, SHOWED RESIDENT #13 WAS FOUND ON THE FLOOR NEXT TO HER BED AT 11:30 P.M ON THAT DATE. A POST FALL EVALUATION COMPLETED BY THE FACILITY REFLECTS THE FOLLOWING FACTORS RELATED TO THIS FALL; NARCOTIC [MEDICATION NAME] WAS STARTED WITHIN THE LAST SEVEN DAYS, GIVEN WITHIN THE PREVIOUS 3 ? HOURS AND RESIDENT #13 WAS DISPLAYING AN ALTERED MENTAL STATUS WITH BALANCE/GAIT DISORDER. A NURSES NOTE DATED 1/27/12 AND TIMED 8:35 A.M., READS: "[MEDICATION NAME] PATCH 12 MCG DISCONTINUED, TYLENOL 500 MG 2 TABLETS ORDERED P.O. (ORALLY) EVERY 4 HOURS... DAUGHTER (FM #2) CALLED & INFORMED OF MEDICATION CHANGES. RESIDENT IS SENSITIVE TO NARCOTICS AND FAMILY WISHES NOT TO USE THEM." THIS NURSING NOTE IS SIGNED BY THE DIRECTOR OF NURSING (DON). A SPEECH THERAPY DISCHARGE SUMMARY FOR RESIDENT #13 FROM THE DATES OF 1/20/12 TO 1/28/12 READS IN PART; "...PT HAS PROGRESSIVELY BECOME UNRESPONSIVE THIS WEEK. IV NOW STARTED ...RECOMMEND (ARROW POINTING DOWN/DECREASE) DIET TEXTURE FOR SAFETY SECONDARY TO (ARROW POINTING DOWN/DECREASE) MEDICAL STATUS..." THE NURSES NOTES DATED 1/27/12 AT 7:00 P.M. READ, "NOTIFIED DR... THAT RES (RESIDENT #13) HAS HAD A POOR ORAL INTAKE YESTERDAY AND TODAY... NEW ORDERS... IV FLUIDS..." AN INTERVIEW WITH PHYSICIAN #1 WAS CONDUCTED ON 3/20/12 AT 11:10 A.M. PHYSICIAN #1 WAS ASKED HOW HE OBTAINED RESIDENT #13 INTO HIS SERVICES. HE REPLIED SHE WAS "HANDED OVER FROM ER/HOSPITAL STAY (emergency room )... THE FAMILY WAS NOT HAPPY WITH THE CARE SHE RECEIVED NEXT DOOR (ANOTHER LONG TERM CARE CENTER)." PHYSICIAN #1 WAS ASKED IF HE KNEW RESIDENT #13 WAS SENSITIVE TO NARCOTICS AND HE REPLIED, NOT UNTIL AFTER HE ORDERED THE MS CONTIN. HE FURTHER STATED RESIDENT #13 WAS IN PAIN, "SO I ORDERED THE [MEDICATION NAME] GET BETTER PAIN CONTROL." PHYSICIAN #1 WAS ASKED IF HE REVIEWED THE MAR FOR EFFECTIVENESS OF MEDICATION ADMINISTERED; HE DID NOT ANSWER. A TELEPHONE INTERVIEW WITH FAMILY MEMBER (FM) #1 WAS CONDUCTED ON 3/20/12 AT 10:35 A.M. FM #1 STATED SHE WAS AT THE FACILITY ON THE DAY OF HER MOTHER'S ADMISSION, "I TOLD THE NURSE SHE COULDN'T HANDLE NARCOTICS, THAT'S WHY SHE JUST CAME FROM THE HOSPITAL... THEY DIDN'T LISTEN TO ME OR RECORD WHAT I SAID ABOUT THEM, THEN THE DOCTOR GIVES THEM ANYHOW." THE DIRECTOR OF NURSING WAS ASKED IN AN INTERVIEW ON 3/20/12 AT 1:40 P.M. IF SHE EXPECTED THE NURSES TO UPDATE A RESIDENT'S CHART WITH allergies [REDACTED].? SHE REPLIED, "WE CAN'T DO THAT". WHEN ASKED WHY THE FACILITY CAN'T UPDATE THE MEDICAL RECORDS FOR THEIR RESIDENTS, THE DON DID NOT GIVE AN ANSWER. THE FACILITY FAILED TO REVIEW PERTINENT MEDICAL INFORMATION REGARDING RESIDENT #13'S RECENT hospitalization AND PLAN FOR APPROPRIATE PAIN MANAGEMENT CONTROL. AS A RESULT, RESIDENT #13 RECEIVED A NARCOTIC PAIN RELIEVING MEDICATION (MS CONTIN) ON 1/25/12 AND 1/26/12 WHICH WAS KNOWN TO CAUSE A DECLINE IN HER MENTAL STATUS. RESIDENT #13 WAS FOUND ON THE FLOOR IN HER ROOM AT 11:30 P.M. ON 1/25/12, BECAME PROGRESSIVELY UNRESPONSIVE, REQUIRING INTRAVENOUS THERAPY ON 1/27/12 AND THEN SENT TO THE emergency roiagnom on [DATE]. ( ) --