Every finding on record at Life Care Center of Plainwell

This citation pertains to intakes #2973222 and #2976634.Based on interview and record review the facility failed to ensure adherence to a Legal Guardian's right to medication treatment choices for 1 resident (Resident #1) of 1 resident reviewed for Legal Guardian's rights, resulting in Resident #1 being treated and prescribed medications against the wishes of the Legal Guardian. Findings include: Resident #1 (R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] with pertinent diagnoses including legal blindness, heart failure, dysphagia (difficulty swallowing), alcohol abuse and kidney disease (kidney are damaged and can't filter blood leading to waste buildup). Brief Interview for Mental Status (BIMS) reflected a score of 6 out of 15 which indicated R1 was severely cognitively impaired. He was discharged to the hospital on 3/19/2026. During an interview on 4/3/2026 at 3:30 PM, Family Member/Guardian (FM) U and FM V stated R1 was unable to make his own decisions and they were his legal guardians. FM V reported that R1 had a bad heart and breathing issues so he was very clear with the facility that he did not want resident to be put on any medication that would sedate him since he had a bad reaction to Trazadone (Desyrel- prescription antidepressant often used to treat insomnia due to its sedating effects) prior to coming to the facility. FM V said that they didn't consent to R1 receiving Quetiapine (Seroquel-antipsychotic used to balance neurotransmitters (regulates mood, sleep, digestion and movement) in the body and can cause drowsiness and cardiovascular risk (heart risk) in the elderly} or Clonazepam (Klonopin-treats panic disorders by calming the nervous system). FM V reported that he was in the building on 3/9/2026 to attend care conference and mentioned that he didn't want R1 to be sedated and drugged.Review of R1's guardianship paperwork dated 7/5/2024 revealed that FM U and FM V were R1's co-guardians.Review of the Hospital Discharge Summary from the hospital to the facility on 3/5/2026 revealed .Medications: quetiapine (seroquel) 50 mg (milligrams) 1 tab (tablet).started on quetiapine for agitation with good response, otherwise medically stable for discharge to long term care at this time. Review of the Medication Informed Consent Form dated 3/6/2026 revealed . prolonged treatment . antipsychotic medication: quetiapine. Dosage: 50 mg (milligrams). Side effects: sedation, drowsiness. It is my decision to: Consent to the use of this medication. Under Resident/Legal Representative it had (no names listed) verbal on the phone. Date 3/6/2026 and was signed by the facility representative. The reason why it was prescribed was left blank. Review of the Medication Informed Consent Form dated 3/12/2026 revealed . Reason why medication was prescribed: Anxiety.prolonged treatment.anti-anxiety medication: clonazepam (Klonopin). Dosage: .25 mg. Side effects: Sedation, drowsiness, ataxia (drunk walk).special attention: if given with other sedatives. It is my decision to: Consent to the use of this medication. Under Name of Responsible Party it listed (FM U) verbal consent. Date discussed 3/12/2026 and was signed by the facility representative {Registered Nurse (RN) C}. Review of the Medication Informed Consent Form dated 3/18/2026 revealed . Reason why medication was prescribed: Anxiety.prolonged treatment.anti-anxiety medication: clonazepam (Klonopin). Dosage: (blank). Side effects: Sedation, drowsiness, ataxia (drunk walk).special attention: if given with other sedatives. It is my decision to: Consent to the use of this medication. Under Name of Responsible Party, it listed (FM U and FM V names). Date discussed 3/18/2026 and was signed by the facility representative (RN F). FM U and FM V did not sign the form. Review of the Order Summary revealed . Quetiapine Fumarate (Seroquel) oral tablet 50 mg, give 1 tablet via tube two times a day for behavior. Order date 3/5/2026 and start date 3/6/2026 . clonazepam oral tablet disintegrating .25mg. Give .25 mg orally two times a day related to primary open-angle glaucoma (eye disease), unspecified eye.order date 3/12/2026. Start date 3/13/2026 (stopped on 3/18/2026).clonazepam oral tablet .5mg. Give .5 mg by mouth two times a day for anxiety. Order date: 3/18/2026. Start date 3/18/2026. Review of R1's progress note dated 3/9/2026 revealed IDT (Interdisciplinary Team) completed initial care conference with the resident's legal guardians. The departments that participated were Nursing, Therapy, Social Services, Activities. IDT addressed all concerns with the family. Social Services completed admissions packet with the legal guardian (FM V) . Review of R1's progress note dated 3/12/2026 revealed New order from {Medical Director (MD) Y} for clonazepam 0.25mg BID (twice a day).Review of R1's progress note dated 3/12/2026 and documented by RN C revealed Late Entry: (written 4/8/2026). This nurse spoke with resident's DPOA (Durable Power of Attorney/Guardian) via phone and received verbal consent to give resident medication. Review of the Physician Progress Note dated 3/18/2026 revealed . I had a conversation with (RN F), nurse in charge at 2:38 PM regarding (R1's) restlessness, being anxious, and behavioral issues. (R1) started on Klonopin .25 mg twice a day on 3/13/2026. (R1's) management was hard and (R1's) Klonopin was increased to .5 mg twice a day.Review of R1's progress note dated 3/18/2026 revealed (MD Y) ordered clonazepam to be increased from 0.25mg bid to 0.5mg bid.Review of R1's progress note dated 3/18/2026 revealed Behavior Note: Spoke with pt (R1) guardian who was apprehensive at first about changing orders on clonazepam from 0.25mg to 0.5mg out of concern that pt would become sedated. After talking to guardian concerning pts care plan, recent behaviors, and upcoming BCS (Behavioral Care Solutions) visit, Guardian stated we will follow the recommendations of the doctor. Psychotropic consent signed and filed.Review of progress note dated 3/19/2026 revealed At 1230 family member (FM V) came in to visit with (R1), came right back out of the room yelling and demanding to know what (medications) he had been given. Stated that he had been given his prescribed medications. Review of progress note dated 3/19/2026 revealed (FM U) called the facility around 1920, wanting to know what my name was and if I was the nurse caring for (R1) this morning? I stated that I was. She also wanted to know when he was started on the Clonazepam, answered her questions. She phoned again at 2000, asking similar questions.During an interview on 4/8/2026 at 2:48 PM, RN C stated he put the initial order for Klonopin since the doctor wanted it and he called FM U and she gave verbal consent for it but FM V said he didn't want R1 on it and didn't want him drugged up. RN C said that FM U said she would agree to the doctor treating him but didn't want him sedated. When asked why he put a progress note in on 4/8/2026 regarding his conversation with FM U on 3/12/2026, RN C stated that he was told by Director of Nursing (DON) B to put a note in that day. During an interview on 4/8/2026 at 3:00 PM, Social Services Director (SSD) T stated that the unit managers were getting medication consents from residents/families before and now he was involved with it. When discussing the care conference on 3/9/2026, SSD T said that FM U and FM V didn't say anything about not putting R1 on psychotropic medications (medications that affect brain function, used to treat mental health conditions). During an interview on 3/8/2026 at 3:17 PM, RN F stated that he filled out the medication consent form for the Klonopin increase to .5 mg on 3/18/2026 due to anxiety since Seroquel and the Klonopin dose of .25 mg wasn't working. RN F reported that he called FM V and he was reluctant about increasing it since he didn't want R1 to be sedated. During an interview on 4/8/2026 at 4:35 PM, MD Y stated that he couldn't remember R1 or his recommendation to increase the Klonopin. During an interview on 4/9/2026 at 12:20 PM, DON B stated that on 4/8/2026 she asked RN C to hand write a note regarding R1's Klonopin consent on 3/12 but he put it in the progress note instead. DON B reported that her expectations for a medication consent was that a verbal consent had to be documented on the form with the name, medication, dose, yes or no to the consent and either the resident or the DPOA/guardian name of who they talked to. DON B stated that they were unable to get a physical signature from FM U or FM V since they didn't come to the facility much and once they get a verbal signature, they didn't get a physical signature. When discussing that FM V discussed at the care conference at the facility on 3/9/2026 that he did not want R1 sedated, DON B said she wasn't aware of it. Review of the visitor log revealed that FM U and FM V visited R1 at the facility on 3/9/2026 and 3/19/2026.During another interview on 4/9/2026 at 11:20 AM, FM U and FM V stated again that the facility did not contact them on 3/6/2026, 3/12/2026 or 3/18/2026 regarding medication consents for Seroquel and Klonopin. FM V said that he told the facility even with behavior problems he did not want R1 sedated. FM V stated he agreed to the physician treating R1 and orders the physician would put in but did not agree to him getting Seroquel or Klonopin.

Based on interview and record review the facility failed to notify resident's guardians regarding a fall for 1 resident (Resident #1) of 3 residents reviewed for falls resulting in Resident #1's guardians being unaware of the fall and if any injuries occurred. Findings include: Resident #1 (R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] with pertinent diagnoses including legal blindness, heart failure, dysphagia (difficulty swallowing), alcohol abuse and kidney disease (kidney are damaged and can't filter blood leading to waste buildup). Brief Interview for Mental Status (BIMS) reflected a score of 6 out of 15 which indicated R1 was severely cognitively impaired. He was discharged to the hospital on 3/19/2026. Review of R1's guardianship paperwork dated 7/5/2024 revealed that Family Member/Guardian (FM) U and FM V were R1's co-guardians.Review of R1's Progress note dated 3/18/2026 revealed . (R1) was found on his knees facing his bed with his oxygen and tube feed tube (tube that provides artificial nutrition directly into the stomach or small intestine) wrapped around him at 0640. Assessed for injuries, none noted, helped back into bed, tubing straightened out and vitals/neuros (neuro checks-assess for brain injury or increased intracranial pressure) started. Continued with his fast breathing, B/Ps (blood pressure) were high in the beginning, but came down throughout the day. called out frequently, addressed needs as they presented, no complaints of pain and no bruising noted to knees.Review of R1's fall report dated 3/18/2026 revealed . Nursing Description: Resident observed sitting on his knees leaning over his bed. Tube feeding (provides artificial feeding into the stomach or small intestine) and foley (tube) in place. Was not wearing nasal cannula when nurse entered the room. PT (patient) was restless and dressing and was exhibiting compulsory behavior of calling out and self transferring from chair to bed and bed to chair, despite staffing encouragement to allow staff to assist pt.Agencies/People Notified: Physician (Medical Director (MD) Y) , DON (Director of Nursing B) It was not documented that the family was notified. During an interview on 4/8/2026 at 12:20 PM, RN H stated that she worked on 3/18/2026 when R1 was found on his knees. RN H reported that she assumed he fell and she couldn't remember if she notified his guardians but she notified the physician and DON B. During an interview on 4/8/2026 at 11:50 PM, FM U and FM V stated that they were unaware of R1's fall on 3/18/2026 since the facility did not notify them. FM V was surprised that R1 fell and that no one contacted him about it. Review of the Changes in Resident Condition or Status Policy with a review date of 8/29/2025 revealed .Federal Regulations: Notification of Changes: (i) A facility must immediately inform the resident,; consult with the resident's physician and notify consistent with his or her authority, the resident representatives when there is an accident involving the resident which results in injury and has a potential for requiring physical physician intervention.

This citation pertains to intakes #2973222 and #2976634.Based on interview and record review the facility failed to ensure that a resident's behavior was managed and interventions were put in place prior to starting a chemical restraint affecting 1 resident (Resident #1) of 1 resident reviewed for medication management resulting in Resident #1 being prescribed Seroquel {antipsychotic used to balance neurotransmitters (regulates mood, sleep, digestion and movement) in the body and can cause drowsiness and cardiovascular risk (heart risk) in the elderly} upon admission and then adding Klonopin (treats panic disorders by calming the nervous system) to help manage behaviors. Findings include: Resident #1 (R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] with pertinent diagnoses including legal blindness, heart failure, dysphagia (difficulty swallowing), alcohol abuse and kidney disease (kidney are damaged and can't filter blood leading to waste buildup). Brief Interview for Mental Status (BIMS) reflected a score of 6 out of 15 which indicated R1 was severely cognitively impaired. He was discharged to the hospital on 3/19/2026. Review of the Order Summary revealed . Quetiapine Fumarate (Seroquel) oral tablet 50 mg, give 1 tablet via tube two times a day for behavior. Order date 3/5/2026 and start date 3/6/2026 . clonazepam oral tablet disintegrating .25mg. Give .25 mg orally two times a day related to primary open-angle glaucoma (eye disease), unspecified eye.order date 3/12/2026. Start date 3/13/2026 (stopped on 3/18/2026).clonazepam oral tablet .5mg. Give .5 mg by mouth two times a day for anxiety. Order date: 3/18/2026. Start date 3/18/2026. Review of R1's 30-day behavior lookback documentation that Certified Nursing Assistants (CNAs) complete revealed 2 days of documenting behaviors regarding disruptive sounds.Review of R1's care plan revealed . Focus: (R1) has a behavioral problem where he will drink water out of his/roommate's urinal. (R1) has a history of being non-compliant with fluid restriction related to drinking water and drinking out of roommates in his own urinal. (R1) also was observed drinking out of the toilet.Intervention/Tasks: Anticipate and meet the resident's needs. Educate (R1)/family/caregivers on successful coping and interaction strategies such as (Specify). The resident needs encouragement and active support by family/caregivers when the resident uses these strategies. Date initiated 3/6/2026. There were no intervention strategies listed for R1. Review of R1's progress noted dated 3/6/2026 revealed Behavior Note: DON (Director of Nursing B) and social worker {Social Services Director (SSD) T} contacted the residents POA (Power of Attorney/Guardians) to speak with about resident's noncompliance with NPO/ no drinking liquids. DON and Social Worker spoke about the importance of the resident being adherent to the NPO order. POA states he will come to the initial care conference on 3/9/26. Social Services and IDT will follow up as needed to ensure the resident's safety.Review of R1's progress note dated 3/6/2026 revealed Behavior Note: Pt (patient) keeps drinking out of the sink even though he's NPO and we keep reminding him. His roommate said that he drank out of his (the roommate's) water basin. He also keeps pulling on his G-Tube (gastrostomy tube placed for feedings, fluids and medication when oral intake is not possible) and it is getting really red and we keep reminding him not to.Review of R1's progress note dated 3/8/2026 revealed Patient was wheeling self to sink to get a drink and tube feeding (artificial feeding that goes to the stomach) pole fell over. When reminded he is not supposed to have anything to drink he became upset with rapid breathing. Offered to get swab to perform oral care and he declined saying he did not want to brush his teeth he wants to drink.Review of R1's progress note dated 3/8/2026 revealed Walked by room and found patient at sink, TF (tube feeding) pole on floor, roommate visitor states he has been at the sink for about 10 minutes drinking water. Patient said he is thirsty and is not going to stop.Review of R1's progress note dated 3/9/2026 revealed IDT (Interdisciplinary Team) completed initial care conference with the resident's legal guardians. The departments that participated were Nursing, Therapy, Social Services, Activities. IDT addressed all concerns with the family.Review of R1's progress note dated 3/9/2026 revealed Patient yelling out most of day. Staff assists patient and when they leave the room, he immediately starts yelling out again. Patient given a tablet from activities to watch music videos and listen to music he likes. Since the tablet has been in his room he has not yelled out. Noted large amount of sputum on floor around patient. Patient spitting on floor. He was given a basin to spit in, and he continues to spit on the floor.Review of R1's progress note dated 3/10/2026 revealed Behavior Note: Resident awakened at approximately 0230-0300am (2-3 AM) and began to holler out, hey hey hey each time staff enters his room, he is requesting to go outside. Unable to assist resident outside at this time. Instructed resident that more staff will be present later in AM and this may be possible, but not at this time. He lies back down a short time, than begins again. Same process. Oriented to call light. Will continue to monitor.Review of R1's progress note dated 3/10/2026 revealed Resident pulled out G-tube. Review of R1's progress note dated 3/10/2026 revealed Skilled note: Repeated calling out Hey asking everyone who will listen if they get him ice chips or water. Has a tube with continuous feeding going at 64ml's per hour with 35ml's of water flush per hour. He pulled out his tube this morning around 0650, a Foley catheter was placed in the interim. An appointment was made for tomorrow to replace the feeding tube (provides artificial feeding into the stomach or intestine). resident is alert and oriented to self, able to make some needs known, staff to anticipate needs at times. resident has peg tube, is on continuous feeding and is NPO. V/S WNL. no s/s of pain or discomfort and he denied pain. pt pulled g-tube out, has appointment to have replaced on 3/11/26. Pt on 2l o2 and removed o2 at times then becomes tachypneic and drops spO2 down to low 80's. once O2 is replaced, spo2 climbs back to 90's. Constan calling out, regardless of repeated education on not being able have ice chips and or water, he continues to ask anyone who will listen. Does not use call light, just yells out.Review of R1's progress note dated 3/11/2026 revealed Patient returned from hospital from having PEG tube inserted. Patient refusing to start tube feeding, wants to push self around hallway. Review of R1's progress note dated 3/11/2026 revealed Resident asked this nurse for a glass of water, this nurse informed resident that the doctor has resident's diet as nothing by mouth, resident said ok, moments later resident again asked this nurse for some water, this nurse informed resident that he just asked for water and was told the about his diet order, resident said no you didn't. this nurse again informed resident that he was NPO, resident within moments again asked this nurse for some water.Review of R1's progress note dated 3/11/2026 revealed Patient in his room listening to music. RN asked patient if tube feeding could be started and patient states he wants water first. When instructed that the physician has an order not allowing any intake by his mouth. Patient started screaming and would not allow tube feeding to be restarted.Review of R1's progress note dated 3/12/2026 revealed Saw pt in the hallway holding on to his bedside commode, walked down there to help him and see his oxygen was around his waist, his feeding pump was knocked over on the floor and his g-tube was on the floor next to it. I asked him if his stomach hurt where it got pulled out and he said no. helping him get his oxygen back on, picked up his feeding pump and put a bandage on his stoma. {Registered Nurse (RN) F} was notified.Review of R1's progress note dated 3/12/2026 revealed New order from {Medical Director (MD) Y} for clonazepam 0.25mg BID.Review of R1's progress note dated 3/13/2026 revealed IDT (Interdisciplinary Team)/ Behaviors: [NAME] is impulsive, g-tube dislodged times 2, drinking from sink in room, from toilet, water turned off in room per guardian request. Hand hygiene per hand sanitizer. Room is across from shower room, which is used for all hygiene for (R1). Can have small amount if ice chips supervised. Continuously asks for water.Review of R1's progress note dated 3/13/2026 revealed IDT/RAR (Resident at Risk): Pt has dislodged g-tube 2 times in 2 days. Pt is restless and anxious. Calls out frequently and rolls his w/c (wheelchair) around totally unaware of being connected to 24 hour tube feed. Intervention to prevent further dislodgment is to use stat (immediate) lock, applied pole to w/c to hold pump and tube feed. Review of R1's progress note dated 3/18/2026 revealed Behavior Note: pt continues to yell out, hey, hey, hey all throughout the day for hours at a time. Pt asks to be put to bed, and then minutes later will ask to be put back in w/c, and vice versa. Pt often attempts to transfer self to and from bed, several times an hour. Pt also has poor spacial awareness lending to tugging on g-tube and nasal cannula (tube put on nostrils that delivers oxygen) when propelling self in w/c. IV (intravenous pole that you hang bags of tube feeding and fluids) pole installed on w/c to prevent this. (MD Y) notified.Review of R1's progress note dated 3/18/2026 revealed (MD Y) ordered clonazepam to be increased from 0.25mg bid to 0.5mg bid.Review of the Physician Progress Note dated 3/18/2026 revealed . I had a conversation with (RN F), nurse in charge at 2:38 PM regarding (R1's) restlessness, being anxious, and behavioral issues. (R1) was started on Klonopin .25 mg twice a day on 3/13/2026. (R1's) management was hard and (R1's) Klonopin was increased to .5 mg twice a day.During an interview on 4/9/2026 at 11:20 AM, Family Member/Guardian (FM) U and FM V stated that the facility did call them regarding R1's behaviors but they did not ask them about non-pharmacological interventions that they could try to help decrease these behaviors. FM V reported that there was a care conference meeting on 3/9/2026 where they discussed R1's status and he told the facility even with behavior problems he did not want R1 sedated. During an interview on 4/8/2026 at 8:25 AM, RN G stated that R1 had behaviors daily which included yelling out, noncompliance with NPO (nothing by mouth) status since he drank water from the sink and toilet, and he pulled his feeding tube out several times. RN G didn't know of any interventions besides checking on him. During an interview on 4/8/2026 at 12:20 PM, RN H stated that R1 called out all the time and would try to get the attention of staff. RN H reported that he constantly wanted water but he was unable to have it and he pulled his feeding tube out several times. During an interview on 4/8/2026 at 1:35 PM, RN I stated that R1 had behaviors daily such as drinking water despite his NPO status and trying to pull out his feeding tube. She did not know of any known interventions that worked. RN G didn't know of any interventions besides checking on him.During an interview on 4/8/2026 at 2:48 PM, RN C stated that R1 hollered a lot saying Hey, hey, hey and yanking on his feeding tube. RN C also reported that R1 was non-compliant with his oxygen and NPO status. RN C said Klonopin was started on 3/12/2026 because of R1's behaviors and anxiety. During an interview on 4/8/2026 at 3:00 PM, Social Services Director (SSD) T stated that R1 called out all the time and even when his needs were met. SSD T stated they had a care conference on 3/9/2026 with FM U and FM V where they discussed resident status. During an interview on 4/8/2026 at 3:17 PM, RN F stated that R1 had repetitive behaviors with calling out constantly, self-transferring, pulling out his tube and he could not be educated due to his cognition. RN F' stated R1 was started on Klonopin on 3/12/2026 and then it was increased on 3/18/2026 due his behaviors and anxiety. During an interview on 4/8/2026 at 4:35 PM, MD Y stated that he couldn't remember R1 or his recommendation to increase the Klonopin. During an interview on 4/9/2026 at 12:20 PM, Director of Nursing (DON) B stated that R1 was challenging and impulsive with poor safety awareness. DON B said he pulled off oxygen, pulled out his feeding tube several times and would drink water when he was NPO. When discussing that R1's care plan didn't list any interventions and what non-pharmacological interventions staff tried to help decrease his behaviors, DON B' said they tried multiple interventions such as activities and checking on him regularly. DON B said that FM U and FM V weren't realistic about R1's limitations and prognosis. Review of the Psychotropic Medication Use Policy with a revision date of 3/1/2025 revealed . Procedure: The facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors.2.1.1. Facility staff should take a holistic approach to behavior management that involves A thorough assessment of underlying causes of behaviors and individualized person centered non drug and pharmaceutical interventions. 2.1.3 staff should become familiar with the cultural, medical, and psychological information about the resident to identify potential environmental and other triggers to prevent or reduce behavioral symptoms and/or distress types and the consequences of behaviors exhibited by the resident and interventions that may be indicated for specific behavior type.3. Facility should involve the resident or the resident representatives in the discussion of potential nonpharmacologic and medication interventions to address the management of behaviors and the involvement should be documented in the residence medical record. 3.1 Psychotropic medications may be used to address behaviors only if non drug approaches and interventions were attempted prior to their use. 3.2. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medication or psychiatric causes of behavioral symptoms.9. Where physician/prescriber orders a psychotropic medication for a resident facility should ensure physician prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary.

This citation pertains to intake #2960916.Based on interview and record review the facility failed to maintain quality of care by ensuring implementation of skin care treatment and ensure skin care was completed for 1 resident (Resident #2) of 3 residents reviewed for quality of care resulting in dressing changes not being implemented and being monitored causing unmet resident care needs. Findings include: Resident #2 (R2)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R2 admitted to the facility on [DATE] with pertinent diagnoses including morbid obesity, difficulty walking, heart failure and chronic pain. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R2 was cognitively intact. She had a planned discharge to the hospital on 3/27/2026. During an interview on 4/8/2026 at 1:57 PM, R2's Family Member (FM) W stated that R2 received skin tears from her fall on 3/9/2026. FM W said when she was in the facility on 3/21/2026 she noticed the bandage on her left arm was dated 3/10/2026 and it wasn't changed until she mentioned it to the nurse that day. FM W reported that R2's arm got worse and was weeping. Review of R2's Fall report completed by Registered Nurse (RN) F and dated 3/9/2026 revealed Resident was getting assistance from the CNA (Certified Nursing Assistant) to go to the hospital. While the CNA was transferring the resident to the toilet the resident stated that she was feeling dizzy. CNA stated the resident was lowered to the floor and as soon as she was on the floor the CNA said the resident was safe on the floor and came to get this nurse. Injuries: back of left hand, right elbow, back of right hand. Review of R2's Care Plan revealed Focus: The resident has skin tear, fragile skin. Date initiated 1/9/2026.Interventions/Tasks.Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Date initiated 1/9/2026. Review of R2's progress note dated 3/9/2026 revealed Resident was getting assistance from the CNA to go to the hospital. While the CNA was transferring the resident to the toilet the resident stated that she was feeling dizzy. CNA stated the resident was lowered to the floor and as soon as she was on the floor the CNA said the resident was safe on the floor and came to get this nurse. Nurse assessed residents' vitals and blood pressure was 74/54 with a pulse of 42. Resident obtained a skin tear to bilateral upper arms. Resident was not harmed during the transition from standing to lowering. Resident was assisted back to bed via hoyer lift x 3 staff members. She was positioned back into bed to her liking. Physician will be notified of blood pressure.Review of R2's Physician progress note dated 3/16/2026 revealed Reason for Evaluation: I am asked by nursing staff to evaluate the patient/s (R2's) left arm swelling. Subjective: This is an [AGE] year-old white female. The patient was on the other side of the unit and the nurses knew about the patient's swelling. The redness is better but the patient is developing a little bit more fluid now. Assessment: Arm swelling. Plan: 1. Will start the patient on Bumex (diuretic-gets rid of fluid) again one time a day. 2. Observation.Review of provider progress note dated 3/21/2026 revealed .History Present Illness : Patient sustained a fall last week. Skin tear was treated on left forearm. Dressing had not been changed since and today when removing, tear reopened. Does have moderate bleeding noted, on Eliquis. Area is reddened and bruised throughout entire forearm.Review of progress note dated 3/23/2026 revealed Discussed care concerns with (FM W). Will talk to (MD Y) this afternoon when he is in facility about L (left) arm swelling and weeping, and changing pain medication from scheduled from prn (as needed) since she forgets to ask and then is in a lot of pain. Discussed wound care orders for skin tears on arms.Review of R2's progress note dated 3/25/2026 revealed This wound is a skin tear from blisters opening on the forearm from fluid overload in this left arm due to her heart failure. This arm is dependent and needs to be elevated at all times as the resident will allow, provider is following this closely and there has been lab work ordered and medication changes ordered to try and treat the symptoms of the heart failure.Review of R2's weekly skin assessment and wound observation assessment did not address R2's skin tear that occurred on 3/9/2026 until 3/22/2026. Review of R2's March 2026 Treatment Assessment Record (TAR) revealed Wound care-right forearm: spray with wound cleanser, pat dry with gauze, apply xeroform to both proximal (closest to skin tear area) and distal (farther away from the skin tear), cover with 4x 4 green foam silicone dressing, change every other day and prn (as needed) for soiled, loose or missing dressing. Order date 3/23/2026. Wound care-right forearm: spray with wound cleanser, pat dry with gauze, apply xeroform to both proximal and distal skin tear, cover with 4x 4 green foam silicone dressing, change every 3 days for soiled, loose or missing dressing. Order date 3/23/2026.Wound care to left forearm. Cleanse with normal saline, pat dry, betadine paint, cover with non adherent pad, then 4 by 4 over the non-adherent pad, secure with coban with light pressure (lightweight, breathable elastic wrap that only sticks to itself). Every day shift for skin tear. Drainage-N-None, S-serous (clear, thin, watery), Se-Serosangious (thin, watery, pinkish red discharge), B-Bloody, P-Purulent (thick, cloudy and foul smelling), Odor-Y-Yes, N-No. Periwound (area surrounding wound)-P-Pink, R-Red, I-Indurated (hard tissue), W-Warm, Wound Bed-G-granulation (new tissue forming during wound healing), S-Slough (dead tissue separating from living skin) , E-Eshar (dead tissue), Ep-Epithelialization (new skin cells on a wound), Wound outcome-U-Unchanged, I-Improved, D-Deteriorated. Order date 3/21/2026. The first treatment was started on 3/24/2026.Review of R2's shower sheet completed by CNA R on 3/18/2026 revealed documentation on the person diagram Left bandage was stuck on skin and smelled bad. During an interview on 4/8/2026 at 9:18 AM, CNA P' stated that on 3/21/2026 R2's left arm bandage was nasty since the nurses didn't change it in a while so she told the nurse about it that day so she could change it. CNA P reported that R1's bandage was weeping through and was black/brownish in color. During an interview on 4/8/2026 at 3:17 PM, RN F' stated that resident had skin tears on her arms from the fall on 3/9/2026 and 1 arm was weeping but he didn't know which one. RN F stated that he was the wound nurse on his unit and he ensured treatments were in place for skin tears. RN F' stated that he did weekly wound rounds but didn't think he did one with her because she moved to the other hall and Licensed Practical Nurse (LPN) J is the unit manager on that side. Review of the facility census report revealed that R2 switched rooms and units on 3/16/2026. During an interview on 4/8/2026 at 3:56 PM, LPN J' stated that she only saw R2's wound 1 time with Medical Director (MD) Y since R2 was new to her unit. LPN J' stated the left arm skin tear looked like a blister when she saw it. LPN J also reported that she only saw wounds such as pressure ulcers and not skin tears or other skin areas. LPN J said that usually a nurse would find a skin area or CNAs would tell her and then a treatment was put in place. During an interview on 4/8/2026 at 4:07 PM, CNA R stated that she gave R2 a shower on 3/18/2026 and she tried to take the bandages off her left arm but it was stuck, stinky and looked like it wasn't changed for a while. So, she notified the nurse. During an interview on 4/8/2026 at 4:35 PM, MD Y stated that he couldn't remember R2 and her skin tear on her left arm. During an interview on 4/9/2026 at 9:23 AM, LPN L stated that she was the nurse on duty when R2 fell on 3/9/2026. LPN L said that R2 scrapped both her arms on the side of the toilet when she was lowered to the ground by the CNA. LPN L' didn't remember getting treatment orders from the physician for her skin tears. During another interview on 4/9/2026 at 9:46 AM, RN F stated that he prepared the fall report on 3/9/2026 and he should have obtained treatment orders at that time. When discussing the fact that the TAR did not have any orders from 3/9/2026 when the fall and skin tears occurred until 3/21/2026 when an order was put in, RN F said I got busy and it got missed. It's on me.During an interview on 4/9/2026 at 12:20 PM, Director of Nursing (DON) B stated that she was unaware of R2's skin tears and having no treatment orders and she said to ask RN F about it. DON B stated that the normal process was to notify the doctor for skin issues, get a treatment and follow the orders and monitor the wound. Review of the Skin Care and Wound Management Policy with no date revealed .6. If any new skin alteration/wound is identified, it is the responsibility of the nurse to perform and document as assessment/observation, obtain treatment orders, and notify MD (Medical Doctor) and responsible party.7. Orders are required for wound dressings.

Based on observation, interview, and record review, facility staff failed to wear appropriate PPE (personal protective equipment) for 1 resident (Resident #5) of 4 residents reviewed for infection control practices resulting in the potential for the spread of disease in a vulnerable population.Findings include: Resident #5(R5)Review of R5's orders revealed Isolation: Contact and Droplet Precautions, Diagnosis: RSV. Directions every shift. Start date 4/7/2026.Review of R5's progress notes dated 4/7/2026 revealed RSV positive results received. Isolation precautions per policy.During an observation on 4/8/2026 at 8:25 AM outside R5's room, the following signs were noted: Enhanced Barrier Precautions and Droplet Precautions. The Enhanced Barrier Sign displayed Stop: Everyone must clean their hands, including before entering and when leaving room. Providers and staff must also: Wear gloves and a gown for the following high contact resident care activities: dressing bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. The droplet precaution sign displayed Stop: Everyone must: Clean their hands, including before entering and when leaving the room. Make sure eyes, nose, mouth are fully covered before room entry. Remove face protection before room exit.During an observation on 4/8/2026 at 8:33 AM, Infection Preventionist (IP) E walked into R5's room with only a mask on and when she came out, she had the same mask on and continued to walk down the hallway. During an interview on 4/8/2026 at 8:40 AM, IP E stated that she was new in the position and was learning. IP E said that R5 has RSV (Respiratory Syncytial Virus) and the signs were put up so staff knew what PPE to wear. When discussing the appropriate PPE to wear in a RSV positive room, IP E stated that she should have worn a gown, gloves and changed out her mask. IP E stated that she was only in the room for a few minutes and didn't think about PPE. During an observation on 4/8/2026 at 8:50 AM, IP E put a contact precautions sign up on R5's door along with the other signs which displayed Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use and another person. During another interview on 4/9/2026 at 9:10 AM, IP E stated that RSV should have both contact and droplet precautions signs which included wearing a gown, gloves, mask but eye protection was optional.During an interview on 4/9/2026 at 12:20 PM, Director of Nursing (DON) B stated that IP E felt bad about walking into R5's room without the appropriate PPE. DON B reported that with RSV it included contact and droplet precautions which included a gown, gloves, mask and eye wear was optional. DON B stated that the droplet sign was put on the door to make sure staff changed their mask out when leaving the room. DON B reported that eye wear was available at the nurses' station if anyone wanted to wear it.

This citation is related to intake 2646852Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect in 3 (Resident #3, #7, and #18) of 18 residents reviewed for dignity/respect, and 4 of 5 residents from the confidential group meeting, resulting in extended call light wait times, unmet care needs and the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Resident # 3 Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included critical illness myopathy (severe muscle weakness and wasting in critically ill patients) and end stage renal disease. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 10/1/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident # 15 was cognitively intact. In an interview and observation on 12/15/2025 at 1:44 PM, This writer knocked on Resident #3's room door. As this writer was entering Resident #3's room, Licensed Practical Nurse (LPN) U walked by this writer and stated, Be careful with him (Resident #3), he is a really cranky person. It was noted that LPN U made the statement about Resident #3 as his room door was open, and she was close enough for Resident #3 to hear her statement. In an interview on 12/15/2025 at 1:44 PM, Resident #3 reported feeling angry and frustrated with the way that staff treated him at the facility. Resident #3 reported that he often had to wait between 30-45 minutes for staff to answer his call light. Resident #3 reported he felt like most of the staff at the facility did not like him, and that he often heard staff talking about him. Resident #3 reported that he had heard staff call him cranky and difficult on several occasions. Resident #3 reported he had talked to facility management about the way that staff had treated him before, but he felt like it made things worse and that staff were retaliating against him, and the facility didn't do anything about his concerns, so he no longer voiced concerns. Resident #3 reported that he was just so tired of being treated like I am a nobody. They don't like me, and they have made that clear. In an interview on 12/16/2025 at 12:01 PM, Nursing Home Administrator (NHA) A reported she was aware that Resident #3 had concerns with staff interactions at the facility. NHA A reported that several staff members had also voiced concerns about interactions with Resident #3. When this writer queried about what the facility had done regarding Resident #3'c concerns with staff interactions, NHA A reported she had offered to assist Resident #3 in going to a new facility. NHA A reported that she had not completed any recent education with staff on treating residents with dignity and respect. NHA A reported that Resident #3 was not speaking to NHA A at the time, and that the facility was at a loss at what to do for him. In a follow up interview on 12/17/2025 8:53 AM, Resident #3 reported that he had stopped talking to NHA A because he felt like the facility would not address his concerns and just swept things under the rug. When this writer queried about what kinds of things he had heard staff say about him, Resident #3 cried as he talked about hearing staff say that he was mean, cranky, and not my resident so I am not answering his light. Resident #3 reported he was so tired of being so angry and that he was angry because they just don't even treat me like I am a human being. In a follow up interview on 12/17/25 at 1:45 PM, NHA A reported she expected staff to treat all residents with dignity, and calling a resident cranky was not treating a resident with dignity and respect. Review of the facility's Dignity policy, last reviewed 9/6/25, revealed, Policy: Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input. Resident #7 Review of an admission Record revealed Resident #7 was a female, with pertinent diagnoses which included: hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 10/22/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #7 was cognitively intact. Review of Resident #7's current Care Plan revealed a focus of, Resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Disease Progress (Bipolar Disorder), Impaired mobility and balance last revised 7/29/25 with care planned interventions which included BED MOBILITY: Resident requires assistance by 1 to turn and reposition in bed frequently and as necessary last revised on 11/20/25 and PERSONAL HYGIENE: Resident requires assistance by staff with personal hygiene and oral care last revised 4/28/25. In an interview on 12/15/25 at 2:51 PM, Resident #7 reported, on average, it can take at least 30 minutes for staff to answer her call light. Resident #7 explained that because she is paralyzed on one side of her body, she needs help getting boosted up in bed when she wants repositioned. Resident #7 reported when she turns her call light on for assistance and is waiting to get repositioned it is painful. Resident #7 also reported she has had to wait in her soiled brief for an extended period after turning her call light on for assistance and it itches while she is waiting for staff to assist her. Resident #7 reported it makes her sad and angry when she has had to wait extended periods for her call light to be answered. Resident #18 Review of an admission Record revealed Resident #18 was a female, with pertinent diagnoses which included: generalized anxiety disorder and major depressive disorder, recurrent, unspecified. Review of a Brief Interview for Mental Status (BIMS) assessment for Resident #18, signed 12/16/25 revealed a BIMS score of 15, out of a total possible score of 15, which indicated Resident #18 was cognitively intact. In an interview on 12/15/25 at 2:30 PM, Resident #18 reported it has taken 30 minutes or more at night for staff to respond to her call light. Resident #18 reported during the day, call light response time was good but at night it takes a long time. Resident #18 reported when it has taken a long time for staff to respond to her call light at night, it made her feel agitated because she would like to go to sleep and would like to see staff for her need before I have to give up. Resident #18 reported it can also take a long time for staff to respond to her call light on the weekend and that sometimes I had my light on forever and nobody would come. Resident #18 reported that was very unpleasant and sometimes she has fallen asleep without having her needs met. In an interview on 12/15/2025 at 4:38 PM, Certified Nurse Aide (CNA) Q reported residents have complained to him about long call light wait times. In an interview on 12/16/2025 at 10:41 AM, Licensed Practical Nurse (LPN) U reported residents have complained to her about long call light wait times, specifically related to night shift. In an interview on 12/16/2025 at 10:44 AM, Registered Nurse (RN) O reported sometimes residents have complained to her about long call light wait times. Review of Resident Council Meeting Minutes for 12/10/25 revealed, .Several residents expressed exceptionally long call light wait times during the evening shift, typically during 8pm - 10pm. Residents expressed waiting over 45 minutes . During a confidential resident council meeting interview held on 12/16/2025 at 1:15 PM, 4 out of 5 residents in attendance were visibly frustrated and reported the average call light wait time on night shift was 30 minutes. The council group reported the delayed call light response wasn't isolated to just one hall but affected four different halls.

Based on observation and interview, the facility failed to maintain kitchen plumbing equipment and surfaces in a manner that would allow for safe, clean, and consistent operation. Findings include: On 12/17/25 at 8:35AM, observation of the walk-in cooler floor found it moved and buckled when walked on. Further observation found cracks in portions of the floor where water could accumulate. Food Service Director (FSD) AA stated it was something that the facility had plans to repair. On 12/17/25 at 8:44AM, observation of the two door Traulson refrigeration unit found heavy black staining of the rubber gasket seals. An interview with FSD AA found that staff clean the gaskets, but the staining does not come off. The surveyor attempted to clean the staining, with minimal improvement. FSD AA stated they are in the process of getting new gaskets, but they seem to take awhile to arrive.On 12/17/25 at 8:46AM, observation of the automatic hand sink, next to the drink station, found that the automatic faucet only ran four to five seconds before needing to be reactivated. When asked if this is how it normally runs, FSD AA stated yes, and that he prefers the other hand sink because of it. According to the 2022 FDA Food Code section 5-202.12 Handwashing Sink,Installation.(C) A self-closing, slow-closing, or metering faucet shall provide a flow of water for at least 15 seconds without the need to reactivate the faucet.On 12/17/25 at 1:43 PM, observation of the left of the garbage grinder area, at the end of the cook line, found stagnant hot and cold-water lines capped off with no way to properly flush the domestic water. Further observation found the garbage grinder with a water line (submerged inlet) feeding the grinder to help food go down. The water line to the garbage grinder had an Atmospheric Vacuum Breaker (AVB) to protect the potable water supply, but the AVB was not six inches above the overflow rim of the sink. An interview with FSD AA, found that this area had plumbing work done a year or so ago to get the sink operational, and the facility is looking to renovate this area further so they can add another sink (and connect it to the unused water lines).

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for ants and winged-insects in five resident rooms (rooms #118, 117, 119, 120, and 106) of 88 resident rooms, and one-resident common area, resulting in the potential for pest transmitted diseases to a vulnerable population. Findings include:Observed on 12/15/25 at 1:00 PM room [ROOM NUMBER] to have ants crawling on the floor in both bed areas, on the bathroom floor, and in the bathtub. During an interview on 12/16/2025 at 9:20 AM, Housekeeping R stated she has seen ants here and there throughout the building usually by resident room doors. Observed on 12/16/25 at 9:21 AM room [ROOM NUMBER] to have ants crawling on the floor in both bed areas, on the bathroom floor, and in the bathtub. Observed on 12/16/2025 9:27 AM room [ROOM NUMBER] to have ants crawling on the bathroom floor. Observed on 12/16/25 at 11:23 AM room [ROOM NUMBER] to have ants crawling on the floor of the bathroom. During an observation and interview on 12/16/25 at 11:30 AM, room [ROOM NUMBER] with current residing resident and family member (FM) SS reported family had counted 15 ants crawling on the floor of the room earlier that morning. Surveyor observed at least 15 ants crawling on the floor of the room. Crawling ants were observed in the bathroom on the floor and in bathtub. Dead ants also were in the bathtub and floor. FM SS stated the ants had been reported to staff on numerous occasions. Observed on 12/16/25 at 11:35 AM room [ROOM NUMBER] had ants crawling on the floor of the bathroom. Observed on 12/16/25 at 11:39 AM room [ROOM NUMBER] to have live ants crawling on the bathroom and room floor. Observed on 12/16/25 at 11:50 AM room [ROOM NUMBER] to have ants crawling on the bathroom floor. Review of facility Closed Work Orders dated September 15, 2025-December 16, 2025, revealed room [ROOM NUMBER] bed 2 had ants in the room, no date listed. This was identified by the facility as a medium concern. Review of facility policy, Pest Control revised 7/9/25 stated, The facility will maintain an effective pest control program that provides frequent treatment of the environment for pests so that the facility is free of pests.the facility's staff will do monitoring of the environment. Pest control problems will be reported to the Director of Maintenance promptly. During a confidential resident council meeting interview held on 12/16/2025 at 1:15 PM, 4 out of 5 residents in attendance reported the facility had an ant problem and reported seeing ants in their rooms and hallways.

Based on interview and record review, the facility failed to ensure timely physician follow up with pharmacy recommendations for 4 residents (Resident #88, Resident #12, Resident #15 and Resident #80) of 5 reviewed for medications resulting in the potential for residents to experience avoidable medication side effects and/or receive unnecessary medications.Findings include: Resident #88 Review of an admission Record revealed Resident #88 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: adjustment disorder with mixed disturbance of emotions and conduct (short-term mental and behavioral condition that occurs when someone has an unhealthy reaction to a stressful life change), major depressive disorder (persistent depressed mood or loss of interest in activities causing significant impairment in daily life). anxiety disorder (excessive worry and fear that are persistent, intense, and often out of proportion to the situation), and vascular dementia (a decline in thinking skills caused by reduced blood flow to the brain). Review of a Minimum Data Set (MDS) assessment for Resident #88 with a reference date of 10/24/25, revealed the resident was prescribed antianxiety medication, an antidepressant, opioid pain medication and anticonvulsant medication. Review of a Care Plan for Resident #88 with a reference date of 9/30/24 revealed the following focus/goal/interventions: Focus: (Resident #88) uses anti-anxiety medications r/t (related to) anxiety disorder. Goal: (Resident #88) will be free from.adverse reactions related to anti-anxiety therapy.Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Review of Pharmacy Consultation Report for Resident #88 with a reference date of 5/20/25 revealed Comment: (Resident #88) receives alprazolam for insomnia. Recommendation: Please consider alternative (trazadone, doxepin, ramelteon). Rationale for Recommendation: Benzodiazepines have an increased risk for prolonged sedation, cognitive impairment, delirium, falls, and fractures in older adults and should be avoided.Physician's Response: ( ) I accept the recommendation(s) above, please implement as written ( ) I accept the recommendation(s) above WITH THE FOLLOWING MODIFICATION(S): ( ) I decline the recommendation(s) above and do not wish the implement any changes due to the reasons below. Rationale; ____. No response from the physician was documented. Review of Pharmacy Consultation Report for Resident #88 with a reference date of 7/22/25 revealed: 1. Comment: (Resident #88) receives alprazolam and melatonin for insomnia. Recommendation: Please consider discontinuing alprazolam and melatonin and initiate ramelteon 8mg (milligrams) QHS (every night). Rationale for Recommendation: Benzodiazepines have an increased risk for prolonged sedation, cognitive impairment, delirium, falls, and fractures in older adults and should be avoided.Physician's Response: ( ) I accept the recommendation(s) above, please implement as written ( ) I accept the recommendation(s) above WITH THE FOLLOWING MODIFICATION(S): ( ) I decline the recommendation(s) above and do not wish the implement any changes due to the reasons below. Rationale; ____. No response from the physician was documented. 2. Comment: (Resident #88) receives omeprazole 20mg QD (everyday) since April. Recommendation: Please reevaluate the continued need for omeprazole and consider discontinuation via slow taper.or change to famotidine 20mg QD. Rationale for Recommendation: Long term PPI (proton pump inhibitors) use is associated with increased risk of C. difficile (contagious bacterial infection of the digestive system) infection, bone loss and fractures. Physician's Response: ( ) I accept the recommendation(s) above, please implement as written ( ) I accept the recommendation(s) above WITH THE FOLLOWING MODIFICATION(S): ( ) I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale; ____. No response from the physician was documented. Review of Pharmacy Consultation Report for Resident #88 with a reference date of 9/17/25 revealed: 1. Comment: (Resident #88) receives alprazolam and melatonin for insomnia. Recommendation: Please consider discontinuing alprazolam and melatonin and initiate ramelteon 8mg (milligrams) QHS (every night). Rationale for Recommendation: Benzodiazepines have an increased risk for prolonged sedation, cognitive impairment, delirium, falls, and fractures in older adults and should be avoided.Physician's Response: ( ) I accept the recommendation(s) above, please implement as written ( ) I accept the recommendation(s) above WITH THE FOLLOWING MODIFICATION(S): ( ) I decline the recommendation(s) above and do not wish the implement any changes due to the reasons below. Rationale; ____. No response from the physician was documented. 2. Comment: (Resident #88) receives omeprazole 20mg QD (everyday) since April. Recommendation: Please reevaluate the continued need for omeprazole and consider discontinuation via slow taper.or change to famotidine 20mg QD. Rationale for Recommendation: Long term PPI (proton pump inhibitors) use is associated with increased risk of C. difficile (contagious bacterial infection of the digestive system) infection, bone loss and fractures. Physician's Response: ( ) I accept the recommendation(s) above, please implement as written ( ) I accept the recommendation(s) above WITH THE FOLLOWING MODIFICATION(S): ( ) I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale; ____. No response from the physician was documented. In an interview on 12/17/25 at 10:18am Director of Nursing (DON) B reported it was important for the physician to follow pharmacist recommendations to avoid residents receiving unnecessary medications and/or experiencing avoidable medication side effects. Review of A Pharmacist's Guide to Medication Review, Journal of the American Pharmacists Association, Volume 42, Issue 1, P131-132, 2002, revealed As the drug therapy expert, the pharmacist is an essential member of the patient's medication education team.1 Information obtained directly from the medication review process contributes to the safe and effective use of medications, including the identification and prevention of drug–related problems. Resident #12 Review of an admission Record revealed Resident #12 was originally admitted to the facility on [DATE] with pertinent diagnoses which included anxiety disorder and depression. Review of Resident #12's Electronic Medical Record (EMR) revealed documentation that Resident #12 had monthly medication regimen (MMR) reviews completed by the facility's consulting pharmacist on 8/22/25, 11/11/25, and 12/8/25. It was noted that the monthly review on 12/8/25 indicated there was a recommendation noted and to see report. On 12/16/2025 at 11:12 AM, This writer requested documentation to verify that Resident #12 had MMR reviews competed for October 2025, September 2025, and July 2025 and verification that pharmacy recommendation was reviewed by the facility's Medical Director. The facility did not provide the requested documents prior to survey exit. Review of Resident #12's Pharmacy consultation report dated 6/16/25 revealed, . Recommendation: Please monitor a fating lipid panel on the next convenient lab day and at least annually thereafter . Provider response: This section was left blank and not signed by the facility Medical Director. It was noted that Resident #12 did not have a lipid panel order or results in his EMR. Review of Resident #12's Pharmacy consultation report dated 10/13/25 revealed . Recommendation: Please Monitor a B12 and a serum magnesium concentration on the next convenient lab day and at least annually thereafter. Provider response: This section was left blank and not signed by the facility Medical Director. It was noted that Resident #12 did not have a B12 and serum magnesium level in his EMR. Resident #80 Review of an admission Record revealed Resident #80 was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder and muscle weakness. Review of Resident #80's Electronic Medical Record (EMR) revealed documentation that Resident #80 had MMR reviews completed by the facility's consulting pharmacist on 8/22/25, 11/11/25, and 12/8/25. It was noted that the monthly review on 12/8/25 indicated there was a recommendation noted and to see report. On 12/16/2025 at 11:12 AM, This writer requested documentation to verify that Resident #12 had MMR reviews competed for October 2025, September 2025, and July 2025 and verification that pharmacy recommendation was reviewed by the facility's Medical Director. The facility did not provide the requested documents prior to survey exit. Review of Resident #80's Pharmacy Consultation Report dated 6/17/25 revealed, . Recommendation: Please reevaluate the continued need for omeprazole (medication used to treat excess stomach acids) and consider discontinuation via slow taper . or change to famotidine 20 mg (milligrams) QD (every day) . Provider response: This section was left blank and not signed by the facility Medical Director. Review of Resident #80's Orders indicated that Resident #80 was taking Omeprazole 20 mg daily. Review of Resident #80's Pharmacy Consultation Report dated 7/22/25 revealed, . Recommendations: Please monitor a TSH (Thyroid stimulating hormone) concentration on the next convenient lab day and at least annually. Provider response: This section was left blank and not signed by the facility Medical Director. It was noted that Resident #80 did not have any TSH lab results noted in his EMR. Review of Resident #80's Pharmacy Consultation Report dated 9/17/25 revealed, . Recommendations: Please monitor a TSH (Thyroid stimulating hormone) concentration on the next convenient lab day and at least annually. Provider response: This section was left blank and not signed by the facility Medical Director. It was noted that Resident #80 did not have any TSH lab results noted in his EMR. Review of Resident #80's Pharmacy Consultation Report dated 9/17/25 revealed, . Recommendation: Please reevaluate the continued need for omeprazole (medication used to treat excess stomach acids) and consider discontinuation via slow taper . or change to famotidine 20 mg (milligrams) QD (every day) . Provider response: This section was left blank and not signed by the facility Medical Director. Review of Resident #80's Orders indicated that Resident #80 was taking Omeprazole 20 mg daily. Review of Resident #80s Pharmacy Consultation Report dated 10/14/25 revealed, . Recommendation: Please decrease insulin glargine to 25 units daily . Rationale for recommendation: Overtreatment of diabetes should be avoided, especially in older adults, to reduce the risk of hypoglycemia (low blood sugar) . Provider response: This section was left blank and not signed by the facility Medical Director. Review of Resident #80's Orders revealed that Resident #80 Insulin Glargine was ordered at 30 units daily. In an interview on 12/17/25 at 11:32 AM, Director of Nursing (DON) B reported the facility's Unit Managers were responsible for ensuring that MMR's were provided to the facility Medical Director, and that he had just recently learned that this might have been occurring. DON B was unable to report how many MMR's had been missed, or if the facility had completed any audits to ensure any missed MMR's were reviewed. In an interview on 12/17/2025 at 2:24 PM, Medical Director (MD) BBB reported he was responsible for ensuring that MMR's were reviewed and responded to. MD BBB reported that he completed the MMR's when the facility provided them to him, but he did not know how often he was supposed to review them, how often the reviews were being missed, or if he had missed any reviews. Resident #15: Review of Resident #15's diagnoses list indicated an admission date of 5/12/2025 and included a pertinent diagnosis of anemia (blood does not have enough healthy red blood cells or hemoglobin (carries oxygen)). Review of Resident #15's pharmacist consultation report, stated, .Recommendation date: 06/15/2025.Comment: (Resident #15) has an order for BID (twice a day) ferrous sulfate (iron supplement often used to treat anemia) .Recommendation: Please consider decreasing the dose to ferrous sulfate 325 mg (milligrams) QOD (every other day) . The report was signed by the pharmacist on 6/15/2025 and the Physician's Response: . section of the form was empty/blank, didn't indicate if the recommendation was accepted or declined, no rationale was provided, and had no physician signature or date of signature. There was no physician response noted on the form. Review of Resident #15's pharmacist consultation report, stated, .Recommendation date: 09/16/2025.Comment: (Resident #15) has an order for BID (twice a day) ferrous sulfate (iron supplement often used to treat anemia) .Recommendation: Please consider decreasing the dose to ferrous sulfate 325 mg (milligrams) QOD (every other day) . The report was signed by the pharmacist on 9/16/2025 and the Physician's Response: . section of the form was empty/blank, didn't indicate if the recommendation was accepted or declined, no rationale was provided, and had no physician signature or date of signature. There was no physician response noted on the form. Review of Resident #15's progress note, dated 12/8/2025, stated, Pharmacy Note.Medication regimen review performed.Comment/Recommendation noted – see report. The facility was unable to provide a report/document before the end of survey that showed what the Registered Pharmacist's recommendation was from the review performed, if the physician had received that recommendation, and/or what the physician's response was. Review of the pharmacist's Consultation Report, dated 7/1/2025-7/31/2025, stated, The following residents were reviewed and based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgement that at such time, the resident's medication regimens contained no new irregularities.Resident #15 wasn't on this list which would indicate she had an irregularity with her medication regimen. The facility was unable to provide any documentation before the end of survey that showed what the medication irregularity was, what the pharmacist's recommendation was, if the physician received a report, and/or responded to the report/recommendation. Review of Resident #15's physician orders included an order for FeroSul (brand of iron supplement) Oral Tablet 325 (65 Fe (iron)) MG (milligrams) (Ferrous Sulfate) (iron supplement), a start date of 6/20/25, and Give 1 tablet by mouth two times a day.During an interview on 12/17/2025 at 10:39 AM, Regional Registered Nurse YY reported the facility had been unable to find the physician responses for some noted irregularities from the pharmacist's reports for Resident #15.

Based on observation, interview, and record review the facility failed to ensure clean resident rooms and comfortable temperatures of facility care areas for 9 of 18 residents (Residents #15, 6, 11, 30, 27, 26, 7, 19 and 3) and 3 of 5 residents from a confidential resident council meeting reviewed for clean and comfortable environment, resulting in residents being uncomfortable living in an unclean and cold environment.Findings include:Residents #15, 6, 11, and 30: During an observation and interview on 12/15/2025 at 10:04 AM, Resident #15 was sitting on her bed in her room and reported her room was cold and it has been since it got cold outside. The room was observed to feel cold. During an observation on 12/15/2025 at 10:02 AM, the hallway ceiling vent between rooms [ROOM NUMBERS] was blowing out cold air. During an observation on 12/15/2025 at 10:39 AM, the hallway ceiling vent between rooms [ROOM NUMBERS] was blowing out cold air.During an observation on 12/16/2025 at 8:44 AM, undesirable cold air was felt blowing out of the ceiling hallway vent outside of room [ROOM NUMBER]. The cold air could be felt as you walked under or stood beneath it. The feeling in the hallway was cold. During an observation and interview on 12/16/2025 at 8:49 AM, cold air was flowing from the hallway ceiling vents between rooms [ROOM NUMBERS] and between rooms [ROOM NUMBERS]. Resident #15 was nearby and reported she slept in her zip up hoodie sweatshirt to stay warm last night. Review of Resident #15's brief interview for mental status, dated 11/8/25, was scored 14 which reflected she was cognitively intact. During an interview on 12/16/2025 at 8:58 AM, Resident #6 reported the facility was so cold. Resident #6 stated, I was freezing.I had to wear a coat all the time in the hallway.it stayed that way (cold) since it got cold outside.it's ridiculous. Review of Resident #6's brief interview for mental status, dated 11/17/25, was scored 15 which reflected she was cognitively intact. During an interview on 12/16/2025 at 9:07 AM, Confidential Informant (CI) DDD who worked in the building reported they were cold, it was always that cold, and the facility coldness concern had been brought to the facility multiple times. CI DDD confirmed it has been cold inside the facility since it got cold outside. During an observation and interview on 12/16/2025 at 9:52 AM, Residents #11 and #30 were awake, lying in their beds, and under their bed sheets. Resident #11 stated, I was awake last night because it was so cold. Resident #30 reported she couldn't comfortably hang/expose her arm out from under her sheets to eat because it was so cold yesterday. Review of Resident #11's brief interview for mental status, dated 11/17/25, was scored 15 which reflected she was cognitively intact. Review of Resident #30's brief interview for mental status, dated 11/25/25, was scored 14 which reflected she was cognitively intact. During an observation on 12/17/2025 at 9:46 AM, cold air was felt coming out of the hallway ceiling vent between rooms [ROOM NUMBERS]. During an observation on 12/17/2025 at 9:49 AM, cold air was felt coming out of the hallway ceiling vent outside room [ROOM NUMBER]. During a confidential resident council meeting interview held on 12/16/2025 at 1:15 PM, 3 out of 5 residents in attendance reported the facility was too cold and the temperature was uncomfortable. They reported the undesirable cold temperature was not a new problem and confirmed it had been a problem. Review of the facility's, Resident Belongings and Home Like Environment, reviewed 5/15/25, stated, The facility will provide a safe, clean, comfortable, and homelike environment .Environment - Refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms .hallways . Applying the reasonable person concept, for those that were not cognitively intact and unable to answer questions regarding facility temperature, one would not want to live in a cold indoor environment during wintertime. Observed on 12/15/25 at 1:00 PM room [ROOM NUMBER] to be cool upon entering the room. Upon entering the private bathroom, it was extremely warm. The thermostat was set at 90 degrees causing surveyor to step quickly out of that area and back into the bed area. There was a noticeable change in temperature between the two areas. Observed on 12/15/25 at 1:00 PM room [ROOM NUMBER] to have the threshold, under the heat register, areas where the wall and floor meet, and the corners of the room and bathroom filled with dirt and debris. During an interview on 12/16/2025 at 9:20 AM, Housekeeping R reported she was told by her supervisor not to clean room [ROOM NUMBER] at this time but instead was to make the bed in room [ROOM NUMBER]-1 because family was coming to visit soon. Observed on 12/16/25 at 9:21 AM room [ROOM NUMBER] to have the threshold, under the heat register, areas where the wall and floor meet, and the corners of the room and bathroom filled with dirt and debris. Cobwebs with dead winged insects and ants were in the corners of the wall and ceilings and inside closet area. Observed on 12/16/25 at 9:21 AM room [ROOM NUMBER] and adjoining bathroom, multiple dead ants in the bathtub. The bathtub drain had greenish corrosion. On the floor of the bathroom were multiple dead winged insects and ants. The same number of dead bugs as the prior day. Observed on 12/16/25 at 9:21 AM room [ROOM NUMBER] to be cool upon entering. Upon entering the private bathroom, it was extremely warm. The bathroom thermostat was set at 90 degrees causing surveyor to step quickly out of that area and back into the bed area. There was a noticeable change in temperature between the two areas. Observed on 12/16/2025 9:27 AM room [ROOM NUMBER] to have a dead ant floating in the toilet. Cobwebs in the corners of the walls and floor with dead winged insects and ants. room [ROOM NUMBER]'s bathroom shared a wall with room [ROOM NUMBER]'s bathroom. In the room and closet at the corners of the walls and floor and walls and ceilings were cobwebs with dead winged insects. In the bathtub was a pair of men's underwear that were fecal soiled and toilet paper. Observed on 12/16/25 at 11:23 AM room [ROOM NUMBER] to have cobwebs in the corners of the walls and floor with dead winged insects and ants. In the bathtub was a pair of men's underwear that were fecal soiled and toilet paper. During an observation and interview on 12/16/25 at 11:30 AM, room [ROOM NUMBER] had dead ants in the bathtub and bathroom floor. During an observation and interview on 12/16/25 at 1:00 PM, R27 was in his room with four of his family members. Upon entering the room, it was cool. The door to the bathroom was open with the thermostat set at 90 degrees. A noticeable temperature increased was felt between the door areas making the surveyor leave the bathroom. FM SS reported the family left the bathroom door open to get heat into the bed area and that they or the resident had not touched the thermostat. Observed on 12/16/25 at 11:30 AM, room [ROOM NUMBER] to have the threshold, under the heat register, area where the wall and floor meet, and the corners of the room and bathroom filled with dirt and debris. Cobwebs with dead winged insects and ants in the corners of the wall and ceilings and inside closet area. Resident #26 Review of an admission Record revealed Resident #26 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #26 with a reference date of 10/29/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. During an observation and interview on 12/15/25 at 1:02pm, Resident #26 sat at the edge of her bed, dressed in clothing of choice, and reported her room was cold. When queried about how often she felt her room was cold, Resident #26 stated It's cold everyday. Resident #26 reported she would be comfortable if her room could be kept between 71-75 degrees. Resident #7 Review of an admission Record revealed Resident # 7 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #7 with a reference date of 10/22/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. During an observation and interview on 12/15/25 at 11:02am, Resident #7 was lying in bed, covered with a sheet, a thin white woven facility blanket, and a blue personal blanket that appeared to be 1/4 thick. When asked if she was comfortable, Resident #7 reported it was never warm enough in her room and she felt cold at this time. During an observation and interview on 12/16/25 at 7:52am, Resident #7 was lying in bed, covered by a sheet, a thin white woven facility blanket, and a blue personal blanket. When queried about her comfort, Resident #7 stated I'm freezing. I think I need to put on my coat. Resident #19 Review of an admission Record revealed Resident #19 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #19 with a reference date of 10/29/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 14 /15, which indicated the resident was cognitively intact. During an observation and interview on 12/15/25 at 11:32am, Resident #19 sat in her wheelchair next to her bed, dressed in personal clothing of choice. Resident #19 reported she was cold and that it was usually cold in her room. In an interview on 12/15/25 at 11:20am, Certified Nursing Assistant (CNA) NN reported she usually worked on the 200-hall, and it was common for residents on that hall to complain they were cold. CNA NN reported the maintenance department had been made aware of the complaints about the temperature. In an interview on 12/16/25 at 7:53am, CNA OO reported the 200 hall was cold in certain rooms and she always tried to put sweaters on the residents in those rooms. When further queried, CNA OO reported she noticed Resident #7's room usually felt cold and that maintenance was aware of the issue. In an interview on 12/16/25 at 1:59am, Registered Nurse (RN) N reported he usually worked the 200-hall. When queried regarding the temperature on the unit, RN N stated It's really cold in the winter and the residents want extra blankets all the time. RN N reported he told the maintenance department several times that the unit felt too cold for the residents. During an observation and interview on 12/15/25 at 11:45am, the thermostat for the 200 hall was set at 69 degrees. Maintenance Director (MD) S confirmed the common areas of the 200-hall felt cool this morning, but she had not had time to evaluate the heating system or adjust the thermostat. MD S measured the temperature in Resident #7's room and reported it was 69 degrees. In an interview on 12/16/25 at 10:00am Maintenance Assistant (MA) FFF reported he checked ambient temperatures in resident rooms and hallways each morning when he worked. MA FFF reported he recorded temperatures as low as 68 degrees at times. Resident # 3 Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included critical illness myopathy (severe muscle weakness and wasting in critically ill patients) and end stage renal disease. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 10/1/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #15 was cognitively intact In an interview on 12/15/2025 at 1:44 PM, Resident #3 reported concerns with cold temperatures in the facility, especially in his room. Resident #3 reported that he had used a heated blanket, but the facility had to take the blanket because it was against fire safety code. Resident #3 reported that he had told the facility he had used the blanket to keep warm because his room was too cold, but the facility had not attempted to adjust the temperature in his room., so it remained cold.

Based on interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place for 1 of 18 residents (Resident #7) reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers.Findings include:Resident #7Review of an admission Record revealed Resident # 7 was originally admitted to the facility on [DATE] with a pertinent diagnosis that included: hypertensive heart disease with heart failure (damage to the heart caused by chronic high blood pressure that results in the heart not pumping blood properly).Review of a Minimum Data Set (MDS) assessment for Resident #7 with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact.Review of a Care Plan for Resident #7 with a reference date of [DATE] revealed the following focus/goal/interventions: (Resident #7) has Advance Directives CPR (Cardiopulmonary Resuscitation)- Full Code. Goal: Resident's Advance Directives will be honored. Interventions: .Resident has decided to remain a Full Code.Review of an Advanced Care Planning progress note for Resident #7 with a reference date of [DATE] revealed CONSENTING INDIVIDUALS PRESENT: (Resident #7) .CODE STATUS: Full Code.Review of a Care Management progress note for Resident #7 with a reference date of [DATE] revealed (Resident #7) is a full code and she and her family stated she wants to be a DNR (Do Not Resuscitate). (Staff member's name omitted) will work on her becoming a DNR.Review of a Care Management progress note for Resident #7 with a reference date of [DATE] revealed (Resident #7) is a full code and she stated she wants to be a DNR. (Staff member's name omitted) will work on her becoming a DNR.In an interview on [DATE] at 1:39pm, Resident #7 reported she decided several months ago that she did not want to receive CPR if her heart stopped and had voiced that preference during her care conferences. Resident #7 reported her spouse, who was here Durable Power of Attorney (DPOA), needed to sign an Advance Directive with her wishes. Resident #7 reported the staff said they would coordinate revising her advance directive with her DPOA, but she had not received any more information about it. Resident #7 reported she worried her wishes would not be followed if her heart stopped.In an interview on [DATE] at 1:45pm, Nursing Home Administrator (NHA) A confirmed Resident #7 had asked to change her code status to DNR several months ago and the facility had no documentation regarding any follow up on revising her advance directive. NHA A confirmed that currently, if Resident #7's heart stopped, staff would be expected to provide her CPR.Review of a Area of Focus: Advance Directives policy with a reference date of [DATE] revealed What: An advance directive is a written document prepared by the resident as to how she wants medical decisions to be made.When: Each time a resident is admitted , quarterly.the facility should review the advance directive.This review should focus on if advance directives match the current goals of care for the resident. The social services director or designee should.assist as needed with updated the documents that need revision.

Based on observation, interview, and record review the facility failed to ensure timely provision of podiatry services for 1 (Resident #15) of 1 resident reviewed for foot care resulting in a delay in foot care and potential worsening of conditions of the feet.Findings include:Review of Resident #15's diagnoses list included type 2 diabetes mellitus (condition of having elevated blood sugar levels) and other chronic pain. Review of Resident #15's diabetes care plan, revised 8/22/2025, stated, Diabetes Mellitus, is at risk of .infections. and noted an admission date of 5/12/2025. Review of Resident #15's brief interview for mental status, dated 11/8/25, was scored 14 which reflected she was cognitively intact.During an interview on 12/15/2025 at 10:04 AM, Resident #15 reported she had a concern that she had requested to see the podiatrist since she was admitted but hadn't seen the podiatrist yet or been assessed by the podiatrist. Resident #15 reported she had toe fungus, was diabetic, and needed the podiatrist to do nail care.On 12/16/2025 at 10:49 AM all podiatry documentation as it related to Resident #15 during her entire stay was requested from Nursing Home Administrator (NHA) A. By the end of survey the only documentation provided, on 12/16/25 at 1:41 PM, was facility physician/medical director BBB's NON-ROUTINE VISIT form, dated 9/22/25, which stated, .The patient has a history of multiple diabetic foot issues.ASSESSMENT: 1) Diabetic neuropathy (dysfunction of one or more nerves). 2. Diabetic ulcer (wound). PLAN: 1. Podiatry consult.4. Discussed with the nurse. No other documentation was received to show the facility took further action to have Resident #15 seen and assessed by a podiatrist.Review of Resident #15's Attending Physician Request for Services/Consultation form, dated 8/5/2025, stated, .Podiatry.Please have the [Company Name] Podiatrist examine the resident for the following reason(s): .Foot pain.Review of Resident #15's physician orders, included, Podiatry consult dated 9/22/2025 and Toe nail fungal liquid.every day and night shift dated 5/16/2025.During an interview on 12/17/2025 at 10:48 AM, NHA A confirmed there was only one podiatrist that had arrangements to treat residents of the facility.During an observation and interview on 12/17/2025 at 1:12 PM, podiatrist AAA was observed in the facility with a list of residents to care for. Podiatrist AAA reported Resident #15 was added to his list of residents to see by an email request from the facility approximately 3 hours ago. Podiatrist AAA reported he had not received any consult or request to see Resident #15 prior.

Based on observation, interview, and record review the facility failed to ensure urinary catheters were maintained appropriately for two residents (R8 and R76) of two residents reviewed for urinary catheter care resulting in over-filled indwelling catheter bag and sediment laden catheter tubing and connections, resulting in the potential for urinary tract infections. Findings include: R8According to the Minimum Data Set (MDS) dated [DATE], R8 was unable to complete his BIMS (Brief Interview Mental Status) indicating he was cognitively impaired. Section H-Bladder and Bowel revealed he had an indwelling catheter related to a diagnosis of obstructive and reflex uropathy. During an observation, interview, and record review on 12/15/2025 at 12:50 PM, Family Member (FM) RR stated R8 had a urinary foley catheter and used a leg bag to collect the urine. Observed a pouch underneath the resident's right lower pant leg. FM RR reported R8 had been anxious and agitated during the night and did not sleep. Staff had talked about testing the resident for a UTI (urinary tract infection) but review of R8's chart did not indicate a urine analysis had been ordered. Further review of the medical chart revealed the resident was restless and agitated on the night of 12/10/25. According to https://medlineplus.gov, A urinary catheter is a tube placed in the body (via ureter) to drain and collect urine from the bladder .An indwelling catheter collects urine by attaching to a drainage bag. The bag has a valve that can be opened to allow urine to flow out. Some of these bags can be secured to the leg.Observed on 12/16/2025 at 9:27 AM, R8 was in bed with eyes closed. R8 woke then stood up and made his way to his bathroom, turned around and motioned to the urinary bag strapped to the inside of his right leg. R8 pulled up his sleeping pant leg over the urinary bag. The urinary bag was full of dark orange colored urine. In the bottom of the bag, approximately 150-200 ml (milliliters) was a darker red-orange colored sediment. Capacity of bag was 1000 ml. R8 indicated he needed the bag emptied. No CNAs (certified nursing assistant) were found in the hall around R8's room. Licensed Practical Nurse (LPN) U was at the end of the hall preparing medications. When the LPN was told R8 needed assistance with his urinary collection bag, LPN U stated It is? I'll go look and went to check on the resident herself. Review of R8's Concern and Comment Form dated 12/16/25 at 10:06 AM indicated LPN U had filled out the form stating, Resident (R8) foley catheter leg bag was over full at maximum fill. CNA drained over 1500 cc (ml). Reported to Unit Manager (UM) EEE. During an interview on 12/16/25 at 12:00 PM, FM RR and LPN U held a conversation regarding R8's increased agitation and aggression. LPN U stated an order for urine analysis had not been done yet and she had not talked to the physician about the possibility of checking for a UTI. LPN U reported to FM RR she had filed a grievance on behalf of R8 having a full urine collection bag and it not being addressed by staff this morning. During an observation and interview on 12/16/25 at 11;45 AM, FM RR was with R8 in the resident's room. R8 was confused and left the room. FM stated in the last 2 days R8's confusion had increased and was hoping the facility would check R8's urine for a UTI. Review of R8's medical chart did not indicate staff had reported to the physician R8's dark colored urine and increased confusion and agitation as a result of a UTI. R76 According to R76's Minimal Data Set (MDS) dated [DATE], the resident scored 14/15 on her BIMS (Brief Interview Mental Status) indicating she was cognitively intact. Section H Bowel and Bladder indicated R76 had a supra pubic catheter with diagnosis that included a neurogenic bladder. According to Fundamentals of Nursing 9th Edition by [NAME] & [NAME], a suprapubic catheter is a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis.During an observation on 12/15/2025 at 11:18 AM, R76 was in bed supine (on back) wearing sound cancelling headphones with eyes closed. A urinary collection bag held 1200 ml of cloudy yellow urine. The urinary tubing held white sediment. The connection at bag and tubing had an accumulation of white dark yellow almost orange colored sediment making it so the surveyor could not see inside the tubing/connection. According to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066753 .Encrustations can occur either in the lumen of the catheter or extraluminally. This can possibly result in blockage or retention of the catheter. The main cause of catheter encrustation is infection by urease-producing organisms.crystals of calcium and magnesium phosphate are formed and a crystalline biol film develops which eventually blocks the flow of urine from the bladder. Review of R76's Order Summary dated 11/12/25, revealed, Change catheter bag as needed for infection, obstruction or when the closed system is compromised.Review of Medication Administration Record (MAR) dated December 2025 revealed, supra pubic catheter to straight drainage size 18 bulb, 10 cc. change for infection, obstruction or when the closed system is compromised as needed related to neuromuscular dysfunction of bladder, unspecified. Order date 12/12/2025. Reviewing the MAR, the catheter had not been changed from 12/1212/25 to 12/16/25 at 10:25 AM. Review of Medication Administration Record (MAR) dated December 2025 revealed change catheter bag as needed for infection, obstruction or when the closed system is compromised. Order date 11/12/25. Reviewing the MAR, the catheter bag had not been changed from 12/1/25 to 12/16/25 at 10:25 AM. Review of R76's History and Physical dated 12/3/25 08:00 revealed, .recurrent UTI. Review of R76's Progress Notes dated from December 13, 2025, through December 17, 2025 did not contain documentation of the sediment in urinary tubing or connection. Review of R76's Care Plan focus of suprapubic catheter for diagnosis of neuromuscular dysfunction of bladder had a revision date of 12/12/25 revealing a goal of having no complications related to indwelling catheter use. Interventions to meet the goal included catheter care every shift, and observe for and report to MD (medical director) for signs/symptoms UTI: including pain, burning, blood-tinged urine, cloudiness, and deepening of urine color initiated 11/26/25. Supra pubic catheter to straight drainage. Size: 18 bulb 10 cc. Change for infection obstruction or when the closed system is compromises or PRN (as Needed) initiated 12/12/25. During an observation and interview on 12/16/25 at 11:47 AM, R76 stated her catheter was changed about a month ago. Observed R76's urinary catheter tubing to be coated with a white sediment with cloudy yellow colored urine. The connection between the tubing and urinary collection bag was coated with white and dark yellow sediment. The urinary collection bag itself contained 400 ml of dark yellow urine. R76 stated she had a UTI in the past and did not know it but her mind was confused when she had it. R76 stated she didn't think she was confused at this time but if she was, she may not know it.During an observation and interview on 12/17/25 at 9:00 AM, Registered Nurse (RN) F stated while looking at R76's urinary tubing and collection bag, (R76) catheter tubing is fine. She gets sediment all the time. If the urine backs up in the tubing into her bladder, that's when you must worry about infection. I don't know if her urine backs up. I don't know when the tubing was last flushed. Observed the connection between the bag and tubing of R76's urine collection system to be filled with white and yellow sediment. RN F just shrugged her shoulders and left the area. During an interview on 12/17/25 at 2:19 PM, UM EEE stated, (R76) gets sediment all the time and never gets a UTI. I can't tell you when her catheter tubing was last flushed.According to https://pmc.ncbi.nlm.nih.gov/ Exploring Relationships of Catheter Associated Urinary Tract Infection and Blockage in People with Long-Term Indwelling Urinary Catheters- .Blockage- Urinary sediment which causes encrustation and blockage of the catheter lumen is caused by the precipitation of calcium, phosphorus, and magnesium minerals in the urine in the presence of urea splitting microorganisms ([NAME] et al. 2006), in particular Proteus mirabilis ([NAME], Feneley 2010) and Providencia stuartii ([NAME] 1989). This process results in formation of a crystalline structure biofilm which protects the bacteria, making eradication of the biofilm very difficult. In the presence of such microorganisms, catheters can block within two days ([NAME] et al. 2006), and all catheter materials seem to be colonized with this type of biofilm. Blockage of the catheter caused by sediment and encrustation within the lumen disrupts urine flow and can cause increased pressure within the bladder, which could contribute to pyelonephritis and septicemia ([NAME], [NAME] 2008, [NAME] 2008).

Based on interview and record review, the facility failed to ensure pre and post dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) assessments were completed for 2 (Resident #3 and #101) of 2 resident reviewed for dialysis care, resulting in the potential of being unprepared for a potential decline in resident condition, due to the adverse effects from dialysis. Findings include: Resident # 3 Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included critical illness myopathy (severe muscle weakness and wasting in critically ill patients) and end stage renal disease. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 10/1/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #15 was cognitively intact. Review of Resident #3's Care Plan revealed, (Resident #3) is at risk for complications d/t (due to) renal failure with Hemodialysis (new). Left arm fistula (surgically created connection between an artery and a vein, primarily used for hemodialysis access). Date Initiated: 10/08/2024. Interventions: . Assess shunt site for bruit and thrill, as ordered by MD. Date Initiated: 01/16/2025. Dialysis treatments as ordered. Date Initiated: 10/08/2024. Do not take blood pressure on arm left arm with fistula Date Initiated: 01/16/2025 . Observe for bleeding at dialysis access site. Date Initiated: 10/08/2024 . Observe/report PRN any s/sx (signs and symptoms) of infection to access site: Redness, Swelling, warmth or drainage. Date Initiated: 10/08/2024. Observe/report PRN (as needed) for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds.Date Initiated: 10/08/2024 . In an interview on 12/15/2025 at 1:44 PM, Resident #3 reported that he went to dialysis 3 times a week, and that he had returned from dialysis shortly before this writer met with him. Resident #3 reported that the nurse caring for him had not completed a post dialysis assessment, and that it was common for the nursing staff to skip pre and post dialysis assessments, and that the staff never took his vital signs when he returned from the dialysis facility. Review of Resident #3's Electronic Medical Record (EMR) revealed that Resident #3's most recent blood pressure documented was on 10/7/25. This writer was not able to find documentation of pre or post dialysis assessments or refusals of assessments for Resident ## in his EMR. In an interview on 12/16/2025 at 11:35 AM, Licensed Practical Nurse (LPN) U reported that she was the nurse caring for Resident #3 on 12/15/25 when he returned from dialysis. LPN U confirmed that nurses were supposed to complete a dialysis communication form with pre assessment notes that would include the resident's weight and vitals prior to dialysis. LPN U reported after the resident returned from dialysis the nurse should assess the resident review the dialysis communication form to see if there are any new orders or changes. LPN U reported that the post dialysis assessment should have been documented on the dialysis communication form and placed in the resident's dialysis binder. LPN U confirmed that she did not assess Resident #3 after he returned from dialysis on 12/15/25, and therefore she did not complete a dialysis communication form. LPN U was not able to report why she did not assess Resident #3 after his dialysis treatment. On 12/16/2025 at 11:43 AM, This writer requested all dialysis communication forms for Resident #3 for the past 30 days. The facility uploaded dialysis notes which were completed by Resident #3's dialysis facility center but did not provide any dialysis communication forms as requested. In an interview on 12/17/25 at 11:32 AM, Director of Nursing (DON) B reported that nurses were required to complete pre and post dialysis assessments and document the assessments on the dialysis communication forms. DON B reported that nursing assessments before and after dialysis were important to ensure that a change in condition would be identified. DON B reviewed the dialysis notes which were completed by Resident #3's dialysis facility center and confirmed that the notes did not verify that nursing staff at the facility had completed pre and post dialysis assessments for Resident #3. DON B reported that nurses were supposed to document any missed assessments in the EMR. DON B confirmed that Resident #3's EMR did not provide documentation of any missed assessments. DON B confirmed that he had not been monitoring dialysis communication forms to ensure that nurses were completing pre and post dialysis assessments. The facility did provide any dialysis communication forms form the last 30 days for Resident #3 prior to survey exit. Review of the facility's Dialysis Policy last reviewed 12/1/25, revealed, . The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences . R101 According to R101's admission Record, the resident was admitted on [DATE] with diagnoses that included dependence on renal dialysis. Review of R101's Order Summary dated 5/19/25, revealed, Dialysis patient. for dialysis treatment. Review of facility policy, Dialysis dated 12/1/25, revealed, . Maintain dialysis transfer form in the resident's medical record – do not destroy.post-dialysis - complete the Pre/Post Dialysis Communication Form Review of R101's medical chart did not contain any dialysis communication forms. It was noted R101 was admitted to the facility 5/19/25 on dialysis. During an interview on 12/17/25 at 11:07 AM, Nursing Home Administrator (NHA) A stated when requested to provide R101's Dialysis Communication forms that there were no dialysis communication forms for R101.

Based on interview and record review, the facility failed to ensure the Medical Director fulfilled their responsibility of implementing Medication Regimen Review (MRR) policies/procedures to include coordination of care between the facility and the consulting pharmacist/pharmacy for 4 (Resident #88, 12, #15 and #80) of 5 residents reviewed for medications. This deficient practice has the potential to affect all residents that reside at the facility. Findings include:In an interview on 12/17/25 at 11:32 AM, Director of Nursing (DON) B reported the facility's Unit Managers were responsible for ensuring that Monthly Medication Reviews (MMR) were provided to the facility Medical Director, and that he had just recently learned that this might have been occurring. DON B was unable to report how many MMR's had been missed, or if the facility had completed any audits to ensure any missed MMR's were reviewed. In an interview on 12/17/25 at 1:45 PM, Nursing Home Administrator (NHA) A reported that the facility had jus recently identified that MD BBB had not been reviewing and responding to the resident's MMR's, NHA A reported that MMR's was not a topic that MD BBB was reporting on during the monthly QAPI (Quality Assurance Performance Improvement) meetings. In an interview on 12/17/2025 at 2:24 PM, Medical Director (MD) BBB reported he was responsible for ensuring that MMR's were reviewed and responded to. MD BBB reported that he completed the MMR's when the facility provided them to him, but he did not know how often he was supposed to review them, how often the reviews were being missed, or if he had missed any reviews. MD BBB reported that he was aware that MMR's were part of his responsibility as the Medical Director. Please see F756 for additional information.

Based on interview and record review, the facility failed to: 1) effectively identify quality deficiencies, develop, and implement appropriate action to correct deficiencies; and 2) sustain a system to ensure corrective measures related to resident rights, dialysis, bowel/bladder incontinence/catheter care, and advance directives as evidenced by repeated deficiencies on the past three surveys. This deficient practice has the potential to affect all residents that reside in the facility. Findings include: In an interview in 12/17/2025 at 1:41 PM, Nursing Home Administrator (NHA) A reported the facility was currently working on PIPS (Process Improvement Projects) related to ensuring staff education was completed, and the QAPI team had just closed a PIP related to meal tickets not matching what was served in November 2025 after reaching 100% on audits. NHA A reported that the facility was obtaining feedback from the residents from resident council minutes and asking for resident feedback. NHA A reported the facility was not currently working on any performance improvement projects (PIPS) related to the repeat deficiencies that the facility had been cited for on the last two recertification surveys. NHA A reported that the facility would bring deficiencies from surveys to QAPI and would remove them once the facility had met the compliance date noted in the plan of correction. NHA A confirmed that the facility had repeat deficiencies related to resident rights, dialysis, bowel/bladder incontinence/catheter care, and advance directives, but that all of those areas had not been brought to QAPI as PIPs for the facility to work to improve on. NHA A confirmed that the repeat deficiencies that the facility had been cited for on the past two recertification surveys were high priority areas. NHA A confirmed that the facility was reviewing monthly medication reviews (MMR) at QAPI, but they had just identified that they were missing the Medical Director's review of MMR'S in November 2025. NHA A reported that Medical Director (MD) BBB was attending the monthly QAPI meetings, but he was not reporting on any areas for the facility. Review of the Resident Council Meeting Minutes indicated that in October 2025 several residents had concerns with dietary staff not following preferences on tickets. Review of Review of the Resident Council Meeting Minutes indicated that in November 2025 several residents were still expressing concerns related to dietary staff not following meal tickets. In an interview on 12/17/2025 at 2:24 PM, Medical Director (MD) BBB reported he attended the facility's QAPI meetings. When this writer queried as to what his role was in QAPI, and how he was participating, MD BBB reported that he was the doctor and had no other information to provide. Review of the facility's QAPI policy last reviewed 11/4/25, revealed, Policy: The facility will have a QAPI program that is ongoing, comprehensive, and capable of addressing the full range of care and services it provides. At a minimum the QAPI program will: 1. Address all systems of care and management practice. 2. Include clinical care, quality of life, and resident choice. 3. Utilize the best available evidence to define measures of quality and facility goals that reflect the processes of care and facility operations that have been shown to be predictive of desired outcomes for residents; and 4. Reflect complexities unique care and services that the facility provides .

This citation pertains to Intake MI00153382 Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for 1 (Resident #102) of 7 residents reviewed for abuse, resulting in Resident #101 punching Resident #102 in the face. Findings include: Resident #101 Review of an admission Record revealed Resident #101 was a male, with pertinent diagnoses which included: schizophrenia and autistic disorder. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 3/3/25 revealed a Staff Assessment for Mental Status assessment of Short- and Long-term Memory as Resident #101 having a Memory problem. Resident #102 Review of an admission Record revealed Resident #102 was a male, with pertinent diagnoses which included: major depressive disorder, single episode, moderate and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #102 was cognitively intact. Review of a Facility Reported Incident (FRI) Incident Summary Report dated 5/12/25 at 7:52 PM revealed, Incident Summary On Monday, May 12, 2025, at approximately 6:40pm, it was reported to the Executive Director (ED A) that resident (Resident #101) came running out of his room and hit resident (Resident #102) on the right side of his face and then (Resident #101) dropped himself on the floor .A nurse examined (Resident #102) and there was some redness on his right cheek. (Resident #101) had a small laceration on his shin from contact with (Resident #102)'s wheelchair . In an interview on 6/17/25 at 10:17 AM, Business Office Manager (BOM) Q reported on 5/12/25 she had been the manager on duty for dinner and had come back to the Bridge unit from the dining room when she saw Resident #102 wheeling himself to the Bridge unit. BOM Q reported Resident #102 had asked her to push him up to the front corner across from where the Bridge nurses' station was. BOM Q reported she had turned around to let the nurse know that she had brought Resident #102 up front when out of the corner of her eye she saw Resident #101 run out of his room, grab Resident #102's shoulder, and hit Resident #102 in the face right over his cheek bone. BOM Q reported Resident #101 then put himself on the floor and continued to lay there. BOM Q reported there had not been any other staff in the hall, nor had there been anyone at the nurses' station until after the incident occurred. In an interview on 6/17/25 at 10:30 AM, Dietary Aide (DA) N reported she had witnessed the incident between Resident #101 and Resident #102. DA N reported she had been at the menu board right by the nurses' station changing the menu for the day. DA N reported out of the corner of her eye, she saw Resident #101 punch Resident #102. DA N reported besides herself, she had not seen any other staff in the hall at the time other than the staff member who was headed back toward the dining room. In an interview on 6/18/25 at 12:53 PM, Registered Nurse (RN) DD reported she had been the nurse for Resident #101 and Resident #102 on the evening of 5/12/25 when Resident #101 punched Resident #102 in the face. RN DD reported Resident #101 was known to go from one extreme to the other with no warning. RN DD reported she saw Resident #101 punch Resident #102 and separated them. RN DD reported to her knowledge they had not been doing any increased supervision with Resident #101 at the time of the incident because we didn't even think he could get up. RN DD explained she believed that staff had been using a sit-to-stand machine (a machine to assist a resident from seated to standing position) for transfers at the time. Review of Resident #101's Behavior Note dated 4/1/25 at 6:10 PM revealed, Note Text: Resident came walking out of room with BM (bowel movement) on hands. CNA (certified nurse aide) redirected resident to shower room to clean him up. Resident came up behind CNA, grabbed her from behind and would not let go. Other CNA came in and finally got him to release CNA . Review of Resident #101's Behavior Note dated 4/4/25 at 5:54 PM revealed, Note Text: pt (patient) kept putting himself on the floor then asking to get up then putting himself back on the floor. I went in to ask him if he was okay because it looked like he was crying and then he punched me in the face .Later, another CNA was trying to feed him and he was saying he was sorry for punching the other girl and then she asked why he did it and he swung at her and kept trying to hit her. Review of Resident #101's Behavior Note dated 4/28/25 at 4:14 PM revealed, Note Text: Patient up in wheelchair talking to nurse when he all of a sudden he started swinging at nurse and punched nurse 2 times in chest . Review of Resident #101's Care Plan with a focus of (Resident #101) is physically aggressive with staff, he bites, hits, kicks, scratches with a Date Initiated of 3/14/25 revealed no new interventions were initiated following Resident #101's behaviors as documented on 4/1/25, 4/4/25, and 4/28/25 in the Behavior Notes. Review of Resident #101's Behavior Note dated 5/12/25 at 5:45 PM revealed, Note Text: Patient came out of room and started running down the hallway with brief at ankles .stopped resident and pulled up his brief and this RN (registered nurse) obtained patients wheelchair and had patient sit in wheelchair. Patient would not speak with staff and was rocking back and forth in wheelchair. Wheeled to front desk where staff were present. Patient asked if he wanted lemonade and he replied yes. Staff gave patient a glass of lemonade and within 30 seconds a resident who was within 3 feet of patient started yelling. When RN look (sic) over patient had thrown his lemonade all over resident. Patient went back to not speaking and looking down towards lap. In an interview on 6/18/25 at 9:57 AM, Executive Director (ED) A reported the facility had not increased supervision for Resident #101 following the incident on 5/12/25 at 5:45 PM when he threw the lemonade at another resident. In an interview on 6/17/25 at 10:39 AM Registered Nurse Infection Preventionist (RNIP) D reported Resident #101 had schizophrenia and was autistic and he would be fine and then quickly he flips and then after he will lay himself on the floor and staff need to leave him without stimulation for 15-30 minutes and then he will be more cooperative to answer yes or no questions. Review of Resident #101's Event Note dated 6/17/25 at 9:32 PM revealed, Note Text: Resident observed on floor in front of and to the right of nursing station. Informed that he was ambulating independently then he had struck another resident (referring to Resident #102) in the face, unprovoked . Review of Resident #102's Event Note dated 6/17/25 at 9:32 PM revealed, Resident was struck in face by another resident (referring to Resident #101) walking down hallway. Pink area observed to right side of face below ear. Res (resident) denied pain. Res removed from area and provided snack per his request . Review of a current Care Plan for Resident #101 revealed a focus of (Resident #101) is physically aggressive with staff, he bites, hits, kicks, scratches. (Resident #101) can be physically aggressive with other residents: hitting, throwing drinks with a revision date of 5/13/25 and care planned interventions which included 15 minute checks with a date initiated of 5/13/25. Review of 15 Minute Check worksheets for the period 5/13/25 - 6/17/25 revealed no documentation that 15 minute checks had occurred on 6/17/25. In an interview on 6/18/25 at 1:50 PM, Executive Director (ED) A reported 15 minute checks had been initiated following the incident between Resident #101 and Resident #102 on 5/12/25. ED A confirmed there was no documentation of 15 minute checks having been completed on 6/17/25. ED A reported the purpose of 15 minute checks was so staff would put eyes on the resident every 15 minutes to make sure nothing negative was occurring and to make sure the resident needs were met.

This citation pertains to intake number MI00151225 Based on interview and record review, the facility failed to ensure nursing staff had appropriate skill sets and completed required annual trainings, resulting in the potential for the delivery of nursing and related services that did not support the attainment or maintenance of the Resident's highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an Education and Training Requirements policy with a reference date of 10/3/24 revealed Policy: The facility will maintain an effective in-service and orientation program for: a. all associates .Procedure .6. Training, in-service, and education should be based on the needs of the facility and the facility assessment. 7. Competencies and skill sets will for all new and existing staff, be consistent with their expected roles. 8. The facility will need to ensure staff are trained to be able to interact in a manner that enhances the resident's quality of life and quality of care .9. The following training requirements should be met .annually .c. iii. Dementia Management and Resident abuse .13. The Staff Development Coordinator/designee will be responsible for maintaining training records . Review of a Facility Assessment with a reference date of 8/6/24 revealed: Diagnosis Potentially Treated at the Facility: Dementia-Alzheimer's or Non-Alzheimer's Dementia, Number of residents served during previous 2 quarters: 19, .Competent Support and Care for Resident Population, Topic: .Dementia and care of the cognitive impaired .Which staff are trained: All staff, Upon hire, annually and as needed. In an interview on 6/18/25, at 1:12pm, Certified Nursing Assistant (CNA) CC on 3/4/25 at approximately 9:30pm, Resident #103 began yelling for help in the hallway and as she walked toward him, she saw CNA S standing behind the resident as he sat in his wheelchair. CNA CC reported CNA S pulled the resident's gown up from the shoulder area, covering Resident #103's mouth for several seconds. CNA CC reported she arrived in front of Resident #103, crouched down to gain his attention and make eye contact with him, and he was almost calmed down when CNA S sprayed him with the aroma therapy mist. CNA CC reported CNA S sprayed an aroma therapy bottle toward Resident #103 and CNA CC, hitting them both in the face with the mist. CNA CC reported Resident #103 flipped out when the mist hit him. CNA CC reported the actions of CNA S made Resident #103 more upset and she should have not of sprayed him with anything. In an interview on 6/17/25 at 10:59am, CNA S reported on 3/4/25 at approximately 9:30pm, Resident #103 began yelling in the hallway near the rooms to which she was assigned. CNA S reported she was stressed because she thought the resident's yelling might awaken the other resident's she had already assisted to bed. CNA S confirmed she sprayed an aroma therapy mist on Resident #103. CNA S described working at the facility as very stressful because many residents had behaviors. When further queried about dementia care training provided by the facility, CNA S reported she did not recall receiving any dementia care training. Review of a (name of online training organization omitted) Training Report for CNA S with a reference date of 3/6/24-4/8/25 revealed the staff member did not complete 60 of 62 required trainings during the 13-month period. Incomplete trainings included: Alzheimer's Disease: The Facts, Challenging Behaviors: Care and Interventions for Individuals Experiencing Dementia, Cognitive Impairment: Advanced, Mental Health: Caring for the Older Adult in LTC (long-term care) and Understanding Dementia, along with many additional topics. In an interview on 6/17/25 at 2:03pm, Registered Nurse/Staff Development Coordinator (RN/SDC) C reported staff were assigned monthly computer-based trainings at the corporate level and until recently, staff completion of education assignments was not being monitored by the facility. RN/SDC C reported she recently learned that several staff members had not completed the required online trainings and due to the number of assignments, it would take time for them to complete them. RN/SDC C reviewed the (name of the online training organization omitted) Training Report for CNA S and confirmed the staff member had not completed 60 of 62 trainings in the 13 months. RN/SDC C reported staff could only complete the required trainings while in the facility and several staff had expressed difficulty finding an available computer. In an interview on 6/17/25 at 2:11pm, Human Resources Director (HRD) R confirmed any training topic marked as not attempted on (name of online training organization omitted) Training Report had not been completed. HRD R confirmed CNA S worked at the facility for more than 12 months and should have completed the assigned training but had not done so. In an interview on 6/18/25 at 2:06pm, Nursing Home Administrator (NHA) A confirmed CNA S had not completed most of the required computer-based training in the last 13 months, including the education related to dementia care. NHA A reported other than orientation training, the facility had no documentation of CNA S attending any in-person dementia care related training during her 13 months of employment. NHA A confirmed the facility had not tracked staff compliance with corporate assigned computer-based training until recently.

This citation pertains to intake number MI00151225 Based interview and record review, the facility failed to ensure individualized approaches were provided to 1 (Resident #103) of 3 residents reviewed for dementia care, resulting in Resident #103 experiencing avoidable stress responses to care interventions. Findings include: Review of The Unmet Needs Model, [NAME]-[NAME] and [NAME] (1995), revealed that those with Dementia develop problem behaviors from an imbalance in the interaction between life-long habits and personality, current physical and mental states and less than optimal environmental conditions. Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: metabolic encephalopathy (a change in how your brain works due to an underlying condition), dementia (a term used to describe a group of symptoms affecting memory, thinking, and social skills that interfere with daily life) and cognitive communication deficit (difficulty understanding and expressing thoughts through spoken or written words). Review of a Minimum Data Set (MDS) assessment for Resident #103 with a reference date of 2/20/25, revealed a Brief Interview for Mental Status (BIMS) score of 4/15 which indicated Resident #103 was severely cognitively impaired. Review of a Care Plan for Resident # 103 with a reference date of 2/19/25, revealed a focus/goal/interventions of: (Resident #103) has impaired cognitive ability r/t (related to) dementia dx (diagnosis). BIMS of 4. Goal: (Resident #103) will follow 1 to 2 step instructions. Interventions: Allow extra time for resident to respond to questions and instructions, Ask yes/no questions in order to determine resident's needs .Identify yourself at each interaction, face the resident when speaking and make eye contact, reduce distractions .the resident understands consistent, simple, directive sentences, provide the resident with necessary cues-stop and return if agitated. Review of an Incident Report for Resident #103 with a reference date of 3/4/25 revealed Incident Summary: On 3/4/25 .CNA (Certified Nursing Assistant) CC reported .she witnessed CNA S with an agitated resident, (Resident #103) who was yelling and making loud noises. CNA S had (Resident #103's) gown pulled up by the shoulders so it .covered his mouth .CNA S sprayed an essential oils type spray toward (Resident #103 and CNA CC) and was pretty close (sic) to their faces . In an interview on 6/18/25, at 1:12pm, CNA CC on 3/4/25 at approximately 9:30pm, Resident #103 began yelling for help in the hallway and as she walked toward him, she saw CNA S standing behind the resident as he sat in his wheelchair. CNA CC reported CNA S pulled the resident's gown up from the shoulder area, covering Resident #103's mouth for several seconds. CNA CC reported she arrived in front of Resident #103, crouched down to gain his attention and make eye contact with him, and he was almost calmed down when CNA S sprayed him with the aroma therapy mist. CNA CC reported CNA S sprayed an aroma therapy bottle toward Resident #103 and CNA CC, hitting them both in the face with the mist. CNA CC reported Resident #103 flipped out when the mist hit him. CNA CC reported Resident #103 became very angry and began trying to hit us, grabbed the railing in the hallway and would not let go. CNA CC reported it took several minutes for Resident #103 calm down after the incident. CC reported after she was able to get Resident #103's attention again, she told him they could go call his spouse together which was always his way of calming down. In an interview on 6/17/25 at 10:59am, CNA S reported on 3/4/25 at approximately 9:30pm, Resident #103 began yelling in the hallway near the rooms to which she was assigned. CNA S reported she was stressed because she thought the resident's yelling might awaken the other resident's she had already assisted to bed. CNA S confirmed she sprayed an aroma therapy mist on Resident #103. When queried about where she got the aroma therapy spray, CNA S reported she bought it at a pharmacy and brought it in to use on residents. CNA S described Resident #103 as out of control after she used the spray, as he began hitting the railing in the hallway, then refused to release his left hand from the railing and tried to hit the staff with his right arm. CNA S described working at the facility as very stressful because many residents had behaviors. When further queried about dementia care training provided by the facility, CNA S reported she did not recall receiving any dementia care training. In an interview on 6/17/25 at 2:32pm, Licensed Practical Nurse (LPN) W reported he arrived to assist with Resident #103 after her heard yelling coming from the hallway and ultimately assisted with getting the resident back to his own unit. LPN W reported CNA S had not asked him for permission to use aroma therapy mist on residents. In an interview on 6/18/25 at 9:03am, CNA EE reported CNA S provided his orientation when he started working at the facility and during that time, he witnessed CNA S spray aroma therapy mist on several residents. In an interview on 6/18/25 at 10:17am, Registered Nurse (RN) V reported on the night of 3/4/25 she saw Resident #103 upset and several staff members were trying to calm him down around 9:30pm. RN V reported she did not witness CNA S spraying Resident #103, but CNA S had told her previously that she used the aroma therapy mist on residents. RN V reported CNA S never asked her for permission to use the mist on residents. In an interview on 6/18/25 at 12:51pm, LPN/Unit Coordinator (LPN/UM) BB reported she worked on the night of 3/4/25 and CNA CC told her about the incident that took place involving Resident #103 and CNA S. LPN/UM BB reported CNA S had never asked her for permission to use aroma therapy mist on any residents. In an interview on 6/18/25 at 2:06pm, Nursing Home Administrator (NHA) A reported staff were assigned education courses, including education related to Dementia Care, on a computer-based training program. NHA A confirmed until recently, staff compliance with completion of the assigned trainings had not been monitored by the facility. NHA A confirmed that CNA S had not completed the required computer-based training related to caring for residents with dementia. Review of Physician Orders for Resident #103 revealed no orders for the use of aroma therapy products. Attempts to contact the facility's Medical Director were unsuccessful at the conclusion of the survey. Attempts to contact Resident #103's spouse were not successful at the conclusion of the survey. Review of a Care of the Cognitively Impaired (Dementia Care) policy with a reference date of 9/6/24 revealed Policy: The facility will provide dementia treatment and services which may include, both are not limited to the following: 1. Ensuring adequate medical care, diagnosis, and supports based on diagnosis; 2. Ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy .Procedure .Develop individualized interventions related to the resident's symptomology .

This citation pertains to MI00149054. Based on interview and record review, the facility failed to thoroughly investigate and resolve grievances for 1 resident (Resident #3) of 3 residents reviewed for missing items, resulting in the resident missing property and the potential for further unresolved grievances to occur. Findings include: Resident #3(R3) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R3's original admitted to the facility was 3/22/2023 with diagnoses including dementia (impairment in brain function such as memory loss and judgement) and chronic kidney disease (long term condition that occurs when the kidneys are damaged and can't filter blood properly). Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R3 was cognitively intact (13 to 15 cognitively intact). During an interview on 1/27/2025 at 10:58 AM, R3 reported that he lost his wedding ring several months ago. He stated that he was married for [AGE] years and now it was gone and he was sad about it. Review of R3's Concern and Comment Form dated 10/24/2025 revealed Person Reporting Concern: {Social Services Director (SSD) AA} Report Date: 10/24/2024 Resident Name: (R3) Please describe in detail your concern, comment or commendation: (R3's) wedding ring is missing .Were you able to report this concern/comment to a staff member: Yes .Please provide staff member name: (SSD AA). Facility Investigation and Response: Person designated to investigate and follow-up with concern: {Central Supply Director (CSD) U} . Date/Time of initial contact with concerned party: 10/25/2024 .Investigation steps: looked in nightstand, under bed and in closet. Investigation findings: didn't find ring. Actions taken to resolve/respond to concern, Date/Time of findings/action plan shared with concerned party, concerned party's response to the action plan/outcome and Executive Director (ED) A's signature and date were all blank. During an interview on 1/29/2025 at 8:34 AM, Social Services Director (SSD) AA stated that R3 told her about his missing wedding ring and he said he had it and then it wasn't there anymore. She said the staff did a thorough search and didn't find it but they don't suspect theft. SSD AA stated that the facility will replace his ring. SSD AA said that concern forms come to her initially then she gives it to the appropriate department, the department head takes care of it and then it goes to ED A who makes sure it is resolved, signs it and returns it to SSD AA. SSD AA stated that she didn't get the completed concern form back from ED A. During an interview on 1/28/2025 at 4:20 PM, ED A stated that she was aware that there wasn't any follow-up completed on R3's missing ring which she realized when she gave a copy of the concern form to this surveyor.

Based on observation, interview and record review, the facility failed to prevent the further development of pressure ulcers for 1 (Resident 78) of 3 residents reviewed for pressure ulcers, resulting in the development of 7 facility acquired pressure ulcers and worsening of existing pressure ulcers resulting in surgical intervention. Findings include: Review of an Admission Record revealed Resident #78 was a female with pertinent diagnoses which included pressure ulcer of sacral region, stage 4, pressure ulcer of right ankle, stage 3, pressure ulcer of left heal, unstageable, stiffness of right hand, contracture right foot, contracture left foot, multiple sclerosis, urosepsis, gangrene, chronic pain, and cognitive communication deficit. Review of Care Plan for Resident #78, revised on 11/08/2023, revealed the focus, .(Resident #78) has actual skin impairment r/t (related to) MS (muscular sclerosis), poor oral intake, bed bound, and contractures . with the intervention .Foot cradle to the end of the bed, float blankets/sheets over the top to maintain pressure off the tops of her toes/feet .date initiated: 09/07/23 .Has a small pillow or standard pillow placed between knees to alleviate pressure .date initiated: 09/07/23 .Heelz up device, stack of pillows at the end of the bed to prop her LE (lower extremity), heels off the bed surface .date initiated: 07/14/23 .Prevalon boots to bilateral fee except with care as she will allow .date initiated: 09/07/23 .Turn and reposition as resident allows .date initiated: 3/23/23 .Wedge cushion to either side of (Resident #78) to assist with offloading pressure, reposition .(Resident #78) is staying in bed and not getting up in chair due to were her stage 4 is located on the buttocks .date initiated: 04/21/23 . Review of Skilled Note dated 3/11/23 at 2:43 PM, revealed, .Pt has MS without ability to use her right arm and requires total care .She is unable to move herself/feed herself. She is not able to communicate needs. Pt has a very large wound on her sacrum/stage 4 .Pt is very painful to touch . Review of Skilled Note dated 3/12/23 at 4:17 PM, revealed, .Takes two staff to turn her from side to side. She has a stage four wound that is a 75% of her buttocks/coccyx region with an area that is tunneled . Review of Skilled Note dated 3/15/23 at 12:43 PM, revealed, .Resident is receiving wound care with a wound vacto sacral/coccyx area. The right foot has an ulcer and the left heel is necrotic. These wounds were acquired prior to arrival to facility .Requires max assistance for ADLs, including feedings for meals . Review of Health Status Note dated 4/19/23 at 7:22 PM, revealed, .Found open area outer aspect right calf, appear to be a pooped (sic) blister .Measures: 3.2x1.7x0.1 . Review of Wound Assessment Details dated 4/20/23, revealed, .1. Medial coccyx .Stage 3 .2. Right Lateral Shin .Stage 2 .3. Right Ankle .Stage 2 .4. Right Lateral Foot .Stage 2 .5. Left Heel .Unstageable .6. Right Heel .Unstageable .Additional Orders: Off-Loading: Use/Wear offloading when in bed: - offload heels in bed and legs as much as possible. Wear prevalon boots at all times, even for transport .Specialty Bed/ Mattress for Pressure Reduction. - Please try to get patient sand bed, it will offload ulcer to promote healing .Turn every 2 hours. Avoid position directing pressure to wound site. Limit side lying to 30 degrees tilt. Limit HOB (head of bed) elevation to 30 degrees in bed .Turn Frequently .Avoid pressure at wound site . Review of Nutrition/Dietary Note dated 4/24/23 at 1:09 PM, revealed, .RD skin review: Facility acquired US to her right heel and her right inner foot; Stage IV to her sacrum; Stage IV to her left heel; stage III to her right ankle; Wounds are dressed and followed by her nurse .Diet: Regular .PO intake poor @ 0-25% most of the time .Dependent on staff for feeding .Resident has MS .She is bedbound .Wgt: 3/10 190#/69, BMI: 28.1 .Resident face appears thinner than her admission picture. Est. needs @ ABW 160#/73kg x 25- 30cal/kg = 1800-2190cal .Protein @ 1.3gm = 94.9gm Fluids: @ 30ml/kg = 2190ml PO intake does not appear to be meeting her needs .Writer spoke with resident during her noon meal, her tray was sitting at bedside. When asked if she was going to eat her lunch she stated no. She had Ensure, Milk, and Juice at bedside she had not drank her Ensure. It does appear that resident would need 1:1 feeding assistance even for her fluids. Both hands are curled into her palms. She answered only yes no questions and did not elaborate on any one subject. Due to poor intake weight loss is anticipated . Review of Health Status Note dated 4/27/23 at 2:34 PM, revealed, .Noted to have a new wound to her right palm, stage 2 noted . Review of Wound Assessment Details dated 4/28/23, revealed, .1. Medial coccyx .2. Right Lateral Shin .3. Right Ankle .(Worsened) .4. Right Lateral Foot .5. Left Heel .6. Right Heel .Additional Orders: Off-Loading: Use/Wear offloading when in bed: - offload heels in bed and legs as much as possible. Wear prevalon boots at all times, even for transport .Specialty Bed/ Mattress for Pressure Reduction. - Please try to get patient sand bed, it will offload ulcer to promote healing .Turn every 2 hours. Avoid position directing pressure to wound site. Limit side lying to 30 degrees tilt. Limit HOB (head of bed) elevation to 30 degrees in bed .Turn Frequently .Avoid pressure at wound site . Review of Skin/Wound Note dated 5/10/23 at 3:42 PM, revealed, .Dr. made aware of the change in rt (right) ankle wound and other skin disturbances noted upon skin assessment . Review of Wound Assessment Details dated 5/12/23, revealed, .1. Medial coccyx .2. Right Lateral Shin .(Worsened) .3. Right Ankle .4. Right Lateral Foot .5. Left Heel .(Worsened) .6. Right Heel .Additional Orders: Please order bilateral x-rays of heels .Off-Loading: Use/Wear offloading when in bed: - offload heels in bed and legs as much as possible. Wear prevalon boots at all times, even for transport .Order second set of prevalon boots if able so patient has set when additional set is being laundered .Specialty Bed/ Mattress for Pressure Reduction. - Please try to get patient sand bed, it will offload ulcer to promote healing .Turn every 2 hours. Avoid position directing pressure to wound site. Limit side lying to 30 degrees tilt. Limit HOB (head of bed) elevation to 30 degrees in bed .Turn Frequently .Avoid pressure at wound site . Note: After each Additional Order there were check marks indicating review with initials on the paper. Review of Wound Assessment Details dated 5/25/23, revealed, .1. Medial coccyx .2. Right Lateral Shin .3. Right Ankle .4. Right Lateral Foot .5. Left Heel .6. Right Heel .Additional Orders: Please order bilateral x-rays of heels .Off-Loading: Use/Wear offloading when in bed: - offload heels in bed and legs as much as possible. Wear prevalon boots at all times, even for transport .Order second set of prevalon boots if able so patient has set when additional set is being laundered .Specialty Bed/ Mattress for Pressure Reduction. - Please try to get patient sand bed, it will offload ulcer to promote healing .Turn every 2 hours. Avoid position directing pressure to wound site. Limit side lying to 30 degrees tilt. Limit HOB (head of bed) elevation to 30 degrees in bed .Turn Frequently .Avoid pressure at wound site . Review of Health Status Note dated 6/8/23 at 5:45 PM, revealed, .Enabler bars removed. Resident makes no movement to reposition self. Dependent upon staff for all ADL care, transfers, and mobility . Review of Wound Assessment Details dated 6/8/23, revealed, .1. Medial coccyx .2. Right Lateral Shin .3. Right Ankle .4. Right Lateral Foot .5. Left Heel .(Worsened) .6. Right Heel .Additional Orders: Off-Loading: Use/Wear offloading when in bed: - offload heels in bed and legs as much as possible. Wear prevalon boots at all times, even for transport .Order second set of prevalon boots if able so patient has set when additional set is being laundered .Specialty Bed/ Mattress for Pressure Reduction. - Please try to get patient sand bed, it will offload ulcer to promote healing .Turn every 2 hours. Avoid position directing pressure to wound site. Limit side lying to 30 degrees tilt. Limit HOB (head of bed) elevation to 30 degrees in bed .Turn Frequently .Avoid pressure at wound site . Review of Skin/Wound Note dated 6/14/23 at 1:40 PM, revealed, .Rt and left wound have worsened this week . Review of Wound Assessment Details dated 6/22/23, revealed, .1. Medial coccyx .2. Right Lateral Shin .3. Right Ankle .4. Right Lateral Foot .5. Left Heel .6. Right Heel . Review of Wound Assessment Details dated 7/6/23, revealed, .1. Medial coccyx .2. Right Lateral Shin .3. Right Ankle .5. Left Heel .6. Right Heel .(Worsened) . Review of Skin/Wound Note dated 7/7/23 at 2:14 PM, revealed, .1 wound worsen which was the right heel, note place in Dr. book to inform him of the change . Review of Skin/Wound Note dated 7/14/23 at 1:32 PM, revealed, .N.O. (new order) to d/c (discontinue) the prevalon boots and will continue with the heels up device and pillows as needed to prop her heels, feet off the bed surface. Dr. notified of the decline in the rt (right) heel wound . Review of Wound Assessment Details dated 7/27/23, revealed, .1. Medial coccyx .(Worsened) .2. Right Lateral Shin .3. Right Ankle .(Worsened) .5. Left Heel .6. Right Heel .(Worsened) .#7. Left Hip (New Wound- Acquired 7/27/23) .Additional Orders: PLEASE TURN EVERY 2 HOURS AND KEEP PREVALON BOOTS ON AT ALL TIMES . Review of Discharge Instructions dated 7/27/23, revealed, .Off-Loading: Specialty Bed/Mattress for Pressure Reduction .Turn every 2 hours. Avoid position directing pressure to Wound site. Limit side lying to 30-degree tilt. Limit HOB elevation to 30 degrees in bed. -when turning, make sure catheter is not under patient, it will cause a new wound .Turn frequently .Do not sit for long periods of time .Avoid pressure at wound site . Review of Skin/Wound Note dated 7/28/23 at 3:51 PM, revealed, .A new wound to the left hip area is present which is an intact blister . Review of Wound Assessment Details dated 8/9/23, revealed, .1. Medial coccyx .3. Right Ankle .5. Left Heel .6. Right Heel .#7. Left Hip .#8. Right Lateral Food: New - Acquired on 8/9/23 . Review of Nutrition/Dietary Note dated 8/11/2023 at 12:33 PM, revealed, .IDT RAR: Resident with several pressure injuries. On regular diet, Ensure BID with snack offer. Weight has remained stable at 182.4 lbs. x 3 months. BMI 26.9. PCC shows snack intake typically 0-50%. Eating avg 50% of meals. Sister and mom visit each night, bring food/supplements to resident. Total assist when eating . Review of Skilled Note dated 8/20/2023 at 00:31 AM, revealed, .Regular diet, Regular texture, Thin consistency. No s/s pain or discomfort noted. Routine Neurontin and morphine given @ HS .Right heel wound: cleanse with normal saline. Apply silvasorb to wound bed and apply mepilex dressing. Change daily. Right ankle: cleanse wound with normal saline. pat dry. Apply Silvasorb to wound. Cover with mepilex dressing. Medial coccyx wound care: Cleanse with normal saline. Apply hydrofera blue to wound bed, ABD pads(x3-4) over the hydrofera and cover with foam dressing. Change daily and when soiled or dislodged. if unable to get hydrofera blue initially apply Dakins soaked gauze to wound and cover with foam dressing .Left heel wound: cleanse with normal saline. Apply silvasorb gel to wound. Cover with Mepilex foam. Change Three times a week for wound care.Res Alert. Confusion noted. Most needs anticipated by staff. Dependent for ADLS, transfers, toileting and feeding. Foley in place and draining clear yellow urine. Colostomy Intact. Res turned every two hours as she allows. Prevalon boots in place to bilateral feet. One assist with feeding. Will eat finger foods. Accepted HS meds without difficulty. Resting in bed with eyes closed. Fluids and call light within reach . Review of (Local Hospital) Wound Healing and Hyperbaric Center Progress Note dated 08/30/23, revealed, .(Facility) was not able to keep a good seal on her wound vac, so they have been packing the wound with dakins moistened gauze for the past few weeks instead .She is no longer on a clinitron bed (sand bed - filled with silicone coated microspheres which resemble sand, warm air is forced up through those to create a fluid like state) but does have an air mattress .She does have access to prevalon boots, but does not always have them on .4/28: Right heel wound healed .5/12: New wound on left upper thigh from catheter .5/25: Xrays of heels negative for osteomyelitis .7/6: .Sacral wound .a few areas do probe close to bone at base in middle of wound .Wound #9 Right Hip (New) . Review of Order dated 8/16/23, revealed, .Bilateral Prevalon boots to be worn as resident allows every day and night shift for wounds. Review of Order dated 8/15/23, revealed, .Regular diet: Regular texture, Thin consistency, for diet . Review of Health Status Note at 8/18/2023 at 6:51 PM, revealed, .Note Text: Alert to self. Appetite and fluid intake remains poor. Refused lunch tray. Drinks within reach but resident makes no attempts to drink them herself . Review of Skilled Note dated 8/20/2023 at 00:31 AM, revealed, .Regular diet, Regular texture, Thin consistency .Right heel wound: cleanse with normal saline. Apply silvasorb to wound bed and apply mepilex dressing. Change daily .Right ankle: cleanse wound with normal saline. pat dry. Apply Silvasorb to wound. Cover with mepilex dressing. Medial coccyx wound care: Cleanse with normal saline. Apply hydrofera blue to wound bed, ABD pads(x3-4) over the hydrofera and cover with foam dressing. Change daily and when soiled or dislodged. if unable to get hydrofera blue initially apply Dakins soaked gauze to wound and cover with foam dressing .Left heel wound: cleanse with normal saline. Apply silvasorb gel to wound. Cover with Mepilex foam. Change Three times a week for wound care Res Alert. Confusion noted. Most needs anticipated by staff. Dependent for ADLS, transfers, toileting and feeding .One assist with feeding. Will eat finger foods .Fluids and call light within reach . Note: No further documentation of monitoring to determine appropriateness of finger foods. Review of Resident #78's food preferences for Breakfast: no eggs, ham; Lunch & Dinner: beets, chicken strips, ham, lemon/lime Jello, melon (except watermelon), pot pie, rice, sweet potato, vegetables .Preferences: Extra sauce, gravy, butter, cottage cheese, yogurt, juice of choice: (4 oz), 2 milk whole (8 oz) . Review of Menu - Week 1 provided on 12/4/23 the current menu rotation, revealed for Breakfast eggs were offered 5 out of the 7 days, 1 of the 7 days; Lunch: Sunday: Apple pork chop, honey roasted sweet potatoes, broccoli casserole, dinner roll, pie of the day, beverage of choice; Monday: Beef stew, tossed salad, biscuit, fruit crisp; Tuesday: Tuna noodle casserole, Italian vegetables, garlic bread, banana pudding w/topping; Wednesday: Fried chicken, mashed potatoes/gravy, seas cut green beans, dinner roll, fruit pie; Thursday: Catch of the day, French fries, creamy cole slaw, dinner roll, golden bread pudding; Friday: Roast beef/gravy, baked potato, lemon butter broccoli Florentine, dinner roll, brownie; Saturday: BBQ Chicken, mashed potatoes, herb cut green beans, dinner roll, frosted cupcake; Dinner: Sunday: Baked chicken, potatoes [NAME], saute summer squash, garlic toast, ice cream, beverage of choice, milk; Monday: Garlic pepper pork, macaroni & cheese, vegetable blend, breadstick, SL cheesecake; Tuesday: Baked honey glazed ham, green peas, seas SL carrots, cornbread, fresh baked cookies; Wednesday: Shrimp fettucine, marinated tomato, dinner roll, strawberry shortcake; Thursday: Turkey pot pie, seasoned zucchini, dinner roll, fruit cup; Friday: Soup [NAME] jour, crackers, egg salad sandwich, carrot raisin salad, peach fluff; Saturday: Tamale pie, seasoned beans, chop lettuce/tomatoes, dinner roll, fruit cobbler . In an interview on 12/04/23 at 12:30 PM, Certified Nursing Assistant (CNA) X reported the staff would pass out the meal trays to all the residents and when they were finished passing the trays, they would come back around and feed everyone who needed assistance. Review of Skin/Wound Note dated 8/23/2023 at 1:13 PM, revealed, .Noted that her rt ankle, lateral wound has reopened and is scabbed over . Review of Health Status Note dated 9/1/23 at 12:17 PM, revealed, .New wound on right hip, stage 2 pressure injury . Review of Health Status Note dated 9/1/23 at 2:58 PM, revealed, .Slow to respond, stares. Facial grimacing present. Each movement states Ouch .water within reach but no observation of her attempting to drink herself . Review of Health Status Note dated 9/4/23 at 10:12 AM, .States Ouch with repositioning or during care .Water within reach at bedside, makes no attempt to drink herself . Review of Nutrition/Dietary Note dated 9/5/23 at 7:46 AM, revealed, .Sister states that Juven isn't touched from the time she leaves it to when she arrives the next day .Resident loves the Juven .does not like to drink water .Will enter order for 120 m: fluid offer with med passes (milk, supplement drink, Juven, etc.) . Review of Order dated 9/5/23, revealed, .Magic cup one time a day for supplement . Review of Medication Administration Record (MAR) for November 2023, revealed, Resident #78 was offered the magic cup 13 days out of 30 days. The other days of the month were noted with an x in the box . Review of Medication Administration Record (MAR) for December 2023, revealed, .12/3/23, 12/4/23, 12/5/23, 12/6/23 was documented with an x . Review of Order dated 9/5/23, revealed, .Offer Peanut Butter and Jelly sandwich if resident consumes less than 25% of a meal .with meals for PO (by mouth) intake <25% . Review of Medication Administration Record (MAR) for November 2023, revealed, .0900: 11/24/23: O .1300: Refused on 11/24/23, 11/27/23 .1900: Refused on 11/24/23, 11/26/23, 11/27/23, and 11/28/23 . The other entries for the month at those times were noted with an x in the box . Review of Medication Administration Record (MAR) for December 2023, revealed, .0900, 1300, and 1900 times it was documented with an R on 12/7/23 1900, 12/8/23 1900, 12/9/23 1900, 12/10/23 1900 .other notation were completed with an x . Review of Order dated 9/5/23, revealed, .Arginaide Extra one time a day for supplement . Review of Skin/Wound Note dated 9/7/23 at 6:40 PM, revealed, .Noted changes to the right foot, heel, and new breakdown to her rt great toe . Review of Wound Clinic noted dated 9/13/23, revealed, .She was evaluated by (Medical Doctor) and (Wound Clinic) team. No surgery performed, but irrigating vac was placed in addition to use of a dinitron bed. Her sister (First Name) is with her today. States that (Facility) was not able to keep a good seal on the wound vac, so they have been packing the wound with dakins moistened gauze for the past few weeks instead. She is no longer on a clinitron bed but does have an air mattress. She does have access to prevalon boots but does not always have them on. Eating a general diet. She is diverted . Review of Wound Assessment Details dated 9/14/23, revealed, .1. Medial coccyx .3. Right Ankle .5. Left Heel .6. Right Heel .(Worsened) .8. Right Lateral Foot .(Worsened - Stage 3) .9. Right Hip .New - Acquired on 8/23/23 . Review of (Local Hospital) Wound Healing and Hyperbaric Center Progress Note dated 09/14/23, revealed, .4/28: Right heel wound healed .5/12: New wound on left upper thigh from catheter .9/13: New right heel and right lateral foot pressure wound .Assessment and Plan: New unstageable right heel wound and stage 3 right lateral foot wound. Surgical debridement of lateral foot wound with lodoflex placed. Foam over all open areas. Change dressings every 2 days and prn drainage. Of utmost importance is reducing pressure, continue air flow mattress. Continue prevalon boots at all times. Continue good protein intake. Recheck in 2 weeks . Review of Health Status Note dated 9/15/23 at 12:38 PM, revealed, .IDT RAR: Several wounds. DTI unchanged .unstageable on r (right) 5th toe worsening, unstageable on R heel worsening, stage 4 on coccyx worsening . Review of Nutrition /Dietary Note dated 9/15/23 at 2:43 PM, revealed, .RD offered pig in a blanket to the resident .resident able to eat them without assistance. RD checked in a few minutes later, and most were gone. Resident agreed to a second serving . Review of No Type Specified dated 9/22/23 at 12:19 PM, revealed, .Unstageable pressure wound on r 5th toe unchanged, unstageable pressure wound on right heel worsening . Review of Heath Status Note dated 9/24/23 at 2:44 PM, revealed .Fluids within reach on bedside table, no observation of resident attempting to drink herself . Resident Health Status Note dated 10/7/23 at 11:15 AM, revealed, .Up in cardiac chair for approximately 2 hours .Tolerated well .Weight via hoyer .153.6 pounds . Review of Wound Assessment Details dated 10/11/23, revealed, .1. Medial coccyx .6. Right Heel .8. Right Lateral Foot .10. Right Lateral ankle .New - Acquired on 9/29/23 .Stage 3 . Review of Visit Report Discharge Instruction Details dated 10/25/23, revealed, .Culture of right heel wound, no current antibiotic use .Wound #11: Left Heel (New) .Wound #13: Left buttock .Additional Orders: Please send patient on stretcher . Review of Health Status Note dated 10/23/23 at 6:54 PM, revealed, .Sister informed this writer resident refused supper tray provided here but sister brought here (sic) a philly cheese steak and corn - which she consumer 100% . Review of Wound Assessment Details dated 10/25/23, revealed, .1. Medial coccyx .6. Right Heel .8. Right Lateral Foot .10. Right Lateral ankle .New - Acquired on 9/29/23 .Stage 3 .11. Left Heel .New -Acquired 10/23/22 .Unstageable .12. Right Knee: New - Acquired on 10/23/22 .13. Left Buttock .New - Acquired on 10/23/23 .Stage 2 . Review of Physician Progress Note dated 10/25/23, revealed, .Patient presents for recheck of multiple wounds .Right heel gangrenous changes with cellulitis present, foul odor .Unstageable .Left Heel unstageable pressure wound .Sacrum chronic wound stable but new right buttock stage 2 pressure wound .Assessment and Plan: 1. Right heel: Augmentin x 10 days, urgent referral to (medical doctor) this will require surgical debridement .2. Sacral Wound with new buttock wound: Transport on stretcher .Rotate Q (every) 2 hours .Hydrofera blue on wounds .3. Recheck in 1-2 weeks. If right heel worsens, needs eval in ER (emergency room ) . Review of Health Status Note 10/27/2023 at 09:01 AM, revealed, .Call received from (Physician Assistant) PA w/ the wound clinic. She stated that the culture returned that she did while (Resident #78) was at the Wound Clinic earlier this week. The culture shows proteus mirabilis and MRSA. N.O. received to d/c the Augmentin and start Bactrim DS 1 po q12 hours x 14 days. Call placed to (Power of Attorney), sister to inform her of the above. Review of Order dated 10/27/23, revealed, .Isolation: Enhanced Barrier Precautions Diagnosis: Phone infected wound every shift for infected wound . Review of (Local Hospital) Foot & Ankle Surgery Clinic Note dated 10/31/23, revealed, .Concern for nonhealing, exposed bone and inability to heal .Objective: On her right lower extremity she has a roughly half dollar size full-thickness right heel ulcer to bone. She has ankle joint contracture she has a palpable dorsalis pedis and posterior tibial pulse. No appreciable motor function but she sensate and painful. She has right fifth and first MTP joint ulcers as well. On the left side she has a heel ulcer .Assessment #1: chronic osteomyelitis right heel with likely involvement of the Achilles tendon and plantarflexion/ankle joint contracture .#2: right fifth and first MTP joint ulcers .#3 left heel ulcer .#4 multiple sclerosis .We discussed possible treatment options which could include continued conservative treatment and antibiotics/palliative care .Another option may be a partial calcanectomy (Amputation of the back part of the foot for the treatment of large ulcerations and osteomyelitis) and likely Achilles tendon debridement with attempt at secondary wound closure. Another option could be a below-knee amputation. I think a below-knee amputation would be the most reliable operation. I think continued expectant/conservative treatment is essentially palliative in nature and would ultimately lead to sepsis and possible death. Calcanectomy explained to the patient and her sister may be a 50-50 success rate given the extent of her ulcer. They wish, short of a below-knee amputation, to attempt a partial calcanectomy and debridement .Problem list: Methicillin resistant Staphylococcus aureus .MRSA collected from wound at 10/25/23 . Review of Skin/Wound Note at 11/1/2023 1:39 PM, revealed, .Per the assessments it is noted that the coccyx, right heel wound, and right foot (new) wound have worsened from the previous week . Review of Physician Orders Details dated 11/08/23, revealed, .Other Orders: Please send patient on stretcher .PATIENT NEED TO BE WEARING OFFLOADING PROTECTIVE BOOTS AT ALL TIMES. THESE NEED TO BE FOUND OR REPLACED IMMEDIATELY. PRESSURE MUST BE OFFLOADED FROM HEELS . Review of Wound Assessment Details dated 11/8/23, revealed, .1. Medial coccyx .6. Right Heel .(Worsened) .8. Right Lateral Foot .10. Right Lateral ankle .11. Left Heel .12. Right Knee .13. Left Buttock . Review of Health Status Note dated 11/11/23 at 3:13 PM, revealed, .Alert to self. Uncooperative with repositioning. Grabbing onto staff and bed linen. Pm pain medication adm. prior to wound care. All treatments completed as ordered. Coccyx dressing saturated thru linen. All linen changed .HOB (head of bed) elevated. Heel protectors on. Call light within reach. Fluids on bedside table in front of resident. She continues to make no effort to drink fluids herself . Review of Nutrition Quaterly Nutrition Data Collection dated 11/13/23, revealed, .Not drinking unless someone goes in there. Sister states that the resident does not like a lot of the food served, sister brings meals/snacks in to the resident. Sister provides high protein coffee/yogurt. Per sister, she is eating dinner every night as she is there with her Dining Assistance: Full-assist resident does not typically make attempts to eat or drink herself . Review of (Local Hospital) Progress Note Details dated 11/29/23, revealed, .9/27: Right heel wound worse .Patient drinking protein shakes and eating a good dinner daily .10/25: Patient isn't feeling well, transported via wheelchair van rather than stretcher and has been sitting up in a chair for hours. Has a new right buttock/perianal wound, stage .Of greatest concern is right heel unstageable wound. Odor present with cellulitis and boggy (sponginess, high fluid content), gangrenous changes. Left heel also with unstageable pressure wound .Wound #1 (Pressure Ulcer) Is located on the medial coccyx. A non-selective mechanical debridement with a total area debrided of 90 sq cm. was performed By (Physician Assistant),PA. Non-viable tissue was removed. The procedure was tolerated well with a pain level of 9 throughout and a pain level of 7 following the procedure. Post Debridement Measurements: 7.5cm length x 12cm width x 0.1cm depth; with an area of 90 sq cm and a volume of 9 cubic cm .Additional Orders: please send patient on stretcher .PATIENT NEEDS TO BE WEARING OFFLOADING PROTECTIVE BOOTS AT ALL TIMES. PRESSURE MUST BE OFFLOADED FROM HEELS .Assessment and Plan: Of utmost importance is reducing pressure, continue air flow mattress. Continue prevalon boots at all times . Review of Wound Clinic Progress Note dated 11/29/23, revealed, .Wound #14 Right Heel Is an acute Partial Thickness Surgical Wound and has received a status of Not Healed, initial wound encounter measurements are 9.5cm length x 0.2cm width x 0.1 cm depth, with an area of 1.9 sq cm and a volume of 0.19 cubic cm. No tunneling has been noted. No sinus tract has been noted. No undermining has been noted. There 5 a Scant amount of serous drainage noted which has no odor, The patient reports a wound pain of level 10/10. The wound margin is regular .Wound bed has No granulation, No slough. No eschar. No epithelialization .The periwound skin texture is normal, The periwound skin moisture Is normal. The periwound skin color is normal . Review of Skin/Wound Note daed 5:22 PM, revealed, .Blood blister noted to left hip 0.9x0.3 (Medical Doctor) notified. Order received for skin prep Q shift . During an observation on 12/04/23 at 10:52 AM, Resident #78 was lying in her bed, supine position with a slight tilt to the left side. There was a noted odor in the room upon entry. There was a rolling bedside table near the left side of the bed which was not easily reached from her positioning in the bed. There was a cup on the table labeled Juven (therapeutic nutrition powder for wound healing) with a post it note stated, Please do not throw out. There were observed to be multiple signs in the room prompting staff to place the rolling beside table near Resident #78 so she could reach the drinks. On the rolling bedside table, next to the mirror where staff would wash their hands, etc. Resident #78 was observed to have a prevalon boot on her right foot. Resident #78's lips were dry, and skin was flaking off her lips with no water on the rolling bedside table. There was a blue foot cradle propped against the wall by the window in her room. During an observation on 12/5/23 at 8:26 AM, Resident #78 was observed lying in her bed on her back with her legs bent to the left side. Resident #78 does have a contracted right leg. Resident #78's foot cradle was propped up against the wall by her dresser near the window in her room. There were no noted pillows under her legs. A styrofoam cup with water and a straw was on the rolling bedside table this morning. Her catheter still looks the same as yesterday with more cloudiness to it, tons of sediment in the tubing and calcification all over the top of the opening in the bag. Bag is touching the floor. She does have water today on the rolling table next to her bed. The hair still looks kind of greasy still the same ponytail yesterday. During an observation on 12/5/23 at 2:00 PM, Resident #78 was observed lying in the same position she was lying in this morning. Her table is out of reach, which has her water and her Juven on it. She is still dressed in a hospital gown; right hand is contracted. Resident #78's foot cradle was still propped up against the wall in the same position as yesterday. During an observation on 12/6/023 at 8:51 AM, Resident #78 was in bed without a wedge to either side, no foot cradle under her heels, or a pillow between her knees. It was noted, the resident's knees were touching each other. During an observation on 12/6/23 at 10:20 AM, Licensed Practical Nurse/ Unit Care Coordinator (LPN/UCC) H removed the soiled dressing from Resident #78's right foot, cleansed wound with dakins solution (antiseptic wound cleanser), dried wound with gauze, and applied aquacel (antimicrobial wound dressing), wrapped right foot with kerlix (gauze wrap), and secured dressing with tap [TRUNCATED]

This citation has two deficiency practice statements, A & B. Deficiency Practice Statement A This citation pertains to Intake # MI00139066. Based on interview, and record review, the facility failed to provide protection for a resident after an incident of staff to resident abuse in 1 of 1 resident (Resident #114) reviewed for abuse, resulting in an Immediate Jeopardy when on 7/18/23, Certified Nurse Aide (CNA) C restrained Resident #114 to his wheelchair for several hours and other staff and management were aware of the incident, but allowed CNA C continued access to Resident #114 and 57 additional vulnerable residents without any education for the staff or protection for the residents. Findings include: Resident #114 Review of an Admission Record revealed Resident #114 had pertinent diagnoses which included repeated falls, dementia, Alzheimer's disease, and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #114, with a reference date of 8/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #114 was severely cognitively impaired. Review of the facility reported incident filed by Senior Executive Director (SED) DDD on 7/18/23 at 10:30 AM revealed . Incident .CNA (Certified Nurse Assistant) observed Resident #114's mechanical lift sling utilized as a restraint. 2 CNAs on the unit were suspended pending investigation . Review of facility reported investigation filed by SED DDD on 7/18/23 at 5:43 PM, revealed . Investigation .CNA C and CNA D assisted Resident #114 into his wheelchair via mechanical lift. CNA D provided Resident #114 a gown that was placed over the sling . CNA D put sling straps up over Resident #114's shoulders . the straps were never tied to the wheelchair . The facility is not able to substantiate this misperception by observation. The two associates that were suspended have been returned to duty . Review of Witness Interview/ Statement Form provided by CNA C on 7/18/23 at 10:37 AM, revealed . straps were over his legs, super big sling, didn't know what to do w/ (with) it . I put it up on the handles (bottom straps) . attached to the push handles it was me that did it . This indicated the resident was restrained to the wheelchair. Review of Witness Interview/Statement Form provided by CNA D on 7/18/23 at 12:36 PM, revealed . I came back sling was up above his shoulders, he was naked . I got him a gown. Put it on him, did not remove sling/straps put gown over him & straps. He was wheeling back and forth throughout building all night. No use of bathroom . don't think we toileted him or changed him all NOC (night) . During an interview on 9/12/23 at 2:46 PM, CNA X reported that she saw Resident #114 on the morning of 7/18/23 restrained to his wheelchair. CNA X reported she located Resident #114 on the morning of 7/18/23 sitting in his wheelchair, by the barber shop, asleep. CNA X reported Resident #114 was wearing a gown. CNA X reported she saw the hoyer (mechanical lift) sling leg straps were coming up between Resident #114's legs, crossed over his chest in the shape of an X over his shoulders, and tied to the push handles of his wheelchair. CNA X reported that the hoyer sling was next to Resident #114's chest and the gown was over the hoyer sling. CNA X reported she told CNA C and CNA D that the hoyer sling could not be tied to the wheelchair like that and the response of CNA D was that Resident #114 falls too much and CNA C laughed. During an interview on 9/11/23 at 1:29 PM, CNA C was asked if she recalled a situation that involved Resident #114 and him being restrained to his wheelchair that was reported on 7/18/23. CNA C stated Yeah, that was me, I did that. CNA C reported that Resident #114 was found on the floor next to his bed and CNA C was assisted by CNA D to transfer Resident #114 into his wheelchair using a hoyer with a sling. CNA C reported that the hoyer sling was left under the resident after the transfer. During a telephone interview on 9/12/23 at 5:08 PM, Family Member (FM) ZZ reported when she arrived at the facility on 7/18/23 to visit, Infection Prevention (IP) G asked her into his office and told her that Resident #114 had been restrained with a hoyer sling in his wheelchair last night. During an interview on 9/13/23 at 12:10 PM, IP G reported that he did have a conversation with Resident #114 family member after the situation on 7/18/23. IP G reported that he told FM ZZ that there was a potential for abuse towards Resident #114. IP G reported that he told FM ZZ that it was possible that Resident #114 was restrained to his wheelchair with a hoyer sling last night. During a telephone interview on 9/18/23 at 4:19 PM, Senior Executive Director (SED) DDD reported she spoke to CNA C who stated she was having difficulty removing the sling from the resident and she told me she tried to toss the leg straps over his shoulders, but they didn't stay because it is a high back wheelchair. SED DDD reported that CNA C reported that she did it again and it connected with the handle of the wheelchair, and it stayed. SED DDD reported that CNA C stated it was very loose. The strap over his shoulder was loose and they stayed in place by being hooked on the handles. Review of the Wednesday 7/19/23 schedule revealed CNA C was scheduled to work 7 PM to 6 AM and CNA D was scheduled to work 10 PM to 4 AM, returning to work following their suspension pending investigation. Review of the August 2023 Schedules revealed CNA C was scheduled to work 15 days during the month of August 2023. CNA D was scheduled to work 14 days during the month of August 2023. During an observation on 9/11/23 at 1:29 PM, CNA C was present and providing care and services to the residents of the facility. During a telephone interview on 9/11/23 at 3:38 PM, CNA D stated she was scheduled to work that evening at 6 PM and was the only CNA scheduled on the Bridge unit and would have an assignment of possibly 32 residents. On 9/12/23 at 5:00 PM, NHA A was verbally notified and received a written notification of the Immediate Jeopardy that began on 7/18/23 and was identified on 9/12/23 due to the facility's failure to prevent likelihood of further abuse and protect residents assigned to CNA C and CNA D after it was confirmed that the staff member had applied a physical restraint and the other staff member was aware of the physical restraint that was applied to Resident #114. A written plan for removal for the Immediate Jeopardy was received on 9/13/23 and the following was verified on 9/14/23: * The two CNAs C and D caring for resident #114 were suspended immediately pending investigation on July 18, 2023. Both CNA C and D left the facility at 6:04 am on 7/18/2023. * Resident 114 was assessed by a nurse on July 18, 2023 at 11:55 am, no restraints of any kind were being utilized at that time. * Residents requiring use of sling lifts were reviewed on July 18, 2023 for proper use and none at that time were used in a manner other than per policy. * On July 19, 2023, education was provided to the CNAs C and D caring for Resident #114 on the proper use of sling lifts including the following: manufacturer's recommendations, the appropriate sizing, tucking in the straps at residents sides when in chair to reduce hazards, notification to nurse for non-compliance or accident hazards. After receiving the education, the CNAs returned to duty on 7/19/2023. * Residents requiring use of sling lifts were reviewed again on 9-12-23 for proper use and none were used in a manner other than per policy. Interviewable residents were interviewed on 9-12-23 regarding the use of sling lifts residents did not verbalized improper use of sling lifts by facility staff. * All facility staff (direct and non-direct care) will be educated on the facility abuse policy and restraint policy beginning on 9-12-2023 and will not be allowed to work until the training has been received. As of 4:00 pm on 9/13/2023, 93 staff members have received the education out of 134 total. * The facility abuse training includes definitions and activities of abuse, prohibition, identification, reporting procedures and facility processes for investigating, including removal of the alleged perpetrator(s) by a supervisor to safeguard the resident(s). * The abuse education provided included the understanding of indications of distress, discomfort or negative thoughts and/or reactions. * Residents were visually inspected and restraints are not in use on 9-12-2023. Residents transferring utilizing a mechanical lift will be monitored randomly by licensed nurses or designee, on a daily basis for eight weeks to assure slings are utilized and positioned properly. The director of nursing is responsible for ongoing monitoring. * CNAs C and D were re-suspended on 9-12-2023. * The facility Medical Director is aware of this plan and is in agreement on 9-12-2023 Although the Immediate Jeopardy was removed on 9/13/23, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due the fact that not all facility staff have received the education and sustained compliance has not been verified by the State Agency. 36221 Deficiency Practice Statement B This citation pertains to Intake # MI00139073 & # MI00139098. Based on observation, interview, and record review, the facility failed to thoroughly investigate situations involving potential neglect in 2 of 7 residents (Resident #115 & #116) reviewed for abuse/neglect, resulting in incomplete facility investigations and a lack of documentation. Findings include: Resident #115 Review of an Admission Record revealed Resident #115 was a female, with pertinent diagnoses which included dementia, high blood pressure, peripheral venous insufficiency, depression, muscle weakness, and debility. Review of a Minimum Data Set (MDS) assessment for Resident #115, with a reference date of 7/25/23, revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated severe cognitive impairment. Further review of this MDS assessment revealed Resident #115 required one person extensive assistance for transfers, with unsteady balance, only able to stabilize with staff assistance. Review of a current Care Plan for Resident #115 revealed the focus .(Resident #115) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) impaired mobility, muscle weakness, dementia with impaired cognition . revised 10/17/22, with interventions which included .TRANSFER: Assist x 1 with gait belt. Uses a standard w/c (wheelchair) when up . revised 10/17/22. In an observation and interview on 9/11/23 at 2:17 PM, Certified Nursing Assistant (CNA) DD and CNA HHH assisted Resident #115 with toileting in her room. Noted a wound dressing in place on Resident #115's left shin. Observed CNA DD and CNA HHH utilize a sit-to-stand lift to transfer Resident #115 from her wheelchair to the toilet. CNA HHH reported Resident #115 has utilized a sit-to-stand lift for transfers for over a year. CNA HHH stated in regard to Resident #115's left shin wound .there is a skin tear . Review of an Event Note for Resident #115, dated 8/11/23 at 6:28 PM, revealed .Resident noted with skin tear to left shin. Approximately 6cm in length. Cleansed with sterile normal saline. Surface wound noted. Pat dry with sterile gauze. Mepilex applied. Resident c/o (complained of) discomfort during wound cleansing. Tender to touch left leg . No documentation noted to indicate if the Physician or family/responsible party were notified of the wound. In an interview on 9/11/23 at 2:40 PM, Licensed Practical Nurse (LPN) O reported in regard to Resident #115's left shin wound .I came Saturday (8/12/23). When I took the dressing off I saw a wound I did not think was a small skin tear .Kind of huge to just have Mepilex . LPN O reported she contacted the Physician on 8/12/23 and received orders to send Resident #115 out to the hospital. LPN O reported the hospital staff called to ask what happened and .I didn't have any information . LPN O reported bone was visible in the wound and stated in regard to the dressing in place .I thought the treatment was not right . LPN O reported Resident #115 was sent to the local hospital, however .They couldn't do anything there . and Resident #115 ended up being sent to a larger hospital for treatment. LPN O described the wound as .kind of scary . and reported the edges of Resident #115's skin were folded, with muscle and bone exposed. LPN O reported Resident #115 appeared to be aware of the wound, and didn't want anyone to touch the area. LPN O reported she was initially asked to evaluate the wound by CNA III, and reported when she checked the medical record there was no order for a wound treatment in place. Review of an Order Summary Report for Resident #115, of all active, completed, and discontinued orders, revealed no physician order was obtained for a treatment to the left shin wound on 8/11/23. Review of a Health Status Note for Resident #115, dated 8/12/23 at 5:42 PM, revealed .resident had foam dressing to her left shin was saturated removed the foam dressing noted a wound very deep and white material exposed notified (Physician Name) he assess (sic) the wound ordered to send the resident to ER (emergency room ) for sutures. NOTIFIED DAUGHTER .she requested to send her mother to (Local Hospital Name). covered the wound with non adhesive pad and wrapped with kerlex (sic). notified on call nurse manager .transferred her to ER via (Ambulance Service Name) at 1500 (3:00 PM) . Review of a Health Status Note for Resident #115, dated 8/12/23 at 4:48 PM, revealed .received the call from ER spoke with charge nurse she said she was glad that we send her (Resident #115) out that seems like her wound is [NAME] (sic) deep to the shin bone she also said she may have to go to main hospital but he will keep us informed . Review of an Emergency Physician Documentation note for Resident #115, dated 8/12/23 at 6:58 PM, revealed .Patient is a [AGE] year-old female with a past medical history of dementia, debility, hypertension, hyperlipidemia .She comes to the emergency department today for a laceration to her left shin. Per EMS report, patient fell while being transferred yesterday and caught her left shin on unknown object. I spoke with nurse at facility .She stated that she went to care for the wound today. She unbandaged the wound and saw that the wound extended to the bone. She was not present when this incident happened, but she was very concerned about the severity of the wound .Physical Exam .Skin: Large laceration to left shin, approximately 7 cm, jagged in nature .it does appear to go to the bone .The wound is retracted, there is involved muscle visualized . Review of an Emergency Physician Documentation note for Resident #115, dated 8/12/23 at 8:46 PM, revealed .Patient is a [AGE] year-old female presenting to the emergency department today for wound to left lower extremity .Patient is demented, unable to obtain further history from her .It appears that the wound occurred yesterday while transferring the patient however was unable to speak with anyone who was present at the time of transfer to obtain further history .I am concerned about possible neglect as this is a very large wound extending to the bone, was not brought to medical attention until today .I did call and speak with (Physician Name) of the trauma service at (Hospital Name). The wound is very large, extending to the bone, retracted, happened greater than 24 hours ago, I do not feel it is appropriate to close the wound primarily here in the ER. She will need evaluation by trauma surgery due to the severity of the wound . Review of a Hospital Operative Report for Resident #115, dated 8/12/23 at 11:20 PM, revealed .Procedure: Laceration repair .Left leg laceration measured 7 cm x 5 cm with exposure of bone below .Laceration was irrigated with 100 cc of normal saline. Fascial layer was closed with 3-0 Vicryl in interrupted fashion. Skin was closed with 3-0 nylon with vertical mattress sutures. Incision was dressed with Xeroform, gauze, and wrapped with Kerlix .Patient tolerated repair without complication . Review of a Health Status Note for Resident #115, dated 8/13/23 at 2:38 PM, revealed .resident returned from hospital at around (1:50 PM) alert .dressing to left shin is intact dry old blood stain present . Review of a Physician Note for Resident #115, dated 8/14/23, revealed .This is a [AGE] year old .female who had major trauma to the left leg .transferred to (Hospital Name) for repair of a multilayer wound. Patient has not been started on any antibiotics. Patient has a more than 24 hour open wound, has a high risk for infection .Will start patient on Cipro (antibiotic) . In an interview on 9/13/23 at 9:24 AM, CNA III reported she witnessed the incident that caused Resident #115's laceration to her left shin. CNA III reported on 8/11/23, she and CNA HHH went to Resident #115's room to .get her up for the day . CNA III reported Resident #115 didn't want her to touch her, so CNA HHH assisted Resident #115 with a one person stand-pivot transfer from her bed to her wheelchair. CNA III reported she heard a thump and looked down to see a wound on Resident #115's left shin. CNA III reported Resident #115 did not fall, and was uncertain what her leg hit to cause the wound. CNA III stated the wound .looked terrible . and reported bone was visible. CNA III reported CNA HHH went to notify the nurse of the incident. CNA III stated in regard to Resident #115's wound .She should have went out (to the hospital) that day . CNA III reported CNA HHH did not utilize a gait belt for the transfer. CNA III reported facility management did not ask for a witness statement until days later, after Resident #115 went to the hospital. In an interview on 9/13/23 at 10:52 AM, Registered Nurse (RN) FFF reported she was the nurse assigned to Resident #115 on 8/11/23. RN FFF reported Resident #115 was trying to get out of bed so she asked the CNA's to go in and assist. RN FFF stated .I think they did not use the proper transfer technique . RN FFF reported a CNA notified her after the transfer that Resident #115 had a skin tear. RN FFF stated in regard to Resident #115's wound .It was bleeding but it was a surface wound .It wasn't deep. I cleaned it with saline and I put a dressing on it . RN FFF reported she did not notify the Physician of the wound or obtain an order for a wound treatment. RN FFF reported she was unsure if family was notified, and stated that information would be in the progress notes. RN FFF reported she was not asked to provide a statement after the incident. RN FFF reported she did not complete an incident/accident report related to the wound on Resident #115's left shin. RN FFF stated .I wrote a nurse's note . In an interview on 9/13/23 at 11:52 AM, LPN Unit Care Coordinator I reported she was notified of Resident #115's left shin wound on 8/12/23 by LPN O. LPN Unit Care Coordinator I stated .The CNA had brought it to her attention that there was a dressing on her left shin area . LPN Unit Care Coordinator I reported it was a .significant injury . and reported she was not notified of the incident on 8/11/23. LPN Unit Care Coordinator I reported she initiated an incident/accident report related to Resident #115's wound on 8/12/23, and directed LPN O to contact the Physician and get an order for a wound treatment. LPN Unit Care Coordinator I reported the Physician gave orders to send Resident #115 to the hospital. LPN Unit Care Coordinator I reported Resident #115 requires a one-person staff assist for transfers using a gait belt. LPN Unit Care Coordinator I reported she interviewed staff that worked on 8/11/23 to identify what occurred, completed a reenactment of the transfer, and checked her furniture/equipment for sharp edges. LPN Unit Care Coordinator I reported she was unsure if a gait belt was utilized for Resident #115's transfer on 8/11/23 that resulted in an injury. LPN Unit Care Coordinator I reported Resident #115's left shin wound later became infected, resulting in the need for antibiotics. Reviewed of an Incident/Accident Report for Resident #115, dated 8/11/23 at 10:30 AM, revealed .Incident Description .(Resident #115) was noted with a skin tear to left shin, approximately 6 cm in length .Immediate Action Taken .Nurse cleansed skin tear with NS (Normal Saline), pat dried and mepilix (sic) applied .Resident Taken to Hospital? N (No) .Predisposing Situation Factors .During Transfer . Noted the staff member who prepared the report was LPN Unit Care Coordinator I. The report did not indicate any issues/noncompliance related to the transfer, erroneously stated the resident was not sent to the hospital, and did not contain details to indicate the severity of Resident #115's left shin wound. Noted per the report, the Physician was notified of the wound on 8/12/23 at 1:14 PM, and Resident #115's family member was notified of the wound on 8/12/23 at 3:30 PM. Both more than 24-hours after the original incident which resulted in Resident #115's left shin wound. In an interview on 9/14/23 at 10:25 AM, CNA HHH reported she completed Resident #115's transfer from her bed to her wheelchair on 8/11/23, which resulted in an injury to her left shin. CNA HHH stated .her (Resident #115's) leg scraped against mine . CNA HHH described the wound as .a little skin tear, maybe an inch . and reported no bleeding from the wound. In an interview on 9/14/23 at 10:33 AM, with Administrator A and Director of Nursing (DON) B, DON B reported she was notified of Resident #115's wound on 8/14/23 during morning meeting. DON B reported she was told the wound occurred .during transfer . DON B reported LPN Unit Care Coordinator I would have been responsible to complete the investigation. Reviewed the witness statements obtained as part of the facility investigation into Resident #115's left shin wound. Noted only CNA HHH and CNA III were interviewed as part of the investigation. DON B reported Resident #115 requires one person staff assistance for transfers with a gait belt. Resident #116 Review of an Admission Record revealed Resident #116 was a female, with pertinent diagnoses which included dementia, obstructive lung disease, diabetes, atrial fibrillation (an irregular heart rate which causes poor blood flow), depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #116, with a reference date of 8/2/23, revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a Health Status Note for Resident #116, dated 8/15/23 at 8:32 AM, revealed .CNA (Certified Nursing Assistant) brought resident to my office and stated Something (sic) not right with her. Vital signs obtained and WNL (Within Normal Limits). Eyes closed, when her name is called her eye (sic) [NAME] and will attempt to open them and will open briefly with fast blinks and eyes gazed over and if able to open her eyes then they close. Unable to verbally respond. x 2 CNA's TF (transfer) into bed from w/c (wheelchair) stating that she did bear her weight with their assistance and once in bed, eyes closed again. Called (Physician Name) orders to TF (transfer) to (Hospital Name) for eval (evaluation) and tx (treatment) .(Emergency Transport) called with report and (Hospital emergency room ) report given as well. CNA's with resident at this time . Review of an EMS (Emergency Medical Services) Patient Care Report for Resident #116, dated 8/15/23, revealed .Dispatched Priority One to (Facility Name) Nursing Home for a [AGE] year old female with altered mental status. On arrival the patient is found supine in her bed with snoring, slow respirations. The facility nurse reports the patient was up this morning acting normal for her. She was given her dailey (sic) medications and now they are unable to keep her awake. Facility staff denies providing the patient with any type of narcotic .Initial assessment reveals patient only responds to painful stimuli .pupils are equal, pinpoint and non reactive .respirations are slow .IV established and 1/2 dose of Narcan provided slowly. Respirations began to increase and patient started to awake, within 3-5 minutes the patient was awake and asking where she was going . Review of an Emergency Department Note for Resident #116, dated 8/15/23, revealed XXX[AGE] year-old female with a history of dementia, diabetes, hypertension, and hyperlipidemia presenting to the emergency department after found at her facility unarousable. Patient is arousable in this facility at this time. I believe that this is most likely a mixup of patient's drugs given she became arousable after 1 mg of Narcan so a urine drug screen is pending . Review of a Urine Drug Screen for Resident #116, collected 8/15/23 at 1:53 PM, revealed a positive result for Methadone. Review of an Emergency Department Note for Resident #116, dated 8/15/23, revealed .Patient is a [AGE] year-old female with a history of dementia and diabetes. Presenting to the emergency department for evaluation of likely accidental overdose and altered mental status. Responded to Narcan. UDS (Urine Drug Screen) positive for methadone .On my evaluation, patient was brought apneic and slow to respond and somnolent .Given methadone intoxication, ABG (Arterial Blood Gas Test) previously that showed hypercapnia (high levels of carbon dioxide in the blood), patient given another Narcan bolus IV and another ABG was ordered. This showed still persistent hypercapnia. Given patient's (persistent) dyspnea still after second Narcan bolus in the ER which is third total for today, patient is started on Narcan drip and BiPAP. Patient will be admitted to the ICU service . Review of a Hospital Progress Note for Resident #116, dated 8/15/23, revealed .This is a [AGE] year-old admitted to the ICU on BiPAP with a Narcan drip after presumed accidental methadone ingestion at her nursing home earlier today . Review of a Hospitalist Progress Note for Resident #116, dated 8/16/23, revealed .This is a [AGE] year-old with a history of mental retardation, dementia, borderline personality disorder presenting from her nursing home for altered mental status. The patient is altered and unable to participate in any of the history .Reportedly patient was in her usual state of health until she was found to be altered today by care at her nursing care facility. She was brought to the ER for further evaluation. She was somnolent. EMS noted that she had pinpoint pupils that she did receive Narcan which improved her mental status. Methadone is not noted to be one of her medications on her chart. It is believed that she accidentally received the patient's medicines . Review of a Hospital Progress Note for Resident #116, dated 8/16/23, revealed .ICU Attending Addendum .67f ([AGE] year-old female) with cognitive disorder, dementia, bipolar, htn (hypertension) .who presented to the ED (Emergency Department) encephalopathic, hypoventilating requiring BiPAP after accidental administration of methadone at her nursing home. She is somnolent, arousable on the BiPAP/narcan infusion .We will continue narcan infusion given extended duration of symptoms, wean BiPAP as tolerated .The patient has an acute impairment of respiratory/neurologic organ systems such that there is a probability of imminent or life-threatening deterioration of the patient's condition. Narcan infusion, BiPAP, f/u (follow-up) blood gas diagnostic and or therapeutic interventions were performed to prevent further life-threatening deterioration or organ system failure . Review of a Physician Note for Resident #116, dated 8/17/23, revealed .This patient is readmitted from the hospital. The patient had a change in mental status. The patient was admitted to the hospital. The diagnoses applied by the hospitalist included accidental overdose .The patient was found to have methadone in her system. The patient is not on methadone. Unknown source of methadone present, drug error versus medication error . In an interview on 9/13/23 at 11:52 AM, Licensed Practical Nurse (LPN) Unit Care Coordinator I reported she took over the hall assignment on 8/15/23 at approximately 8:30 AM, which included Resident #116. LPN Unit Care Coordinator I reported the day shift nurse went home early due to illness. LPN Unit Care Coordinator I reported shortly after she took over the assignment, a CNA brought Resident #116 to her for an assessment. LPN Unit Care Coordinator I reported Resident #116 .definitely was not responding . and identified a change in level of consciousness. LPN Unit Care Coordinator I stated Resident #116 .would open her eyes and shut them immediately . LPN Unit Care Coordinator I reported she spoke with the physician and the guardian for Resident #116, and she (Resident #116) was sent to the emergency room . LPN Unit Care Coordinator I reported the hospital completed a drug test and Resident #116 tested positive for Methadone. LPN Unit Care Coordinator I reported Resident #116 does not take Methadone. LPN Unit Care Coordinator I reported there is only one resident on the unit who takes Methadone (Resident #113). LPN Unit Care Coordinator I reported Director of Nursing (DON) B was notified of the incident. LPN Unit Care Coordinator I reported she completed an investigation and brought .all the information that I could compile . to DON B. LPN Unit Care Coordinator I reported DON B planned to follow-up with the night shift nurse, LPN GGG. LPN Unit Care Coordinator I stated she .never heard the outcome . of that interview. Review of an Order Summary Report of all active, completed, and discontinued medications for Resident #116, printed 9/13/23, revealed no physician order for Methadone or any other opioid/controlled substance. Reviewed incident/accident reports for the past three months for Resident #116. No incident/accident report noted related to a significant medication error on 8/15/23. In an interview on 9/14/23 at 10:33 AM with Administrator A and DON B, Administrator A reported there is only one resident in the facility who takes Methadone (Resident #113). Administrator A reported the facility investigated the incident involving Resident #116 on 8/15/23, and determined there were no missed doses of Methadone that could have resulted in an overdose for Resident #116. Administrator A reported the resident at the facility with the ordered Methadone is alert and able to identify if any medications are missed. Administrator A reported facility staff audited the narcotics for the entire facility, checked Resident #116's room, reviewed Resident #116's ordered medications, and checked visitor logs. Administrator A stated .We really have no idea where that (the positive result for Methadone for Resident #116) would have come from . In an interview on 9/14/23 at 11:54 AM, LPN GGG reported she worked the night shift from 8/14/23 to 8/15/23 and was assigned to Resident #116. LPN GGG reported she had observed Resident #116 that morning and stated .She was fine .She was up and about . LPN GGG reported she was shocked to hear what had happened to Resident #116, and reported no one interviewed her or obtained a statement about the events of that shift related to Resident #116. LPN GGG reported Resident[TRUNCATED]

This citation pertains to Intake # MI00139098. Based on interview, and record review, the facility failed to ensure residents are free from significant medication errors in 1 of 6 residents (Resident #116) reviewed for medication administration resulting in an Immediate Jeopardy when, beginning on 8/15/23 at approximately 8:00 AM, Resident #116 was identified to have a decreased level of consciousness and was sent to the hospital. Resident #116 was found to have Methadone (an opioid) in her system, due to receiving another resident's 30 mg dose of Methadone, resulting in hospitalization in the ICU (Intensive Care Unit - provides care and life support for acutely ill/injured patients) on BiPAP (Bilevel Positive Airway Pressure - a device that helps with breathing) with a Narcan drip (a medication used to treat an opioid overdose), and the likelihood of further life-threatening deterioration in condition. Findings include: Review of the policy/procedure Administration of Medications, dated 8/24/23, revealed .The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms .The facility must ensure that its .Residents are free of any significant medication errors .Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration .Right Drug .Every drug administered must have an order from the provider .Right Resident .Controlled substances should be signed out from the descending count sheet and documented on the MAR (Medication Administration Record) for each routine and PRN (as needed) dose of medication administered .Be aware high-alert and hazardous medications .High-alert medications include, but are not limited to .Opioids . Review of an Admission Record revealed Resident #116 was a female, with pertinent diagnoses which included dementia, obstructive lung disease, diabetes, atrial fibrillation (an irregular heart rate which causes poor blood flow), depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #116, with a reference date of 8/2/23, revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a Health Status Note for Resident #116, dated 8/15/23 at 8:32 AM, revealed .CNA (Certified Nursing Assistant) brought resident to my office and stated Something (sic) not right with her. Vital signs obtained and WNL (Within Normal Limits). Eyes closed, when her name is called her eye (sic) [NAME] and will attempt to open them and will open briefly with fast blinks and eyes gazed over and if able to open her eyes then they close. Unable to verbally respond. x 2 CNA's TF (transfer) into bed from w/c (wheelchair) stating that she did bear her weight with their assistance and once in bed, eyes closed again. Called (Physician Name) orders to TF (transfer) to (Hospital Name) for eval (evaluation) and tx (treatment) .(Emergency Transport) called with report and (Hospital emergency room ) report given as well. CNA's with resident at this time . Review of an EMS (Emergency Medical Services) Patient Care Report for Resident #116, dated 8/15/23, revealed .Dispatched Priority One to (Facility Name) Nursing Home for a [AGE] year old female with altered mental status. On arrival the patient is found supine in her bed with snoring, slow respirations. The facility nurse reports the patient was up this morning acting normal for her. She was given her dailey (sic) medications and now they are unable to keep her awake. Facility staff denies providing the patient with any type of narcotic .Initial assessment reveals patient only responds to painful stimuli .pupils are equal, pinpoint and non reactive .respirations are slow .IV established and 1/2 dose of Narcan provided slowly. Respirations began to increase and patient started to awake, within 3-5 minutes the patient was awake and asking where she was going . Review of an Emergency Department Note for Resident #116, dated 8/15/23, revealed XXX[AGE] year-old female with a history of dementia, diabetes, hypertension, and hyperlipidemia presenting to the emergency department after found at her facility unarousable. Patient is arousable in this facility at this time. I believe that this is most likely a mixup of patient's drugs given she became arousable after 1 mg of Narcan so a urine drug screen is pending . Review of a Urine Drug Screen for Resident #116, collected 8/15/23 at 1:53 PM, revealed a positive result for Methadone. Review of an Emergency Department Note for Resident #116, dated 8/15/23, revealed .Patient is a [AGE] year-old female with a history of dementia and diabetes. Presenting to the emergency department for evaluation of likely accidental overdose and altered mental status. Responded to Narcan. UDS (Urine Drug Screen) positive for methadone .On my evaluation, patient was brought apneic and slow to respond and somnolent .Given methadone intoxication, ABG (Arterial Blood Gas Test) previously that showed hypercapnia (high levels of carbon dioxide in the blood), patient given another Narcan bolus IV and another ABG was ordered. This showed still persistent hypercapnia. Given patient's (persistent) dyspnea still after second Narcan bolus in the ER which is third total for today, patient is started on Narcan drip and BiPAP. Patient will be admitted to the ICU service . Review of a Hospital Progress Note for Resident #116, dated 8/15/23, revealed .This is a [AGE] year-old admitted to the ICU on BiPAP with a Narcan drip after presumed accidental methadone ingestion at her nursing home earlier today . Review of a Hospitalist Progress Note for Resident #116, dated 8/16/23, revealed .This is a [AGE] year-old with a history of mental retardation, dementia, borderline personality disorder presenting from her nursing home for altered mental status. The patient is altered and unable to participate in any of the history .Reportedly patient was in her usual state of health until she was found to be altered today by care at her nursing care facility. She was brought to the ER for further evaluation. She was somnolent. EMS noted that she had pinpoint pupils that she did receive Narcan which improved her mental status. Methadone is not noted to be one of her medications on her chart. It is believed that she accidentally received the patient's medicines . Review of a Hospital Progress Note for Resident #116, dated 8/16/23, revealed .ICU Attending Addendum .67f ([AGE] year-old female) with cognitive disorder, dementia, bipolar, htn (hypertension) .who presented to the ED (Emergency Department) encephalopathic, hypoventilating requiring BiPAP after accidental administration of methadone at her nursing home. She is somnolent, arousable on the BiPAP/narcan infusion .We will continue narcan infusion given extended duration of symptoms, wean BiPAP as tolerated .The patient has an acute impairment of respiratory/neurologic organ systems such that there is a probability of imminent or life-threatening deterioration of the patient's condition. Narcan infusion, BiPAP, f/u (follow-up) blood gas diagnostic and or therapeutic interventions were performed to prevent further life-threatening deterioration or organ system failure . Review of a Physician Note for Resident #116, dated 8/17/23, revealed .This patient is readmitted from the hospital. The patient had a change in mental status. The patient was admitted to the hospital. The diagnoses applied by the hospitalist included accidental overdose .The patient was found to have methadone in her system. The patient is not on methadone. Unknown source of methadone present, drug error versus medication error . In an interview on 9/13/23 at 11:52 AM, Licensed Practical Nurse (LPN) Unit Care Coordinator I reported she took over the hall assignment on 8/15/23 at approximately 8:30 AM, which included Resident #116. LPN Unit Care Coordinator I reported the day shift nurse went home early due to illness. LPN Unit Care Coordinator I reported shortly after she took over the assignment, a CNA brought Resident #116 to her for an assessment. LPN Unit Care Coordinator I reported Resident #116 .definitely was not responding . and identified a change in level of consciousness. LPN Unit Care Coordinator I stated Resident #116 .would open her eyes and shut them immediately . LPN Unit Care Coordinator I reported she spoke with the physician and the guardian for Resident #116, and she (Resident #116) was sent to the emergency room . LPN Unit Care Coordinator I reported the hospital completed a drug test and Resident #116 tested positive for Methadone. LPN Unit Care Coordinator I reported Resident #116 does not take Methadone. LPN Unit Care Coordinator I reported there is only one resident on the unit who takes Methadone (Resident #113). LPN Unit Care Coordinator I reported Director of Nursing (DON) B was notified of the incident. LPN Unit Care Coordinator I reported she completed an investigation and brought .all the information that I could compile . to DON B. LPN Unit Care Coordinator I reported DON B planned to follow-up with the night shift nurse, LPN GGG. LPN Unit Care Coordinator I stated she .never heard the outcome . of that interview. Review of an Order Summary Report of all active, completed, and discontinued medications for Resident #116, printed 9/13/23, revealed no physician order for Methadone or any other opioid/controlled substance. Reviewed incident/accident reports for the past three months for Resident #116. No incident/accident report noted related to a significant medication error on 8/15/23. In an interview on 9/14/23 at 10:33 AM with Administrator A and DON B, Administrator A reported there is only one resident in the facility who takes Methadone (Resident #113). Administrator A reported the facility investigated the incident involving Resident #116 on 8/15/23, and determined there were no missed doses of Methadone that could have resulted in an overdose for Resident #116. Administrator A reported the resident at the facility with the ordered Methadone is alert and able to identify if any medications are missed. Administrator A reported facility staff audited the narcotics for the entire facility, checked Resident #116's room, reviewed Resident #116's ordered medications, and checked visitor logs. Administrator A stated .We really have no idea where that (the positive result for Methadone for Resident #116) would have come from . In an interview on 9/14/23 at 11:54 AM, LPN GGG reported she worked the night shift from 8/14/23 to 8/15/23 and was assigned to Resident #116. LPN GGG reported she had observed Resident #116 that morning and stated .She was fine .She was up and about . LPN GGG reported she was shocked to hear what had happened to Resident #116, and reported no one interviewed her or obtained a statement about the events of that shift related to Resident #116. LPN GGG reported Resident #116 does not take any narcotics, but she does have some ordered morning medications. LPN GGG stated .A lot of times I'll give her morning medications for the next shift .She's usually up pretty early . LPN GGG stated in regard to anything unusual with her morning medication pass .I know one of the mornings I though I had pulled his dose (referring to Resident #113 with an order for Methadone) .I remember I thought I had pulled it (the Methadone), then pulled it again. It wasn't there . LPN GGG reported it had been a busy morning between call lights, staffing, and trying to get residents up and about. LPN GGG reported Resident #116 has a tendency to .bug you until you giver her her pills . LPN GGG stated .maybe (I) got distracted when she (Resident #116) came for her meds . Review of the Controlled Substances Proof of Use forms for the controlled medication .Methadone HCL 10 mg tablet . for Resident #113, revealed three tablets of Methadone HCL 10 mg were signed out twice (a second dose was pulled) the morning of 8/15/23 at approximately 5:00 AM by LPN GGG. Review of the Controlled Substances Proof of Use form for the controlled medication .Clonazepam 0.5 mg tablet . for Resident #113, revealed one tablet of Clonazepam 0.5 mg was signed out twice (a second dose was pulled) the morning of 8/15/23 at approximately 5:00 AM by LPN GGG. Review of the Controlled Substances Proof of Use form for the controlled medication .Pregabalin (Lyrica) 225 mg capsule . for Resident #113, revealed one capsule of Pregabalin 225 mg was signed out twice (a second dose was pulled) the morning of 8/15/23 at approximately 5:00 AM by LPN GGG. Reviewed facility investigation into overdose incident involving Resident #116 on 8/15/23. Noted LPN GGG was not interviewed as part of the investigation. On 9/14/23, Administrator A was notified of an Immediate Jeopardy that began on 8/15/23 when Resident #116 experienced a significant medication error, which resulted in a Methadone overdose and hospitalization in the ICU on BiPAP with a Narcan drip. On 9/18/23, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. Resident #116 was sent to the hospital on 8/15/23 upon change in mental status and returned to the facility on [DATE]. 2. An audit was completed which identified only one resident in the facility on Methadone as of 9/14/23. 3. On 9/14/23, discussed with the Pharmacist regarding that with any narcotic taper, the Pharmacist will do a 30-day wean instead of a 21-day step. Will only send a month at a time and will decrease the number of narcotic cards and pink sheets which decreases the risk of medication error. 4. The facility is investigating the possibility of Pharmacy delivering a 15-day supply of controlled substances instead of a of 30-day supply. 5. Licensed Nursing Staff will be in-serviced on Medication Administration Policy which ensures medications are administered safely and appropriately per physician order to address residents' diagnoses and (Pharmacy Name) Clinical Nursing Note on F760 Significant Medication Errors by 9/15/23. Nursing staff will not be able to work until they have completed the training. As of September 15, 2023 at 7:25 PM, 21 out of 33 nurses have been educated. 6. Licensed Nursing Staff will be in-serviced on How to Do a Medication Error Investigation, creating a New Event for report process, and discussion on how to decrease interruptions during medication pass by 9/15/23. Nursing staff will not be able to work until they have completed the training. As of September 15, 2023 at 7:25 PM, 19 out of 33 nurses have been educated. 7. During medication error investigation training, it was presented that Interruptions during med pass can increase the risk of medication errors. Please be aware and work to minimize interruptions while you are preparing a resident's medications. All staff were sent a mass communication regarding refraining from interrupting nurses while preparing medications and unless a phone call for a nurse is time sensitive, to take a message. They too were made aware that decreasing interruptions decreases the risk of medication errors. 8. The Medication Administration Policy was reviewed by the DON and Regional Clinical Services Director and this is the policy that the nurses were educated on. 9. The facility Medical Director is aware of this plan and is in agreement on 9/15/23. Although the immediate jeopardy was removed on 9/15/23, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not Immediate Jeopardy due to the fact that education had not yet been completed and sustained compliance had not yet been verified by the State Agency.

This citation pertains to Intake # MI00139073. Based on observation, interview, and record review, the facility failed to ensure timely and appropriate wound care for a laceration obtained during a transfer in 1 of 3 residents (Resident #115) reviewed for accidents/hazards, resulting in delayed wound closure, hospitalization , and a wound infection. Findings include: .The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 20717-20719). Elsevier Health Sciences. Kindle Edition. Review of the policy/procedure Documentation & Assessment of Wounds, dated 3/31/23, revealed .A wound assessment/documentation is required to occur at a minimum 'weekly'. Nurses performing the treatment would perform a prn (as needed) assessment/documentation if noted change has occurred . Review of an Admission Record revealed Resident #115 was a female, with pertinent diagnoses which included dementia, high blood pressure, peripheral venous insufficiency, depression, muscle weakness, and debility. Review of a Minimum Data Set (MDS) assessment for Resident #115, with a reference date of 7/25/23, revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated severe cognitive impairment. Further review of this MDS assessment revealed Resident #115 required one person extensive assistance for transfers, with unsteady balance, only able to stabilize with staff assistance. Review of a current Care Plan for Resident #115 revealed the focus .(Resident #115) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) impaired mobility, muscle weakness, dementia with impaired cognition . revised 10/17/22, with interventions which included .TRANSFER: Assist x 1 with gait belt. Uses a standard w/c (wheelchair) when up . revised 10/17/22. In an observation and interview on 9/11/23 at 2:17 PM, Certified Nursing Assistant (CNA) DD and CNA HHH assisted Resident #115 with toileting in her room. Noted a wound dressing in place on Resident #115's left shin. Observed CNA DD and CNA HHH utilize a sit-to-stand lift to transfer Resident #115 from her wheelchair to the toilet. CNA HHH reported Resident #115 has utilized a sit-to-stand lift for transfers for over a year. CNA HHH stated in regard to Resident #115's left shin wound .there is a skin tear . Review of an Event Note for Resident #115, dated 8/11/23 at 6:28 PM, revealed .Resident noted with skin tear to left shin. Approximately 6cm in length. Cleansed with sterile normal saline. Surface wound noted. Pat dry with sterile gauze. Mepilex applied. Resident c/o (complained of) discomfort during wound cleansing. Tender to touch left leg . In an interview on 9/11/23 at 2:40 PM, Licensed Practical Nurse (LPN) O reported in regard to Resident #115's left shin wound .I came Saturday (8/12/23). When I took the dressing off I saw a wound I did not think was a small skin tear .Kind of huge to just have Mepilex . LPN O reported she contacted the Physician on 8/12/23 and received orders to send Resident #115 out to the hospital. LPN O reported the hospital staff called to ask what happened and .I didn't have any information . LPN O reported bone was visible in the wound and stated in regard to the dressing in place .I thought the treatment was not right . LPN O reported Resident #115 was sent to the local hospital, however .They couldn't do anything there . and Resident #115 ended up being sent to a larger hospital for treatment. LPN O described the wound as .kind of scary . and reported the edges of Resident #115's skin were folded, with muscle and bone exposed. LPN O reported Resident #115 appeared to be aware of the wound, and didn't want anyone to touch the area. LPN O reported she was initially asked to evaluate the wound by CNA III, and reported when she checked the medical record there was no order for a wound treatment in place. Review of an Order Summary Report for Resident #115, of all active, completed, and discontinued orders, revealed no physician order was obtained for a treatment to the left shin wound on 8/11/23. Review of a Health Status Note for Resident #115, dated 8/12/23 at 5:42 PM, revealed .resident had foam dressing to her left shin was saturated removed the foam dressing noted a wound very deep and white material exposed notified (Physician Name) he assess (sic) the wound ordered to send the resident to ER (emergency room ) for sutures. NOTIFIED DAUGHTER .she requested to send her mother to (Local Hospital Name). covered the wound with non adhesive pad and wrapped with kerlex (sic). notified on call nurse manager .transferred her to ER via (Ambulance Service Name) at 1500 (3:00 PM) . Review of a Health Status Note for Resident #115, dated 8/12/23 at 4:48 PM, revealed .received the call from ER spoke with charge nurse she said she was glad that we send her (Resident #115) out that seems like her wound is [NAME] (sic) deep to the shin bone she also said she may have to go to main hospital but he will keep us informed . Review of an Emergency Physician Documentation note for Resident #115, dated 8/12/23 at 6:58 PM, revealed .Patient is a [AGE] year-old female with a past medical history of dementia, debility, hypertension, hyperlipidemia .She comes to the emergency department today for a laceration to her left shin. Per EMS report, patient fell while being transferred yesterday and caught her left shin on unknown object. I spoke with nurse at facility .She stated that she went to care for the wound today. She unbandaged the wound and saw that the wound extended to the bone. She was not present when this incident happened, but she was very concerned about the severity of the wound .Physical Exam .Skin: Large laceration to left shin, approximately 7 cm, jagged in nature .it does appear to go to the bone .The wound is retracted, there is involved muscle visualized . Review of an Emergency Physician Documentation note for Resident #115, dated 8/12/23 at 8:46 PM, revealed .Patient is a [AGE] year-old female presenting to the emergency department today for wound to left lower extremity .Patient is demented, unable to obtain further history from her .It appears that the wound occurred yesterday while transferring the patient however was unable to speak with anyone who was present at the time of transfer to obtain further history .I am concerned about possible neglect as this is a very large wound extending to the bone, was not brought to medical attention until today .I did call and speak with (Physician Name) of the trauma service at (Hospital Name). The wound is very large, extending to the bone, retracted, happened greater than 24 hours ago, I do not feel it is appropriate to close the wound primarily here in the ER. She will need evaluation by trauma surgery due to the severity of the wound . Review of a Hospital Operative Report for Resident #115, dated 8/12/23 at 11:20 PM, revealed .Procedure: Laceration repair .Left leg laceration measured 7 cm x 5 cm with exposure of bone below .Laceration was irrigated with 100 cc of normal saline. Fascial layer was closed with 3-0 Vicryl in interrupted fashion. Skin was closed with 3-0 nylon with vertical mattress sutures. Incision was dressed with Xeroform, gauze, and wrapped with Kerlix .Patient tolerated repair without complication . Review of a Health Status Note for Resident #115, dated 8/13/23 at 2:38 PM, revealed .resident returned from hospital at around (1:50 PM) alert .dressing to left shin is intact dry old blood stain present . Review of a Physician Note for Resident #115, dated 8/14/23, revealed .This is a [AGE] year old .female who had major trauma to the left leg .transferred to (Hospital Name) for repair of a multilayer wound. Patient has not been started on any antibiotics. Patient has a more than 24 hour open wound, has a high risk for infection .Will start patient on Cipro (antibiotic) . In an interview on 9/13/23 at 9:24 AM, CNA III reported she witnessed the incident that caused Resident #115's laceration to her left shin. CNA III reported on 8/11/23, she and CNA HHH went to Resident #115's room to .get her up for the day . CNA III reported Resident #115 didn't want her to touch her, so CNA HHH assisted Resident #115 with a one person stand-pivot transfer from her bed to her wheelchair. CNA III reported she heard a thump and looked down to see a wound on Resident #115's left shin. CNA III reported Resident #115 did not fall, and was uncertain what her leg hit to cause the wound. CNA III stated the wound .looked terrible . and reported bone was visible. CNA III reported CNA HHH went to notify the nurse of the incident. CNA III stated in regard to Resident #115's wound .She should have went out (to the hospital) that day . In an interview on 9/13/23 at 10:52 AM, Registered Nurse (RN) FFF reported she was the nurse assigned to Resident #115 on 8/11/23. RN FFF reported Resident #115 was trying to get out of bed so she asked the CNA's to go in and assist. RN FFF stated .I think they did not use the proper transfer technique . RN FFF reported a CNA notified her after the transfer that Resident #115 had a skin tear. RN FFF stated in regard to Resident #115's wound .It was bleeding but it was a surface wound .It wasn't deep. I cleaned it with saline and I put a dressing on it . RN FFF reported she did not notify the Physician of the wound or obtain an order for a wound treatment. In an interview on 9/13/23 at 11:52 AM, LPN Unit Care Coordinator I reported she was notified of Resident #115's left shin wound on 8/12/23 by LPN O. LPN Unit Care Coordinator I stated .The CNA had brought it to her attention that there was a dressing on her left shin area . LPN Unit Care Coordinator I reported it was a .significant injury . and reported she was not notified of the incident on 8/11/23. LPN Unit Care Coordinator I reported she initiated an incident/accident report related to Resident #115's wound on 8/12/23, and directed LPN O to contact the Physician and get an order for a wound treatment. LPN Unit Care Coordinator I reported the Physician gave orders to send Resident #115 to the hospital. LPN Unit Care Coordinator I reported Resident #115's left shin wound later became infected, resulting in the need for antibiotics. Reviewed of an Incident/Accident Report for Resident #115, dated 8/11/23 at 10:30 AM, revealed .Incident Description .(Resident #115) was noted with a skin tear to left shin, approximately 6 cm in length .Immediate Action Taken .Nurse cleansed skin tear with NS (Normal Saline), pat dried and mepilix (sic) applied .Resident Taken to Hospital? N (No) .Predisposing Situation Factors .During Transfer . Noted the staff member who prepared the report was LPN Unit Care Coordinator I. In an interview on 9/14/23 at 10:25 AM, CNA HHH reported she completed Resident #115's transfer from her bed to her wheelchair on 8/11/23, which resulted in an injury to her left shin. CNA HHH stated .her (Resident #115's) leg scraped against mine . CNA HHH described the wound as .a little skin tear, maybe an inch . and reported no bleeding from the wound. In an observation and interview on 9/18/23 at 1:27 PM, observed wound care for Resident #115 completed by LPN O. Observed a large healing laceration to Resident #115's left shin. Observed LPN O cleanse the wound with normal saline, apply a wet-to-dry dressing, and wrap the area with a bandage. LPN O reported when she first observed Resident #115's left shin wound on 8/12/23 .it was so much worse . LPN O reported Resident #115 received several rounds of antibiotics to treat a wound infection to the left shin wound. Review of a Health Status Note for Resident #115, dated 8/14/23 at 6:51 PM, revealed .new order for cipro 500 mg (antibiotic) received for left shin wound . Review of a Health Status Note for Resident #115, dated 8/17/23 at 6:44 PM, revealed .atb (antibiotics) continued as ordered for left shin infected skin (tear) .dressing changed warm to the touch .distal to the wound extremity is slightly red .(serosanguineous) drainage noted resident does c/o (complain of) pain during the dressing change . Review of an Infection Note for Resident #115, dated 8/19/23 at 11:05 PM, revealed .continues on antibiotic therapy for leg wound with no adverse reactions noted. Lower extremity swollen and sore per patient . Review of a Health Status Note for Resident #115, dated 8/21/23 at 1:37 PM, revealed .Call placed to (Hospital Surgical Department) and spoke with a representative in regards to our concerns with the condition of her LLE (Left Lower Extremity) ie: area is warm to touch, increased edema to leg into feet/toes, suture line has a darken area (Bluish/purpura) and skinsloughing at the top of the incision line. This writer explained to the (representative) that she has been on cipro (an antibiotic) and today being her last day. She took the info and phoned (Physician Name) and (Physician Name) returned (the call) stating that if we are concerned with an infection then to send her to the ER and to continue with the appt (appointment) with them on 8/29. Nurse aware and will pass onto the Dr this afternoon . Review of a Health Status Note for Resident #115, dated 8/21/23 at 2:11 PM, revealed .resident is alert and oriented to self atb (antibiotics) continued as ordered for left leg wound infection .dressing changed brownish drainage .blisters around the suture line .macerated around the incision line . Review of a Health Status Note for Resident #115, dated 8/21/23 at 7:00 PM, revealed .(Physician Name) in to see residents wound on left lower extremity. Orders received to send to (Hospital emergency room ) for further evaluation and treatment. Daughter .called and informed of transfer. 911 called and transferred resident to (Hospital Name) ER . Review of a Health Status Note for Resident #115, dated 8/21/23 at 10:58 PM, revealed .(Hospital Name) ER doctor called and said patient was going to be admitted for further treatment . Review of the Census information revealed Resident #115 readmitted to the facility on [DATE]. Review of a Health Status Note for Resident #115, dated 9/8/23 at 5:51 AM, revealed .CNA reported residents left foot red and swollen. Upon assessment noted swelling/redness and warmth to left foot beneath bandaging. Notified oncoming nurse and nurse manager and put on doctors list to be addressed. Denies pain at this time. Left leg elevated up on pillows. Pedal pulse present . Review of a Health Status Note for Resident #115, dated 9/8/23 at 9:21 AM, revealed .Charge nurse notified this writer per her assessment of (Resident #115's) LLE this leg is red, warm to touch. Informed (Physician Name) of the above and N.O. (New Orders) for tx (treatment) include bactrim DS x 15 days and Doxycycline x 10days (two different antibiotics) and follow up with surgical group .

This citation pertains to Intake # MI00139073. Based on observation, interview, and record review, the facility failed to utilize a gait belt to ensure a safe transfer in 1 of 3 residents (Resident #115) reviewed for accidents/hazards, resulting in a leg laceration, hospitalization , and a wound infection. Findings include: .A gait belt provides a secure way to steady or guide patients who need assistance with ambulation when transferring or walking . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 25912-25913). Elsevier Health Sciences. Kindle Edition. Review of the policy/procedure Incident and Reportable Event Management, dated 9/14/23, revealed .The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents . Review of an Admission Record revealed Resident #115 was a female, with pertinent diagnoses which included dementia, high blood pressure, peripheral venous insufficiency, depression, muscle weakness, and debility. Review of a Minimum Data Set (MDS) assessment for Resident #115, with a reference date of 7/25/23, revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated severe cognitive impairment. Further review of this MDS assessment revealed Resident #115 required one person extensive assistance for transfers, with unsteady balance, only able to stabilize with staff assistance. Review of a current Care Plan for Resident #115 revealed the focus .(Resident #115) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) impaired mobility, muscle weakness, dementia with impaired cognition . revised 10/17/22, with interventions which included .TRANSFER: Assist x 1 with gait belt. Uses a standard w/c (wheelchair) when up . revised 10/17/22. In an observation and interview on 9/11/23 at 2:17 PM, Certified Nursing Assistant (CNA) DD and CNA HHH assisted Resident #115 with toileting in her room. Noted a wound dressing in place on Resident #115's left shin. Observed CNA DD and CNA HHH utilize a sit-to-stand lift to transfer Resident #115 from her wheelchair to the toilet. CNA HHH reported Resident #115 has utilized a sit-to-stand lift for transfers for over a year. CNA HHH stated in regard to Resident #115's left shin wound .there is a skin tear . Review of an Event Note for Resident #115, dated 8/11/23 at 6:28 PM, revealed .Resident noted with skin tear to left shin. Approximately 6cm in length. Cleansed with sterile normal saline. Surface wound noted. Pat dry with sterile gauze. Mepilex applied. Resident c/o (complained of) discomfort during wound cleansing. Tender to touch left leg . No documentation noted to indicate if the Physician or family/responsible party were notified of the wound. In an interview on 9/11/23 at 2:40 PM, Licensed Practical Nurse (LPN) O reported in regard to Resident #115's left shin wound .I came Saturday (8/12/23). When I took the dressing off I saw a wound I did not think was a small skin tear .Kind of huge to just have Mepilex . LPN O reported she contacted the Physician on 8/12/23 and received orders to send Resident #115 out to the hospital. LPN O reported the hospital staff called to ask what happened and .I didn't have any information . LPN O reported bone was visible in the wound and stated in regard to the dressing in place .I thought the treatment was not right . LPN O reported Resident #115 was sent to the local hospital, however .They couldn't do anything there . and Resident #115 ended up being sent to a larger hospital for treatment. LPN O described the wound as .kind of scary . and reported the edges of Resident #115's skin were folded, with muscle and bone exposed. LPN O reported Resident #115 appeared to be aware of the wound, and didn't want anyone to touch the area. LPN O reported she was initially asked to evaluate the wound by CNA III, and reported when she checked the medical record there was no order for a wound treatment in place. Review of an Order Summary Report for Resident #115, of all active, completed, and discontinued orders, revealed no physician order was obtained for a treatment to the left shin wound on 8/11/23. Review of a Health Status Note for Resident #115, dated 8/12/23 at 5:42 PM, revealed .resident had foam dressing to her left shin was saturated removed the foam dressing noted a wound very deep and white material exposed notified (Physician Name) he assess (sic) the wound ordered to send the resident to ER (emergency room ) for sutures. NOTIFIED DAUGHTER .she requested to send her mother to (Local Hospital Name). covered the wound with non adhesive pad and wrapped with kerlex (sic). notified on call nurse manager .transferred her to ER via (Ambulance Service Name) at 1500 (3:00 PM) . Review of a Health Status Note for Resident #115, dated 8/12/23 at 4:48 PM, revealed .received the call from ER spoke with charge nurse she said she was glad that we send her (Resident #115) out that seems like her wound is [NAME] (sic) deep to the shin bone she also said she may have to go to main hospital but he will keep us informed . Review of an Emergency Physician Documentation note for Resident #115, dated 8/12/23 at 6:58 PM, revealed .Patient is a [AGE] year-old female with a past medical history of dementia, debility, hypertension, hyperlipidemia .She comes to the emergency department today for a laceration to her left shin. Per EMS report, patient fell while being transferred yesterday and caught her left shin on unknown object. I spoke with nurse at facility .She stated that she went to care for the wound today. She unbandaged the wound and saw that the wound extended to the bone. She was not present when this incident happened, but she was very concerned about the severity of the wound .Physical Exam .Skin: Large laceration to left shin, approximately 7 cm, jagged in nature .it does appear to go to the bone .The wound is retracted, there is involved muscle visualized . Review of an Emergency Physician Documentation note for Resident #115, dated 8/12/23 at 8:46 PM, revealed .Patient is a [AGE] year-old female presenting to the emergency department today for wound to left lower extremity .Patient is demented, unable to obtain further history from her .It appears that the wound occurred yesterday while transferring the patient however was unable to speak with anyone who was present at the time of transfer to obtain further history .I am concerned about possible neglect as this is a very large wound extending to the bone, was not brought to medical attention until today .I did call and speak with (Physician Name) of the trauma service at (Hospital Name). The wound is very large, extending to the bone, retracted, happened greater than 24 hours ago, I do not feel it is appropriate to close the wound primarily here in the ER. She will need evaluation by trauma surgery due to the severity of the wound . Review of a Hospital Operative Report for Resident #115, dated 8/12/23 at 11:20 PM, revealed .Procedure: Laceration repair .Left leg laceration measured 7 cm x 5 cm with exposure of bone below .Laceration was irrigated with 100 cc of normal saline. Fascial layer was closed with 3-0 Vicryl in interrupted fashion. Skin was closed with 3-0 nylon with vertical mattress sutures. Incision was dressed with Xeroform, gauze, and wrapped with Kerlix .Patient tolerated repair without complication . Review of a Health Status Note for Resident #115, dated 8/13/23 at 2:38 PM, revealed .resident returned from hospital at around (1:50 PM) alert .dressing to left shin is intact dry old blood stain present . Review of a Physician Note for Resident #115, dated 8/14/23, revealed .This is a [AGE] year old .female who had major trauma to the left leg .transferred to (Hospital Name) for repair of a multilayer wound. Patient has not been started on any antibiotics. Patient has a more than 24 hour open wound, has a high risk for infection .Will start patient on Cipro (antibiotic) . In an interview on 9/13/23 at 9:24 AM, CNA III reported she witnessed the incident that caused Resident #115's laceration to her left shin. CNA III reported on 8/11/23, she and CNA HHH went to Resident #115's room to .get her up for the day . CNA III reported Resident #115 didn't want her to touch her, so CNA HHH assisted Resident #115 with a one person stand-pivot transfer from her bed to her wheelchair. CNA III reported she heard a thump and looked down to see a wound on Resident #115's left shin. CNA III reported Resident #115 did not fall, and was uncertain what her leg hit to cause the wound. CNA III stated the wound .looked terrible . and reported bone was visible. CNA III reported CNA HHH went to notify the nurse of the incident. CNA III stated in regard to Resident #115's wound .She should have went out (to the hospital) that day . CNA III reported CNA HHH did not utilize a gait belt for the transfer. In an interview on 9/13/23 at 10:52 AM, Registered Nurse (RN) FFF reported she was the nurse assigned to Resident #115 on 8/11/23. RN FFF reported Resident #115 was trying to get out of bed so she asked the CNA's to go in and assist. RN FFF stated .I think they did not use the proper transfer technique . RN FFF reported a CNA notified her after the transfer that Resident #115 had a skin tear. RN FFF stated in regard to Resident #115's wound .It was bleeding but it was a surface wound .It wasn't deep. I cleaned it with saline and I put a dressing on it . RN FFF reported she did not complete an incident/accident report related to the wound on Resident #115's left shin. RN FFF stated .I wrote a nurse's note . In an interview on 9/13/23 at 11:52 AM, LPN Unit Care Coordinator I reported she was notified of Resident #115's left shin wound on 8/12/23 by LPN O. LPN Unit Care Coordinator I stated .The CNA had brought it to her attention that there was a dressing on her left shin area . LPN Unit Care Coordinator I reported it was a .significant injury . and reported she was not notified of the incident on 8/11/23. LPN Unit Care Coordinator I reported she initiated an incident/accident report related to Resident #115's wound on 8/12/23, and directed LPN O to contact the Physician and get an order for a wound treatment. LPN Unit Care Coordinator I reported the Physician gave orders to send Resident #115 to the hospital. LPN Unit Care Coordinator I reported Resident #115 requires a one-person staff assist for transfers using a gait belt. LPN Unit Care Coordinator I reported she was unsure if a gait belt was utilized for Resident #115's transfer on 8/11/23 that resulted in an injury. LPN Unit Care Coordinator I reported Resident #115's left shin wound later became infected, resulting in the need for antibiotics. Reviewed of an Incident/Accident Report for Resident #115, dated 8/11/23 at 10:30 AM, revealed .Incident Description .(Resident #115) was noted with a skin tear to left shin, approximately 6 cm in length .Immediate Action Taken .Nurse cleansed skin tear with NS (Normal Saline), pat dried and mepilix (sic) applied .Resident Taken to Hospital? N (No) .Predisposing Situation Factors .During Transfer . Noted the staff member who prepared the report was LPN Unit Care Coordinator I. The report did not indicate any issues/noncompliance related to the transfer. In an interview on 9/14/23 at 10:25 AM, CNA HHH reported she completed Resident #115's transfer from her bed to her wheelchair on 8/11/23, which resulted in an injury to her left shin. CNA HHH stated .her (Resident #115's) leg scraped against mine . CNA HHH described the wound as .a little skin tear, maybe an inch . and reported no bleeding from the wound. In an interview on 9/14/23 at 10:33 AM, with Administrator A and Director of Nursing (DON) B, DON B reported she was notified of Resident #115's wound on 8/14/23 during morning meeting. DON B reported she was told the wound occurred .during transfer . DON B reported Resident #115 requires one person staff assistance for transfers with a gait belt. In an observation and interview on 9/18/23 at 1:27 PM, observed wound care for Resident #115 completed by LPN O. Observed a large healing laceration to Resident #115's left shin. Observed LPN O cleanse the wound with normal saline, apply a wet-to-dry dressing, and wrap the area with a bandage. LPN O reported when she first observed Resident #115's left shin wound on 8/12/23 .it was so much worse . LPN O reported Resident #115 received several rounds of antibiotics to treat a wound infection to the left shin wound. Review of a Health Status Note for Resident #115, dated 8/14/23 at 6:51 PM, revealed .new order for cipro 500 mg (antibiotic) received for left shin wound . Review of a Health Status Note for Resident #115, dated 8/17/23 at 6:44 PM, revealed .atb (antibiotics) continued as ordered for left shin infected skin (tear) .dressing changed warm to the touch .distal to the wound extremity is slightly red .(serosanguineous) drainage noted resident does c/o (complain of) pain during the dressing change . Review of an Infection Note for Resident #115, dated 8/19/23 at 11:05 PM, revealed .continues on antibiotic therapy for leg wound with no adverse reactions noted. Lower extremity swollen and sore per patient . Review of a Health Status Note for Resident #115, dated 8/21/23 at 1:37 PM, revealed .Call placed to (Hospital Surgical Department) and spoke with a representative in regards to our concerns with the condition of her LLE (Left Lower Extremity) ie: area is warm to touch, increased edema to leg into feet/toes, suture line has a darken area (Bluish/purpura) and skinsloughing at the top of the incision line. This writer explained to the (representative) that she has been on cipro (an antibiotic) and today being her last day. She took the info and phoned (Physician Name) and (Physician Name) returned (the call) stating that if we are concerned with an infection then to send her to the ER and to continue with the appt (appointment) with them on 8/29. Nurse aware and will pass onto the Dr this afternoon . Review of a Health Status Note for Resident #115, dated 8/21/23 at 2:11 PM, revealed .resident is alert and oriented to self atb (antibiotics) continued as ordered for left leg wound infection .dressing changed brownish drainage .blisters around the suture line .macerated around the incision line . Review of a Health Status Note for Resident #115, dated 8/21/23 at 7:00 PM, revealed .(Physician Name) in to see residents wound on left lower extremity. Orders received to send to (Hospital emergency room ) for further evaluation and treatment. Daughter .called and informed of transfer. 911 called and transferred resident to (Hospital Name) ER . Review of a Health Status Note for Resident #115, dated 8/21/23 at 10:58 PM, revealed .(Hospital Name) ER doctor called and said patient was going to be admitted for further treatment . Review of the Census information revealed Resident #115 readmitted to the facility on [DATE]. Review of a Health Status Note for Resident #115, dated 9/8/23 at 5:51 AM, revealed .CNA reported residents left foot red and swollen. Upon assessment noted swelling/redness and warmth to left foot beneath bandaging. Notified oncoming nurse and nurse manager and put on doctors list to be addressed. Denies pain at this time. Left leg elevated up on pillows. Pedal pulse present . Review of a Health Status Note for Resident #115, dated 9/8/23 at 9:21 AM, revealed .Charge nurse notified this writer per her assessment of (Resident #115's) LLE this leg is red, warm to touch. Informed (Physician Name) of the above and N.O. (New Orders) for tx (treatment) include bactrim DS x 15 days and Doxycycline x 10days (two different antibiotics) and follow up with surgical group .

This citation pertains to intake #MI00139066 Based on observation, interview, and record review the facility failed to prevent the use of a physical restraint in 1 (Resident #114) of 1 resident reviewed for restraint use, resulting in potential for injury, seclusion, and/or psychological harm. Findings include: Review of an Admission Record revealed Resident #114 had pertinent diagnoses which included repeated falls, dementia, Alzheimer's disease, and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #114, with a reference date of 8/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #114 was severely cognitively impaired. During an observation on 9/11/23 at 12:06 PM Resident #114 was in bed with the head of bed elevated, with a tray table over the bed and his lap with lunch present. Resident #114 was eating. Hoyer sling was present in a high back wheelchair in the room. Resident #114 was unable to confirm if that was his wheelchair. During an interview on 9/11/23 at 1:29 PM, Certified Nurse Assistant (CNA) C was asked if she recalled a situation that involved Resident #114 and him being restrained to his wheelchair that was reported on 7/18/23. CNA C stated Yeah, that was me, I did that. CNA C reported that Resident #114 was found on the floor next to his bed and CNA C was assisted by CNA D to transfer Resident #114 into his wheelchair using a mechanical lift (hoyer) with a sling. CNA C reported that the hoyer sling was left under the resident after the transfer. CNA C stated I was showing the nurse how big the sling was by putting the leg straps from between his legs, across his shoulder (in an x fashion across his body) and hooked the loops of the sling onto the handles of his wheelchair. I was making a joke about how big the sling was and he rolled away from me, and I forgot I put the straps over his shoulder and onto the handles. CNA C reported that Resident #114 was not assisted to the bathroom during her shift. CNA C reported that Resident #114 would not have been able to remove the sling loops from the wheelchair handles. CNA C reported that Resident #114 was a high fall risk. During an interview on 9/11/23 at 1:51 PM, CNA Z reported that Resident #114 was assigned to her on her shift on 7/18/23. CNA Z reported that Resident #114 was found on the floor, and she asked CNA C and CNA D for help to transfer Resident #114 via hoyer and sling. CNA Z reported that CNA C and CNA D completed the hoyer transfer for Resident #114. CNA Z reported that it was an agency nurse assigned that night. CNA Z reported that Resident #114 was able to stand with assistance. CNA Z reported that Resident #114 is a high fall risk. During a telephone interview on 9/11/23 at 2:14 PM, Family Member (FM) ZZ reported she was notified by Infection Preventionist (IP) G that Resident #114 was transferred with a hoyer lift and the belt was left in his wheelchair. FM ZZ reported she was told Resident #114 was restrained in his wheelchair. FM ZZ reported she was very angry when she heard Resident #114 was restrained to his wheelchair. FM ZZ reported that Resident #114 is able to stand, and staff transfer him without a hoyer when she is present. FM ZZ reported that Resident #114 gets up on his own frequently. Review of Care Plan for Resident #114 revealed ADL (activities of daily living) assistance and therapy services needed to maintain or attain highest level of function. Resident wishes to attain prior level of function. Transfer x 2 person assist, initiated 5/2/23. Functional goal care plan . has limited physical mobility r/t (related to) gait difficulty.will maintain current level of mobility of walking 50-200 ft using 4 wheeled walker with gait belt and 1assist through review date, Walking program #2 . will participate with his restorative program by ambulating (walking) 50-200 ft using 4 wheeled walker with assist and gait belt for at least 15 minutes daily x 3-5 days a week revision and initiated 7/10/23 . is at risk for falls initiated on 5/2/23, orient resident to room, supervised at all times when in the bathroom initiated 5/2/23. Review of Kardex for Resident #114 revealed .Transfer x2 person assist, assist with toileting as needed. Review of Progress Notes for Resident #114 revealed no noted documentation of transfer status change to a mechanical lift. During an observation on 9/11/23 at 2:48 PM Resident #114 was in bed with the head of bed elevated, with a tray table over the bed over his lap. Hoyer sling was present in a high back wheelchair in the room. Resident #114 was sleeping. During a telephone interview on 9/11/23 at 3:38 PM CNA D reported Resident #114 was sitting on the floor on the night on 7/18/23 and she assisted CNA C to use the hoyer to transfer Resident #114 to his wheelchair. CNA D reported that Resident #114 was unclothed at the time of the transfer, and she retrieved a gown to place on him once he was sitting in his wheelchair. CNA D reported that the hoyer sling was left under Resident #114 in his wheelchair. CNA D reported that Resident #114 is a hoyer lift for transfers. CNA D reported when she put the gown on Resident #114 the hoyer sling was still in his wheelchair. CNA D reported that Resident #114 falls often. During an interview on 9/12/23 at 11:37 AM, Director of Rehab Services (DRS) MM reported that therapy will evaluate residents for a transfer status and communicate to the unit mangers, minimum data set nurse, case manager, and/or floor nurses. The floor nurses can request an evaluation of a resident's transfer status. DRS MM denied receiving any request for transfer status evaluation of Resident #114. During an interview on 9/12/23 at 12:10 PM, IP G reported Resident #114 is a hoyer transfer. IP G reported that an agency nurse downgraded Resident #114's transfer status but didn't follow the proper steps to involve the therapy department. During an interview on 9/12/23 at 2:46 PM, CNA X reported that she saw Resident #114 on the morning of 7/18/23 restrained to his wheelchair. CNA X reported she located Resident #114 on the morning of 7/18/23 sitting in his wheelchair, by the barber shop, asleep. CNA X reported Resident #114 was wearing a gown, with a hoyer sling behind him. CNA X reported she saw the hoyer sling leg straps were coming up between Resident #114's legs, crossed over his chest in the shape of an X over his shoulders, and tied to the push handles of his wheelchair. CNA X reported that the hoyer sling was next to Resident #114's chest and the gown was over the hoyer sling. CNA X reported she told CNA C and CNA D that the hoyer sling could not be tied to the wheelchair like that and the response of CNA D was that Resident #114 falls too much and CNA C laughed. Review of Resident #114 incident reports revealed Resident #114 had experienced 12 falls between 5/2/23 and 9/12/23. During an interview on 9/12/23 at 3:03 PM Agency Nurse/Licensed Practical Nurse (AN/LPN) R reported she worked on 7/18/23 and recalled seeing Resident #114 up in his wheelchair, but no other details. AN/LPN R reported Resident #114 was a hoyer lift for transfer, could propel himself in his wheelchair, did have frequent falls, and was not combative with care. During a telephone interview on 9/12/23 at 5:08 PM, FM ZZ reported Resident #114 would have been p***ed off if he had been restrained to a wheelchair. He would have fought and swung his arms to be released, and he would have cried because he would not understand why he was being tied down. FM ZZ reported that Resident #114 gets up a lot when he isn't supposed to. FM ZZ reported when she arrived at the facility on 7/18/23 to visit, IP G asked her into his office and told her that Resident #114 had been restrained with a hoyer sling in his wheelchair last night. During an interview on 9/13/23 9:30AM, IP G reported that he did have a conversation with Resident #114 family member after the situation on 7/18/23. IP G reported that he told FM ZZ that there was a potential for abuse towards Resident #114. IP G reported that he told FM ZZ that it was possible that Resident #114 was restrained to his wheelchair with a hoyer sling last night. During an observation and interview on 9/18/23 at 10:15 AM, Resident #114 was sitting in a high back wheelchair by the Bridge Nurse's Station. CNA W and LPN M reported that Resident #114 had used this same high back wheelchair since May of 2023. Review of Witness Interview/ Statement Form provided by CNA C on 7/18/23 revealed . straps were over his legs, super big sling, didn't know what to do w/ (with) it . I put it up on the handles (bottom straps) . attached to the push handles it was me that did it . Review of Witness Interview/Statement Form provided by CNA D on 7/18/23 revealed . I came back sling was up above his shoulders, he was naked . I got him a gown. Put it on him, did not remove sling/straps put gown over him & straps. He was wheeling back and forth throughout building all night. No use of bathroom . don't think we toileted him or changed him all NOC (night) . During a telephone interview on 9/18/23 at 4:19 PM Senior Executive Director (SED) DDD (who completed the investigation) reported when I spoke to CNA C she stated she was having difficulty removing the sling from the resident and she told me she tried to toss the leg straps over his shoulders, but they didn't stay because it is a high back wheelchair. SED DDD reported that CNA C reported that she did it again and it connected with the handle of the wheelchair, and it stayed. SED DDD reported that CNA C stated it was very loose. The strap over his shoulder was loose and they stayed in place by being hooked on the handles. Review of facility policy Physical Restraint Use reviewed 9/12/23 revealed The intent is for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience, prohibits the use of physical restraints to unnecessarily inhibit the resident's freedom of movement or activity . definition of physical restraint- Any manual method of physical or mechanical device, equipment, or material that meets all of the following criteria: a. is attached or adjacent to the resident's body, b. cannot be removed easily by the resident (meaning it can be removed intentionally by the resident in the same manner as it was applied by the staff); and c. Restricts the resident's freedom of movement or normal access to his/her body .

Based on interview and record review the facility failed to keep residents free from significant medication errors for 1 of 8 residents (Resident #28) reviewed for administration of antipsychotic medications, resulting in a oversedation, loss of focus, time and the ability to eat and sleep as usual and the potential for increased psychiatric behaviors, delayed efficacy of medication, and the risk of severe [CONDITION(S)] (absolute [CONDITION(S)] count (ANC) less than 500/uL), can lead to serious and fatal infections .) associated with [MEDICATION(S)] treatment, as well as a change in condition for Resident #28. Findings include: Review of the Antipsychotic Medication-[MEDICATION(S)] protocol revealed: The [MEDICATION(S)] REMS (Risk Evaluation and Mitigation Strategy) a safety program required by the Food and Drug Administration (FDA) to manage the risk of severe [CONDITION(S)] associated with [MEDICATION(S)] treatment .Severe [CONDITION(S)] (absolute [CONDITION(S)] count (ANC) less than 500/uL), can lead to serious and fatal infections .) https://www.newclozapinerems.com/home . Resident #28 Review of an Admission Record revealed Resident #28 was originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #28, with a reference date of 8/7/22 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #28 was cognitively intact. In an interview on 10/16/22 at 12:07 PM., Resident #28 reported staff nurses missed about 4 days of his antipsychotic medication [MEDICATION(S)] because they missed the laboratory blood draw necessary to receive the medication [MEDICATION(S)] from the pharmacy. Resident #28 reported when he goes without that medication [MEDICATION(S)] he looses all focus, doe not eat, cannot sleep, becomes agitated and looses track of time and awareness of surroundings. Resident #28 reported he if goes without the [MEDICATION(S)] too long he begins to get bad thoughts. Resident #28 reported after missing the medication [MEDICATION(S)] for days, and then starting back up on the medication it can take another week to get regulated on how he feels. Resident #28 I don't like missing my medications, especially that one, it ([MEDICATION(S)]) is a very important one for me (Resident #28). Resident #28 reported he has been taking 300 mg of [MEDICATION(S)] for a while, and the medication itself for over [AGE] years. Review of Resident #28's Electronic Medical Record(EMR) revealed: Physicians Order-(Resident #28) Order Summary: 8/3/2022 21:00 [MEDICATION(S)] Tablet 100 MG (antipsychotic medication) Give 3 100 mg tablets by mouth at bedtime related to [CONDITION(S)] Review of Resident #28's Electronic Medical Record (EMR) revealed: Progress Note dated 9/23/22 at 22:03 PM., (Resident #28) received [MEDICATION(S)] tonight for the first time in a few weeks, around 1800, at 2145 (Resident #28) appeared off, snoring with eyes shut, but requesting to go to the bathroom, (Resident #28) cannot sit up in bed, generalized weakness but can follow commands. VS WNL (vital signs within normal limits). will continue to monitor (this progress note was documented by Licensed Practical Nurse (LPN) RR) Review of Resident #28's EMR revealed no order for monthly CBC/ANC (complete blood count/absolute [CONDITION(S)] count) in Resident #28 EMR, nor did the facility provide the order once requested on 10/17/22 at 3:00 PM from Registered Nurse/Unit Manager (RN/UM) Q. Review of Resident #28's EMR revealed no Pharmacy Recommendations in Resident #28's EMR. In an interview on 10/17/22 at 3:02 PM., Registered Nurse/Unit Manager (RN/UM) Q reported the pharmacy does monthly medication review and puts in recommendations including blood levels. RN/UM Q reported the Progress Note dated 9/23/22 at 22:03 PM was not (Resident #28's) normal behavior. The progress note dated 9/23/22 indicated that something was wrong with (Resident #28) that evening. RN/UM Q reported that was not his (Resident #28's) normal affect., (Resident #28's) can usually sit up. RN/UM Q reported she was unaware of the need for [MEDICATION(S)] to have monthly CBC/ANC lab draws/monitoring. RN/UM Q reported she was unaware if (Resident #28's) went without his [MEDICATION(S)] for weeks or not. RN/UM Q reported that the progress note dated 9/23/22 would indicated that something quite serious may have been going on that evening with (Resident #28's), but she (RN/UM) Q had not heard of that in any report since that progress note had been put into (Resident #28's) EMR. In an interview on 10/17/22 at 3:15 PM., Nurse Practitioner (NP) VV reported that [MEDICATION(S)] (antipsychotic medication) was a regulated medication and must have a Complete Blood Count (CBC/ANC) lab draws (per protocol for each individual patient/resident prescribed [MEDICATION(S)]) before the medication can be re-ordered and delivered from the pharmacy. NP VV reported it is extremely important to monitor for this medication due to the fact that this drug ([MEDICATION(S)]) can put can cause neutrophils in the blood to significantly decreased, causing severe [CONDITION(S)] which can result in the body becoming increasingly prone to serious infections. In an interview on 10/18/22 at 1:10 PM.,Pharmacist (Phrm) DDD reported in the pharmacy system for the facility (name omitted) (Resident #28) prescription was showing that [MEDICATION(S)] 100 mg tables were shipped out on 8/4/22 in 3 packages of 28 tablets for a total of 84 tablets that were delivered. Phrm DDD reported the next shipment to the facility for (Resident #28) was not shipped/delivered to the facility until 9/22/22 for 3 packages of 28 tablets totaling 84 tablets. Phrm DDD reported the medication is regulated by the The [MEDICATION(S)] REMS (Risk Evaluation and Mitigation Strategy) system. Phrm DDD reported the reason (Resident #28) did not get his [MEDICATION(S)] prior to 9/22/22 was due to the REMS registry not having laboratory (blood work WBC/ANC) results) required to dispense the [MEDICATION(S)] medication. Phrm DDD reported all pharmacists/pharmacy dispensing [MEDICATION(S)], and all prescriber's/physicians prescribing [MEDICATION(S)] are required to be registered with the REMS registry and the blood-work (WBC/ANC) must be received for the pharmacy to dispense the medication to any patient taking [MEDICATION(S)]. Pharm DDD reported (Resident #28's) lab work (WBC) was not received/available to him (facility pharmacy consultant) until 9/19/22 in which then the medication was prepared and delivered to the facility where (Resident #28) resides. Phrm DDD reported he had no notes in his system of staff calling or inquiring about the medication ([MEDICATION(S)]) for (Resident #28) not being available. Phrm DDD reported typically that is something that he would have caught on his monthly Monthly Medication Regimen Reviews (MMRR) for the facility residents, but due to the fact (Resident #28) was a newer admission, his MMRR would not have been due until later in September 2022. Phrm DDD reported this incident is something of extremely high importance he will educate the facility on going forward. In an interview on 10/18/22 at 1:49 PM., Resident #28 reported he is about due for my blood work now. Resident #28 reported when he missed the doses of [MEDICATION(S)] a few weeks ago he lost all focus, couldn't think straight, and couldn't eat or sleep. Resident #28 reported he has been on the medication ([MEDICATION(S)]) for a long time and without it he get extremely dis-regulated. Resident #28 reported it is very important to get the lab work completed because without it, he cannot get the medication ([MEDICATION(S)]). In an interview on 10/18/22 at 1:54 PM., LPN/UCC - Unit Care Coordinator PP reported he was unaware of the REMS registry, and not familiar with the [MEDICATION(S)] medication regulations and need for bloodwork. LPN/UCC PP reported he found out yesterday that the nursing staff are suppose to be monitoring the medication, and ensuring Resident #28 gets his monthly WBC/ANC in order to receive the [MEDICATION(S)] medication. In an interview on 10/18/22 at 2:40 PM., LPN RR reported he worked 9/23/22 and had put the progress note in about (Resident #28) not receiving his [MEDICATION(S)] for a couple weeks. LPN RR reported that evening he gave the 3-100 mg tablets of [MEDICATION(S)] to (Resident #28) and shortly afterwards he (Resident #28) was acting really weird. LPN RR reported the [MEDICATION(S)] was given to (Resident #28) about 8-PM. LPN RR reported the Certified Nurse Aide (CNA) had come to him (LPN RR) about (Resident #28's) behavior/condition which was completely out of the ordinary for him (Resident #28) per the CNA. LPN RR reported he recalls the CNA was concerned that he (Resident #28) was acting odd shortly after the medication administration, and he (Resident #28) couldn't keep his eyes open. LPN RR reported he went to assess (Resident #28) and was concerned because he appeared and looked sick, he (Resident #28) couldn't sit up all the way and he (Resident #28) looked drunk. LPN RR reported he (Resident #28) looked like he just took a really strong sedative medication, he (Resident #28) kept trying to open his eyes but couldn't. LPN RR reported he is an agency nurse so he then went to the other nurse on the other unit who was a regular employee (LPN RR could not recall what nurse). LPN RR reported he had asked the other nurse about (Resident #28) and if this was a normal situation, or if this was something concerning that he should be sent to the emergency room (ER). LPN RR reported the other nurse reported (Resident #28) had been without his [MEDICATION(S)] for a few weeks. LPN RR reported the other nurse told LPN RR that tonight (9/23/22) was the first time he (Resident #28) would have received the 300 mg's of [MEDICATION(S)] in a while. LPN RR reported he took (Resident #28's) vital signs and continued to monitor as the other nurse did not feel there was concern to send (Resident #28) to the hospital. LPN RR reported he parked his medication cart outside (Resident #28's) doorway and once he was toileted he went to sleep, and once he was asleep he was really really asleep. LPN RR reported he thought throughout the shift that if (Resident #28's) that perhaps that medication should have been titrated (slowly reintroduced to the body-dose reduction) after that long of going without it. LPN RR reported he did feel a bit worried about (Resident #28) as he was so completely out of it, wobbly, and not himself LPN RR reported he had worked with (Resident #28) earlier in the night, he was able to talk, made sense, and usually is a funny, very communicative resident. LPN RR reported he worked the next couple day, and (Resident #28) appeared to be snowed a bit, lethargic, and not focused and needed more assistance than usual. LPN RR reported he had not heard anything of the event after that evening, or the following day despite him putting the progress note. In an interview/record review on 10/18/22 at 3:51 PM., Director of Nursing (DON) B reported the facility failed to ensure proper protocol for the administration of the Antipsychotic Medication-[MEDICATION(S)]. was followed for (Resident #28). DON B reported the the physicians order of the Antipsychotic Medication-[MEDICATION(S)] should have included the importance of monitoring the medication per the The [MEDICATION(S)] REMS-program. as well as the proper laboratory blood monitoring for the pharmacy to dispense. DON B reported we (facility nursing staff, physicians, nurse practitioners, and physicians were not fully aware of the The [MEDICATION(S)] REMS-program. DON B and this surveyor reviewed Resident #28's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] During record review and interview on 10/18/22 at 4:10 PM., Resident #28's MARs for August 2022 and September 2022 and laboratory reported (WBC completed) dated 9/9/22 and received 9/19/22 were reviewed and further revealed that Resident #28 was checked/documented by nursing staff for receiving his [MEDICATION(S)] 300 mg from September 1st-19th 2022 on Resident #28's MAR. In an interview Phrm DDD reported he is unsure how Resident #28 would have received his [MEDICATION(S)] during 9/1/22-9/19/22 when only 84 [MEDICATION(S)] tablets were delivered on 8/4/22 (which would provide enough 3-100 mg (300 mg) [MEDICATION(S)] tablets per night until 8/31/22. Phrm DDD further reported (Resident #28's) laboratory blood drawn was not completed per Resident #28's EMR until 9/9/22 and not received by the pharmacy/facility until 9/19/22). Phrm DDD reported per the REMS program the pharmacy is registered and cannot dispense the [MEDICATION(S)] until the WBC/ANC laboratory results are received (9/19/22). Phrm DDD reported the facility pharmacy (which he Phrm DDD is the consulting pharmacist) did not ship/deliver another 84 [MEDICATION(S)] 100 mg (300 mg per night) tablets for (Resident #28) until 9/22/22 late evening/early morning 9/23/22.

This citation pertains to intake #: MI 231 Based on interview and record review the facility failed to ensure residents received prescribed medications and wound treatments for 1 of 16 residents (Resident #217) reviewed for quality of care, resulting in an increase in pain and anxiety and the potential for the exacerbation of medical conditions, wound infection, and a decline in psychological wellbeing. Findings include: Review of the facility policy Admission Policy last reviewed 5/18/20 revealed, .Admission of Patients: 1. Prior to admission, patients will be evaluated as to physical, emotional, and social needs through a pre-admission screening process. 2. The health referral form submitted by the attending physician will contain medical findings, diagnosis, treatment to follow, prescribed diet, medication/treatment orders, patient's functional state, long or short term goals, rehabilitation potential, and signed orders for immediate care. These should be available at the time of admission. 3. A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. 4. If a physician is located too far away to properly follow a patient's care, then the facility will seek permission for the in-house physicians to take over the patients' care. 5. Patients will only be accepted if his/her needs can be met by (facility) or in cooperation with community resources. Acceptance will also depend on if other providers of care with whom the facility has contracts or signed agreements can meet a patient's needs . Review of the facility policy Physician Order last reviewed 3/18/21 revealed, A physician must personally approve in writing a recommendation that an individual be admitted to a facility. A physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care . 2. Upon admission, a written order approving the admission will be obtained from the attending physician. This may be done by telephone order . 9. Any orders written by a consulting physician must be reviewed and signed by the resident's attending physician. This may be done by telephone order . Resident #217 Review of a Face Sheet revealed Resident #217 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #217's New Admission/Re-Admission Notice dated 4/7/21 revealed, .Primary Dx (diagnosis): (Right) chest Hematoma-Secondary dx: DMII (Diabetes type 2) .Surgical Hx (history): sarcoma resection .Special Equipment or needs .Wound Vac (rc'd orders)(Received Orders) . (Vacuum-assisted closure of a wound is a type of therapy to help wounds heal. It's also known as wound vac). Review of Resident #217's Progress Note dated 4/7/21 revealed, resident arrived at (facility) at 540pm via stretcher. A&O x3 (alert and oriented to person, place, and time). Review of Resident #217's Hospital Discharge Note dated 4/7/21 at 4:41 P.M. revealed, [AGE] year-old male with a stage III A (T2, N0, M 0, G2) chest wall sarcoma. (He) was taken for radical excision of the sarcoma including pectoralis major and minor muscles, a rhomboid local advancement flap from the right flank was selected for coverage of the defect. The next day, the patient developed a hematoma and was taken back for evacuation of the hematoma and release and debridement of the flap. A wound VAC was placed over this right chest wall defect. Endocrinology was consulted for management of his glucose bowel inpatient. Palliative care was consulted for pain control issues. First vac change was performed with sedation. Postoperative day 5, the patient was noted to have increased swelling has right upper extremity. Ultrasound was performed which demonstrated a DVT (blood clot) in the brachial vein. [MEDICATION(S)] drip was started at this time. Second vac change was performed with 10 oxy and 25 IV [MEDICATION(S)]. Postoperative day 8, he was transitioned to therapeutic [MEDICATION(S)] (blood thinner). He tolerated this well. On day of discharge, patient was tolerating a general diet and pain was better controlled. He was being discharged to a [NAME] (subacute rehab) that supplies the own wound vacs and so his wound VAC was taken down and his wound was dressed with saline soaked Kerlix and covered in abd pads. This was tolerated well with oxy for pain. He is stable to be discharged to his subacute rehab with appropriate follow-up in place. CONSULTS / RECOMMENDATION: Endocrinology: Insulin adjustments while in the hospital-Palliative care: Tylenol 1000 q.6 (every 6 hours) scheduled, [MEDICATION(S)] (nerve pain medication) 300 3 times a day, [MEDICATION(S)] (muscle spasm medication) 1000 q.6 scheduled, oxycodone immediate release (pain medication) 5-10 mg every 3 hours as needed. (Indicating Resident #217 required blood thinning medication, pain medications, and insulins to keep him stable). Review of Resident #217's Surgical Oncology physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed, Patient's wound vac removed at bedside after 15mg oxycodone PO (by mouth) for procedural pain control .As patient is being transported to [NAME] (subacute rehab) facility this afternoon with local wound vac system to be applied once he arrives, patient's wound was dressed with saline-moistened kerlix, ABD, and secured with tape . Review of Resident #217's Discharge Summary provided by the facility after survey exit (7/23/21 at 2:08 P.M.) printed 4/7/21 at 3:28 P.M. revealed a follow up appointment for Resident #217 with Physician Assistant (PA XX) for Surgical Oncology scheduled for 4/12/21 (included a phone number and address) .Dressing and Wound Instructions .You have a (name omitted) vac in place over your right chest incision. This vac is covering a closed incision and is used as a prophylactic method to prevent surgical site infection. This vac can be removed 7 days after your procedure .Once removed the incision should be washed DAILY with soap and fresh water and patted dry with a clean towel. The incision may then be left open to air .Wound Care-Change wound vac three times weekly . (Indicating contradictory wound care directions. Review of Resident #217's progress notes for 4/7/21 revealed no order clarification from the provider was completed to ensure proper wound care was provided.) Review of Resident #217's Progress Note dated 4/8/21 at 3:59 P.M. revealed, This author spoke with (Physician Assistant PA XX) from the (name omitted) Surgical Oncology unit regarding his home care. We discussed that they will bring a wound vac here for us to apply before he returns home . (Indicating Resident #217 was to have a wound vac applied to his surgical wound). Review of Resident #217's Progress Note dated 4/9/21 at 1:41 A.M. revealed, Pt is alert and oriented. He voices c/o (complaints of) of not having a w/v (wound vac) applied as soon as he was admitted . He has a dressing intact to his right upper chest .It is to be changed 4x daily and if the dressing is soiled . During an interview on 07/22/2021 at 9:46 A.M., Surgical Oncology Physician Assistant (PA) XX reported that she was the practitioner that was going to be following up with Resident #217 following his surgical excision of the sarcoma (cancerous tumor). PA XX reported that Resident #217's wife contacted PA XX about the facility not applying the wound vac upon admission. PA XX reported the facility was to apply the wound vac upon admission to the facility and the wet to dry dressing that was in place was only temporary until the resident arrived to the facility. PA XX reported concern that the facility accepted Resident #217's admission to the facility when they were unequipped to handle his care which included: wound care/wound vac treatment, insulin administration, blood thinners for a recent blood clot, pain medication for a complicated procedure, and antihypertensive medication. PA XX stated, The facility did not ensure the patient had proper treatment or that the orders were followed. PA XX reported that wet to dry dressing changes were not even completed in place of the wound vac and therefore no treatment was in place at all for an extended period of time. During an interview on 07/22/2021 at 10:25 A.M., Medical Director (MD) WW reported that she arrived to the facility on [DATE] and was notified that Resident #217 received no pain medications since his arrival to the facility on [DATE] at 5:40 P.M. MD WW reported that the facility staff reported that they had to wait for me to get there to prescribe (pain medication.) MD WW reported that there is always a provider on call and if a resident required pain medication or if pain medications were not in the facility the facility staff are to call the on call provider. MD WW reported that she spoke to the nurse that was caring for Resident #217 from 6 P.M. on 4/7/21 until 6 A.M. on 4/8/21 to identify the reason the pain medications were not ordered for Resident #217, and she reported to MD WW that she was new and did not know the procedure. MD WW reported that she was upset about a resident not receiving pain medication after a complex surgical procedure and stated, we cannot leave patients in pain like that. MD WW reported that she was unsure about the specifics of why Resident #217 did not have a wound vac but reported she knew he required a wound vac for his continuing care. MD WW reported that she was notified that the facility had ordered a wound vac for Resident #217 and the facility staff were to complete wet to dry dressing changes until they got the wound vac put in place. MD WW reported that Resident #217's follow up care, when he returned home, was to have a wound vac in place with wound specialists consultation. Review of Resident #217's Physician History and Physical dated 4/9/21 at 12:40 P.M., written by Medical Director (MD) WW revealed, .Skin: Inspection and Palpation: warm and dry; Large right chest wall wound s/p radical resection down to rib bones. Lung motion is seen at depth of the hole in his chest. No signs of infection, drainage, discharge. Measures roughly 12 inches x 6 inches x 3 inches . Patient demands to discharge home. Medications were sent to patients pharmacy. Patient requires home PT/OT/HHA (Physical Therapy, Occupational Therapy, Home Health Assistance) and Wound care with wound vac . Review of Resident #217's Recapitulation of Stay dated 4/9/21 revealed, .Physical & Mental Functional Status .AxOx3 (Alert and oriented to person, place, and time), able to verbalize needs and wants Will need assist with wound care management will have in home services to assist with dressing changes as ordered .Wound vac to his right chest wall, shoulder. In home nursing will be providing the wound vac application and management .Discharging to home with PT/OT/HHA and nurse for wound vac placement . Review of Resident #217's Physician Orders and April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . four times a day for infection prevention. -Order Date-04/08/2021 3:47pm .The April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #217's Progress Note dated 4/8/21 at 1:22 P.M. revealed, waiting on residents meds to be shipped from pharmacy. pharmacy is sending them STAT (immediately). Review of Resident #217's Physician Order revealed, [MEDICATION(S)] Solution ([MEDICATION(S)]) 150 MG/ML Inject 0.95 milliliter subcutaneously every 12 hours for right chest wall hematoma, surgically removed related to CHRONIC EMBOLISM AND [CONDITION(S)] OF UNSPECIFIED VEIN Order Date 04/08/2021 2348 (11:48 pm). Review of Resident #217's April Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #217 was not given his dose of [MEDICATION(S)] on 4/7/21 at 7pm nor his dose of [MEDICATION(S)] on 4/8/21 at 7am. Review of Resident #217's Physician Orders and April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .Novolog Pen (insulin) inject 10 unit related to type 2 diabetes -Order Date- 4/9/21 at 6:30 am . The insulins were not administered until the morning of 4/9/21. Review of Resident #217's Physician Orders and April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #217's April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #217's Physician Orders and April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .the April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #217's Progress Notes revealed no documentation as to why the medication was not administered. Review of Resident #217's Physician Orders and April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . the April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #217's Progress Notes revealed no documentation as to why the medication was not administered. Review of Resident #217's Physician Orders and April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . the April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #217's Progress Notes revealed no documentation as to why the medication was not administered. Resident #217 did not receive a dose of [MEDICATION(S)] until 4/8/21 at 12:00pm. (Resident #217 did not receive a 12:00 am dose on 4/8/21 or a 6:00 am dose on 4/8/21.) Review of Resident #217's Physician Orders and April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .The April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #217's Physician Orders and April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/20/21 at 03:03 P.M., Pharmacy General Manager (PGM) F reported that nursing staff can order medications STAT if needed and the pharmacy will deliver the medications as soon as the order is completed. PGM F reported that if the facility staff order medications Routine by 9:00 P.M. the medications will be sent with other routine orders on the 1:00 A.M. delivery. PGM F reported that medications would be delivered on the same day as the admission to the facility. During an interview on 07/21/2021 at 10:01 A.M., Licensed Practical Nurse (LPN) ZZ reported that Resident #217 arrived at the end of the shift might have been right when I was walking out on 4/7/21. LPN ZZ reported she did not complete an assessment or put orders in for Resident #17 because it was shift change and she was off duty at 6pm. LPN ZZ reported that she documented in the progress notes when Resident #217 arrived but everything else would have been passed off. During an interview on 07/20/2021 at 3:44 PM Registered Nurse (RN) G reported that she was the nurse for Resident #217 the night of 4/7/21 to the morning of 4/8/21. RN G reported that Resident #217 arrived just prior to the start of her shift. RN G reported that some of Resident #217's medications arrived from the pharmacy between 12-2 A.M. on 4/8/21 but some medications were missing. RN G reported that when Resident #217 arrived he was thinking he was going to get a wound vac. RN G stated, When I took over for the day nurse I said well what about the wound vac and they said they didn't have orders for the wound vac yet .it was basically do the best you can until morning. RN G reported that she found that there were orders for the wound vac and there were pictures of the wound and what we were supposed to cut to fill the wound. RN G reported upon her next shift there was a wound vac sitting on the crash cart and she was told that it was for Resident #217 but that they did not have orders to use the wound vac. RN G reported that some of Resident #217's medications were not ordered in the computer on time and some of the medications did not arrive to the facility. RN G reported she did not know which provider was going to take over the care for Resident #217 and therefore she could not report to and obtain orders from a physician. RN G stated, (Resident #217's) meds didn't even get put in the computer before I arrived and then I realized I didn't have a doctor. RN G reported that the facility staff were not notified that Resident #217 would be admitted to the facility. During an interview on 07/20/21 at 12:25 P.M., LPN FF reported that he was not the nurse at the time of Resident #217's admission on 4/7/21. LPN FF reported that he was working on the morning of 4/8/21 and discovered that Resident #217 had not had his admission paperwork/orders completed. LPN FF reported that the night shift nurse did not complete any of the admission paperwork/orders, did not perform wound care, and did not order Resident #217's medications from pharmacy. During an interview on 07/21/21 at 05:03 P.M., Former Unit Manager (FUM) I reported that she was the Unit Manager for Resident #217 at the time of his arrival. FUM I reported that there were no orders and no wound vac for Resident #217 when he arrived at the facility. FUM I reported that Resident #217 arrived after she had left for the day and the facility staff did not know that he was going to be admitted . FUM I stated, I just know when he left, he was unhappy about admission and orders, and I don't blame him. During an interview on 07/20/21 at 03:20 P.M., Resident #217 reported that a nurse assessed his blood sugar on the night of his admission, and it was noted to be in the 200's (elevated level). Resident #217 reported that he told the nurse he needed his insulin injection and his regularly scheduled medications, which included pain medication. Resident #217 reported that he was told that the nurse could not give him any medications but Tylenol because the medications had to be ordered by a physician. Resident #217 reported that in the morning of 4/8/21 he had his wife contact his surgical oncology provider (PA XX) to get him immediately discharged or transferred to another facility. Resident #217 reported he received no other medications or wound care the entire night except for the Tylenol that the nurse administered. Resident #217 stated, no shots and no pills whatsoever (the first night of the admission). The next morning, they came and gave me a couple of pills but still had not administered his [MEDICATION(S)] injection or his insulin injections. Resident #217 reported that he was told that the Administrator, the Director of Nursing, and the Unit Manager were all new to the facility but even if that's the case you cannot not take care of patients. Resident #217 stated, They knew I was coming. If they knew they didn't have the ability to take instructions, then they should have told them not to send me. Resident #217 reported he was in a good amount of pain but it didn't matter because they didn't give me any pills. Resident #217 reported that Director of Nursing (DON) B reported to him that since he did not have a wound vac his dressing was to be changed every 4 hours. Resident #217 reported his dressings were not changed every 4 hours as ordered. Resident #217 stated that he was cut clear to my ribs and the center of my chest around my side. I needed the wound vac. Resident #217 reported that his stay at the facility was Very, very disappointing and disheartening and discouraging. During an interview on 07/21/2021 at 1:08 P.M. Admissions Coordinator (AC) AAA reported that prior to an admission a referral from a physician or hospital is obtained. The progress notes, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . AC AAA reported that any required equipment would be ordered and obtained prior to the resident's arrival by the Central Supply Staff. AC AAA reported that the medication list is reviewed by the nursing staff and orders obtained. During an interview on 07/21/2021 at 1:44 PM Central Supply Staff (CSS) BBB that Resident #217's wound vac was on 4/7/21 and returned on 4/12/21. If a wound vac is ordered the supplier delivers the wound vac within 4 hours. CSS BBB reported that even if the wound vac had not arrived at the time of Resident #217's arrival there was a back up wound available for Resident #217's use.

This citation pertains to intake #MI 446 Based on interview, and record review, the facility failed to implement an effective discharge planning process and complete an accurate discharge plan of care in 1 of 4 residents (Resident #103) reviewed for discharge, resulting in Resident #103 being discharged from the facility without the adequate supports in place, without ensuring the discharge destination met the resident's health and safety needs, and without the necessary information to provide treatment of [REDACTED]. Findings include: Review of a facility policy Discharge Plan reviewed 5/5/20 revealed, Policy: Implement a plan to ensure that the discharge goals and needs of the patient are identified and result in development of a discharge plan. Procedure 1. Identify the patient ' s needs and goals regarding discharge upon or as soon as practicable after admission . 4. Involve the patient and patient representative. Consider the patient ' s support/caregiver ' s availability, capacity, and capability to perform required care when identifying discharge needs. Document the patient/patient representative involvement in the discharge plan development . Chapter 1: Admission/Transfer/Discharge Procedures and Nursing Documentation Clinical Services Manual . 6. After the needs and goals are identified ensure this results in the development of a discharge plan for the patient. 7. Address the patient ' s goals and treatment preferences in the plan. 8. Inform the patient and patient ' s representative of the final plan. 9. Document that the patient has been asked about their interest in receiving information regarding returning to the community. 10. Document any referrals to local contact agencies or other appropriate entities made based on the patient ' s choices and interest in returning to the community. For patients who are transferred to another skilled nursing facility or who are discharge to a HHA (Home Health Agency) . assist residents and their representatives in selecting a post-acute care provider by using data, data on quality measures, and data on resource use to the extent the data is available. Ensure that the use of standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident ' s goals of care and treatment preferences. 11. Document if the discharge to the community is not feasible, who made the determination, and why. 12. Involve the patient, patient ' s representative, and the IDT (Interdisciplinary Team) with any re-evaluation of the patient ' s needs or goals that require modification of the discharge plan and update the plan as needed . 15. The discharge plan will identify the discharge destination, and ensure it meets the residents health and safety needs as well as preferences. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs or appears unsafe, the facility must: Discuss with the resident, (and/or representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to get the information as to why the resident is selecting that location. Document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed. Document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings. Review of an Admission Record revealed Resident #103 was a [AGE] year-old female, originally admitted to the facility on [DATE], and re-admitted on [DATE] after a hospitalization , with pertinent [DIAGNOSES REDACTED]. Resident #103 was discharged to the community on 9/5/20. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 9/5/20 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #103 was cognitively intact. Review of the Functional Status revealed that Resident #103 required extensive assistance from staff for transfers, bed mobility, toilet use and personal hygiene. Review of Behaviors-Rejection of Care revealed that Resident #103 scored 0 (Behavior not exhibited). Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 8/24/20 revealed, Behaviors-Rejection of Care revealed that Resident #103 scored 0 (Behavior not exhibited). During an interview on 9/22/20 at 1:44 P.M., Family Member (FM) I reported that Resident #103 was discharged to her home on 9/5/20 without her caregiver being prepared to take care of her. FM I reported that Resident #103's caregiver was under the impression that he would lose everything if he appealed the insurance's decision to deny payment for Resident #103 to continue to reside in the facility, therefore he agreed to bring her home. FM I reported that Resident #103's caregiver is not able to physically care for Resident #103, had no idea what to do with her when she was sent home and the discharge paperwork did not include contact information for the home health nursing agency. FM I reported that Resident #103's caregiver called 911 on 9/5/20 around 8:30 P.M. to provide assistance to transfer Resident #103 to bed on her first night home. FM I reported that Resident #103 had a wound on her bottom, the discharge paperwork did not include anything about her wound and Resident #103 was not able to get out of bed for several days following her discharge, due to her caregiver not being physically able to assist her. FM I reported that Resident #103 was not able to leave the home to visit her primary care physician for the assessment that was required prior to start home nursing services, therefore the home nursing services were delayed for several days. Review of Police Reports indicated the police were dispatched to Resident #103's home on 9/5/20 at 13:28 (1:28 P.M.) to assist EMS (Emergency Medical Services) with carrying Resident #103 up the stairs in her wheelchair and again on 9/5/20 at 20:59 (8:29 P.M.) to help get Resident #103 out of her chair. Note that both of these incidents occurred following Resident #103's discharge from the facility on 9/5/20. Review of Discharge Summary dated 9/3/20 at 10:02 A.M. revealed, (Resident #103) is alert and oriented times three. She is able to make her needs known to staff. Does not ambulate .Patient needs, strengths, goals, life history and preferences: Support of husband .(Resident #103) will be returning home with husband and will be pursuing normality .Skin Condition: Redness areas in groin area and buttocks. Apply ointment to ceases in groin area and protectant cream to buttocks Participants in Patient's Assessment: (RN-CM C, Dietitian L, Activities Director Z, Social Worker AA, Rehab Director BB) Functional transfers minimal physical assist. Ambulates 10 feet using two wheeled walker requiring minimal physical assist. Toileting tasks dependent. Bathing and dressing tasks require maximum physical assistance .Does patient need outpatient rehab services after discharge? (no answer provided) . Note that this document did not include any information regarding the need for home nursing services or contact information for home nursing services. Note that one of the facility's direct care nursing staff were not included in the resident's discharge assessment as noted above, nor did it indicate a pressure wound. During an interview on 9/23/20 at 11:24 A.M., Registered Nurse Care Manager (RN-CM) C reported that a home assessment was not performed to determine that the discharge destination met the health and safety needs of Resident #103, nor was training provided to ensure that the caregiver was able to perform care and transfers due to the current pandemic. RN-CM C reported that the facility was aware that Resident #103 was not able to leave the home and that she would require a physician's assessment prior to home nursing services beginning. RN-CM C reported that prior to Resident #103 being discharged , it was determined that having a physician come into Resident #103's home to provide the assessment was not available due to Resident #103's insurance and stated, .her caregiver wanted her to see her primary care physician .she did not have an appointment scheduled yet when she left the facility . RN-CM C reported that Resident #103's skin condition instructions on the discharge plan come directly from the orders in the resident's record which the nursing staff should have entered. RN-CM C reported that the facility had repeated difficulty reaching Resident #103's caregiver due to not having the caregiver's contact phone number on file and stated, .the number that we were calling was (Resident #103's) cell phone, which was at the facility . RN-CM C reported that a discharge care conference took place by phone with the caregiver and stated, .the findings were not thoroughly documented . Review of Resident #103's Care Plan revealed, FOCUS: Discharge Plan to return to the community Date Initiated: 08/18/2020 . GOAL: Will develop and follow full discharge plan with comprehensive Date Initiated: 08/18/2020 . INTERVENTION: Unable to determine at this time. Date Initiated: 08/18/2020 .FOCUS: (Resident #103) has potential for nutritional problem r/t (related to) dx (diagnosis) of obesity, type 2 diabetes,[MEDICAL CONDITION](hypertension). - Assessment 8/5 noted open pressure sore in left gluteal fold .Date Initiated: 08/07/2020 .GOAL: (Resident #103) will consume adequate protein, vitamins, and minerals to support wound healing. Date Initiated: 08/07/2020 .INTERVENTION: .Provide adequate protein, vitamins and minerals to support wound healing Date Initiated: 08/07/2020 . FOCUS: (Resident #103) has a potential for impairment to skin integrity r/t DM, fragile skin, immobility Date Initiated: 08/25/2020 . INTERVENTION: . Clean and dry skin after each incontinent episode. Date Initiated: 08/25/2020 .Follow facility protocols for treatment of [REDACTED]. Review of Resident #103's Care Management Note dated 9/2/2020 at 15:03 (3:03 P.M.) revealed, (RN-CM C), SS (social services), Therapy met with (caregiver) via phone and rsd (resident) to discuss discharge plan/plan of care, also insurance would possible be issuing a notice of non coverage due to lack of skilled progress, (caregiver) informed staff he would possible pay for care at home if insurance denied stay. Review of Resident #103's Care Management Note dated 9/2/2020 at 15:17 (3:17 P.M.) revealed, (RN-CM C) received NONC (notice of non-coverage) called (insurance company name omitted) case manger (sic) to discuss rsd, she asked that notice be issued and faxed back, this writer received signature from rsd called (caregiver) discussed notice of non coverage and appeal process and offered appeal numbers at this time he declined appeal and stated he would talk to BOM (business office manager) to possibly have rsd stay private pay and continue therapy under med B services. Review of Resident #103's Care Management Note dated 9/4/2020 at 15:50 (3:50 P.M.) revealed, (RN-CM C) called (Resident #103's caregiver) to inform of HHS (home health services) with (company name omitted) was accepted, ., visiting physicians would not accept rsd (resident) due to insurance, (Caregiver) will have (Resident #103) continue with (Primary Care Physician). (Caregiver) wishes to schedule PCP (primary care physician) f/u (follow up) at his own convenience. Rsd (resident) and (caregiver) had no other questions or concerns at the end of conversation. Review of the Occupational Therapy Discharge Summary dated 9/9/20 at 11:45 A.M. revealed, Discharge Recommendations: pt (patient) retunring home with her husband as well as visiting physicians and home health services. pt will required 1 person assist for transfers, assist for ADL's, there is concern about her returning home with the husband as he is not able to provide any physical assist. 8 steps to enter house as well. unable to complete home evaluation due to covid 19 outbreak. insurance benefits exhausted and husband chose to have wife d/c (discharge) home. During an interview on 9/23/20 at 1:32 P.M., Physical Therapy Assistant (PTA) M reported that a telephone care conference was held with Resident #103's caregiver about a week prior to discharging from the facility and stated, .he (caregiver) said that he was not able to provide physical assistance because of his cardiac issues. PTA M reported that the facility was aware that Resident #103 lived in a 2nd floor apartment, but did not perform an assessment of the home due to the current pandemic. During an interview on 9/22/20 at 2:49 P.M., Social Worker (SW) AA indicated that she was not involved in the discharge of Resident #103 and stated, .having home care in place ensures the safest discharge . SW AA reported that Resident #103's record does not reflect a follow up call made following discharge and stated, .normally those are completed 1-5 days after discharge . Requested any additional documentation regarding the discharge. None received prior to exit. During an interview on 9/23/20 at 12:07 P.M., Home Health Staff (HHS) H reported that when the initial referral was received, the facility did not indicate that Resident #103 was total care. HHS H staff reported that it was understood that Resident #103 was going to first be seen by a home physician and then we would start home nursing services. HHS H reported that they attempted to contact Resident #103's caregiver, but did not have the correct contact number and stated, .the facility gave us (Resident #103's) cell number instead of the caregiver's phone number . HHS H reported that FM I contacted our company to request services to begin urgently for Resident #103 on 9/8/20, due to the caregiver being unable to provide assistance. Review of Resident 103's Visit Note Report from the initial assessment performed by Home Health Services (HHS) dated 9/8/20 revealed, CAREGIVER KNOWLEDGE BASE DEFICITS: .TECHNICAL PROCEDURES, PATHOPHYSIOLOGY OF DISEASE SIGNS AND SYMPTOMS TO REPORT, WHO AND WHEN TO CALL FOR HELP, SPECIAL DIET/FLUID RESTRICTIONS OR REQUIREMENTS, BASIC PRINCIPALS OF CARE PROPER EQUIPMENT USE, HOME SAFETY/EMERGENCY PROCEDURES . MEDICATIONS. GASTROINTESTINAL: .BOWEL INCONTINENCE FREQUENCY: 3 - FOUR TO SIX TIMES WEEKLY . [MEDICAL CONDITION]: .PATIENT IS INCONTINENT . BRADEN RISK ASSESSMENT SCALE SENSORY PERCEPTION: . VERY LIMITED . MOISTURE: . - SKIN IS OFTEN BUT NOT ALWAYS MOIST. LINEN MUST BE CHANGED AS OFTEN AS 3 TIMES IN 24 HOURS.MOBILITY: . VERY LIMITED - MAKES OCCASIONAL SLIGHT CHANGES IN BODY OR EXTREMITY POSITION BUT UNABLE TO MAKE FREQUENT OR SIGNIFICANT CHANGES INDEPENDENTLY.FRICTION AND SHEAR POTENTIAL PROBLEM - MOVES FEEBLY OR REQUIRES MINIMUM ASSISTANCE.BASED ON THE SCORE, THE RISK LEVEL FOR THIS PATIENT IS: MODERATE . FUNCTIONAL: . PATIENT DEPENDS ENTIRELY UPON SOMEONE ELSE FOR GROOMING NEEDS.PATIENT DEPENDS ENTIRELY UPON ANOTHER PERSON TO DRESS UPPER BODY .PATIENT DEPENDS ENTIRELY UPON ANOTHER PERSON TO DRESS LOWER BODY .IS BATHED TOTALLY BY ANOTHER PERSON .IS TOTALLY DEPENDENT IN TOILETING .PATIENT DEPENDS ENTIRELY UPON ANOTHER PERSON TO MAINTAIN TOILETING HYGIENE .UNABLE TO TRANSFER SELF AND IS UNABLE TO BEAR WEIGHT OR PIVOT WHEN TRANSFERRED BY ANOTHER PERSON .CHAIRFAST, UNABLE TO AMBULATE AND IS UNABLE TO WHEEL SELF .UNABLE TO FEED SELF AND MUST BE ASSISTED OR SUPERVISED THROUGHOUT THE MEAL/SNACK . MOBILITY ROLL LEFT AND RIGHT .: DEPENDENT - HELPER DOES ALL OF THE EFFORT . WOUND ASSESSMENT: . POST - UP BUTTOCK, RT, PU (pressure ulcer) STAGE II .LT POST - UP BUTTOCK, LT, PU STAGE I .Narrative: .discharged HOME WITH SPOUSE. PATIENT HAD FALL IN HOME ON 9/5 EMS PUT PATIENT IN BED, PATIENT UNABLE TO AMBULATE DUE TO WEAKNESS SINCE 9/5 . STAGE 2 PRESSURE ULCER TO RIGHT BUTTOCK, STAGE 1 PRESSURE TO LEFT BUTTOCK .CURRENT LIVING SITUATION NOT APPROPRIATE FOR PATIENT. UNABLE TO LEAVE HOME WITHOUT ASSISTANCE FROM EMS . AND INABILITY TO AMBULATE AT THIS TIME . This document indicates that Resident #103 had new and worsened pressure ulcers and the caregiver did not have the necessary knowledge to care for Resident #103. During an interview on 9/23/20 at 1:49 P.M., LPN D reported that Resident #103's record indicated a Stage 1 pressure ulcer was present on 8/19/20 after Resident 103's readmitted to the facility from the hospital and a wound assessment document was triggered, but not completed by the nurses. LPN D reported that Resident #103's record did not include any weekly skin assessments, wound care assessments or wound care orders. LPN D reported that the last documentation of Resident 103's skin status was on 8/19/20 and that there were no follow up notes indicating that the pressure ulcer had healed. Requested additional nursing assessments or progress notes to indicate Resident #103 pressure ulcers had resolved, none received prior to exit. This interview indicated that the last licensed nursing skin assessment was performed 17 days prior to discharge. Review of Resident #103's Physician order [REDACTED]. Review of Nutrition/Dietary Note dated 8/27/2020 at 14:27 (3:27 P.M.) revealed, (Resident #103) states she does not like the nutrijuice drink provided QD for stage 1 PU healing .Resident agreeable to take Glucerna for additional kcal and protein .To aid in wound healing and provide adequate kcal to resident, . Will continue to monitor weight trends, oral intake, and wound status, with nutrition interventions to be updated as needed . Review of Skin/Wound Note dated 8/19/2020 at 00:36 (12:36 A.M.) revealed, (Resident #103) has a 4x3 stage one pressure ulcer on her coccyx. I applied 2 large [MEDICATION NAME] (foam bandage) bandages to reddened area and rolled patient on her side to relieve the pressure. Review of Resident #103's Re-Admission assessment dated [DATE] at 14:44 (2:44 P.M.) revealed .Resident has scattered bruising to both legs and arms, excoriation to inner gluteal folds and large [MEDICATION NAME] to sacrum. Resident is incontinent of bowel and bladder . Review of Resident #103's Admission Nutrition assessment dated [DATE] at 12:05 P.M. revealed, . PU (pressure ulcer) noted to L (left) gluteal fold . Recommend adding nutrijuice drink (6oz,BID) .to aid in wound healing. Review of Resident #103's Nursing Admission/Readmission Collection Tool dated 8/5/20 at 15:00 (3:00 P.M.) revealed, Skin Condition .Left Buttock .open pressure sore on inner gluteal fold. During an interview and record review on 9/23/20 at 2:53 P.M., Review of CNA (Certified Nurses Assistant) Shower Sheets submitted by DON B dated 9/2/20 indicated Extremely Excoriated buttocks on the body diagram. This document included CNA S's signature, an illegible charge nurse signature and an incomplete section for charge nurse assessment. A second CNA Shower Sheet dated 9/4/20 indicated no findings on the body diagram and no charge nurse assessment. DON B reported that if Resident #103 had a pressure ulcer, it would have been documented on the CNA Shower Sheet. Requested nursing skin assessments or progress notes indicating that Resident #103's pressure ulcers had resolved, none received prior to exit. Review of Resident #103's Skilled Note dated 8/28/2020 at 14:12 (2:12 P.M.) revealed, .She is pleasant and cooperative with care. Review of Resident #103's Skilled Note dated 8/29/2020 at 04:09 (4:09 A.M.) revealed, cooperative with staff.

This citation pertains to intake #MI 446 Based on interviews and record review, the facility failed to properly perform monitoring and assessments of the skin and ensure that necessary interventions and treatments were in place to prevent the development or worsening of pressure ulcers for 1 resident (Resident #103), reviewed for pressure ulcers, resulting in new and worsening of pressure ulcers, when Resident #103 was discharged without the necessary information to treat pressure ulcers. Findings include: Review of the facility policy Skin integrity and pressure ulcer/injury prevention and management effective date 10/3/19 revealed, Intent: Provide associates and license nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessments/documentation, and provide treatment and care of the skin and wounds utilizing profession (sic) standards . 1. A comprehensive skin inspection/assessment on admission and readmission . 2. A risk assessment tool, Braden scale . determines the patient's risk for pressure ulcer development. The score is documented on the tool and placed in the residence medical record using the appropriate form. 3. A skin assessment should be performed weekly by a licensed nurse. 4. Measures to maintain and improve the patient's tissue tolerance to pressure are implemented in the plan of care . 6. Patient and significant others involved in the patient's care are educated regarding the preventative skin care plan. 7. When skin breakdown occurs, it requires attention and a change in the plan of care to appropriately treat the patient. Review of an Admission Record revealed Resident #103 was a [AGE] year-old female, originally admitted to the facility on [DATE] and re-admitted on [DATE] after a hospitalization , with pertinent [DIAGNOSES REDACTED]. Resident #103 was discharged to the community on 9/5/20. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 9/5/20 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #103 was cognitively intact. Review of the Functional Status revealed that Resident #103 required extensive assistance from staff for transfers, bed mobility, toilet use and personal hygiene. Review of Behaviors-Rejection of Care revealed that Resident #103 scored 0 (Behavior not exhibited). Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 8/24/20 revealed, Behaviors-Rejection of Care revealed that Resident #103 scored 0 (Behavior not exhibited). Review of Resident #103's Care Plan revealed, FOCUS: Discharge Plan to return to the community Date Initiated: 08/18/2020 . GOAL: Will develop and follow full discharge plan with comprehensive Date Initiated: 08/18/2020 . INTERVENTION: Unable to determine at this time. Date Initiated: 08/18/2020 .FOCUS: (Resident #103) has potential for nutritional problem r/t dx of obesity, type 2 diabetes, HTN. - Assessment 8/5 noted open pressure sore in left gluteal fold .Date Initiated: 08/07/2020 .GOAL: (Resident #103) will consume adequate protein, vitamins, and minerals to support wound healing. Date Initiated: 08/07/2020 .INTERVENTION: .Provide adequate protein, vitamins and minerals to support wound healing Date Initiated: 08/07/2020 . FOCUS: (Resident #103) has a potential for impairment to skin integrity r/t DM, fragile skin, immobility Date Initiated: 08/25/2020 . INTERVENTION: . Clean and dry skin after each incontinent episode. Date Initiated: 08/25/2020 .Follow facility protocols for treatment of [REDACTED]. During an interview on 9/22/20 at 1:44 P.M., Family Member (FM) I reported that Resident #103 was discharged to her home on 9/5/20 without her caregiver being prepared to take care of her. FM I reported that Resident #103 had a wound on her bottom, the discharge paperwork did not include anything about the wound and Resident #103 was not able to get out of bed for several days following her discharge, due to her caregiver not being physically able to assist her. FM I reported that Resident #103 was not able to leave the home to visit her primary care physician for the assessment that was required prior to start home nursing services, therefore the home nursing services were delayed. Review of Resident 103's Visit Note Report from the initial assessment performed by Home Health Services (HHS) dated 9/8/20 revealed, .BRADEN RISK ASSESSMENT SCALE SENSORY PERCEPTION: . VERY LIMITED . MOISTURE: . - SKIN IS OFTEN BUT NOT ALWAYS MOIST. LINEN MUST BE CHANGED AS OFTEN AS 3 TIMES IN 24 HOURS.MOBILITY - ABILITY TO CHANGE AND CONTROL BODY POSITION VERY LIMITED - MAKES OCCASIONAL SLIGHT CHANGES IN BODY OR EXTREMITY POSITION BUT UNABLE TO MAKE FREQUENT OR SIGNIFICANT CHANGES INDEPENDENTLY.FRICTION AND SHEAR POTENTIAL PROBLEM - MOVES FEEBLY OR REQUIRES MINIMUM ASSISTANCE.TOTAL SCORE .: 14 BASED ON THE SCORE, THE RISK LEVEL FOR THIS PATIENT IS: MODERATE .TOILETING HYGIENE: .PATIENT DEPENDS ENTIRELY UPON ANOTHER PERSON TO MAINTAIN TOILETING HYGIENE . MOBILITY ROLL LEFT AND RIGHT PERFORMANCE: - DEPENDENT - HELPER DOES ALL OF THE EFFORT .WOUND ASSESSMENT: . POST - UP BUTTOCK, RT, PU (pressure ulcer) STAGE II .LT POST - UP BUTTOCK, LT, PU STAGE I .Narrative: .discharged HOME WITH SPOUSE. PATIENT HAD FALL IN HOME ON 9/5 EMS PUT PATIENT IN BED, PATIENT UNABLE TO AMBULATE DUE TO WEAKNESS SINCE 9/5 . STAGE 2 PRESSURE ULCER TO RIGHT BUTTOCK, STAGE 1 PRESSURE TO LEFT BUTTOCK . CURRENT LIVING SITUATION NOT APPROPRIATE FOR PATIENT. UNABLE TO LEAVE HOME WITHOUT ASSISTANCE FROM EMS . AND INABILITY TO AMBULATE AT THIS TIME . Review of Discharge Summary dated 9/3/20 at 10:02 A.M. revealed, (Resident #103) .Skin Condition: Redness areas in groin area and buttocks. Apply ointment to creases in groin area and protectant cream to buttocks Participants in Patient's Assessment: (RN-CM C, Dietitian L, Activities Director Z, Social Worker AA, Rehab Director BB) .Toileting tasks dependent. Bathing and dressing tasks require maximum physical assistance .Does patient need outpatient rehab services after discharge? (no answer provided) . Note that a direct care nurse from the facility was not included in the resident's assessment and wound care was not indicated. During an interview on 9/23/20 at 11:24 A.M., Registered Nurse Care Manager (RN-CM) C reported that training was not provided to ensure that the caregiver was able to perform care and transfers for Resident #103. RN-CM C reported that Resident #103's skin condition instructions on the discharge plan come directly from the orders in the resident's record that are entered by the nursing staff. Review of Nutrition/Dietary Note dated 8/27/2020 at 14:27 (3:27 P.M.) revealed, (Resident #103) states she does not like the nutrijuice drink provided QD (everyday) for stage 1 PU healing .Resident agreeable to take Glucerna for additional kcal and protein .To aid in wound healing and provide adequate kcal to resident . Review of Skin/Wound Note dated 8/19/2020 at 00:36 (12:36 A.M.) revealed, (Resident #103) has a 4x3 stage one pressure ulcer on her coccyx. I applied 2 large [MEDICATION NAME] (foam bandage) bandages to reddened area and rolled patient on her side to relieve the pressure. Review of Resident #103's Re-Admission assessment dated [DATE] at 14:44 (2:44 P.M.) revealed .Resident has scattered bruising to both legs and arms, excoriation to inner gluteal folds and large [MEDICATION NAME] to sacrum. Resident is incontinent of bowel and bladder . During an interview on 9/23/20 at 3:18 P.M., LPN F reported to complete Resident #103's re-admissions assessment on 8/18/20 and stated, .there was a large bandage on her bottom .I did not take the bandage off .I don't know what her bottom looked like . Review of Resident #103's Admission Nutrition assessment dated [DATE] at 12:05 P.M. revealed, . PU (pressure ulcer) noted to L (left) gluteal fold . Recommend adding nutrijuice drink (6oz,BID) .to aid in wound healing. Review of Resident #103's Nursing Admission/Readmission Collection Tool dated 8/5/20 at 15:00 (3:00 P.M.) revealed, Skin Condition .Left Buttock .open pressure sore on inner gluteal fold. During an interview on 9/23/20 at 1:49 P.M., LPN D reported that Resident #103's record indicated a Stage 1 pressure ulcer was present on 8/19/20 after Resident 103's readmitted to the facility from the hospital and a wound assessment document was triggered, but not completed by the nurses. LPN D reported that Resident #103's record did not include any weekly skin assessments, wound care assessments or wound care orders. LPN D reported that the last documentation of Resident 103's skin status was on 8/19/20 and that there were no follow up notes indicating that the pressure ulcer had healed. LPN D reported that LPN P was assigned to Resident #103 during the last days of Resident #103's stay at the facility. Requested additional nursing assessments or progress notes to indicate that Resident #103's pressure ulcers had resolved, no additional documentation received prior to exit, indicating that the last licensed nursing skin assessment was performed 19 days prior to discharge. Review of Resident #103's Physician Orders and Treatment Administration Record revealed, no orders for skin monitoring, preventative treatments or wound treatments during her stay at the facility. During an interview on 9/23/20 at 2:48 P.M., LPN P reported that she did not recall working with Resident #103. During an interview on 9/23/20 at 2:53 P.M., Director of Nursing (DON) B reported that Resident #103 was not on rounds for wound assessments and stated, .the admission assessment would trigger an order for [REDACTED]. During an interview and record review on 9/23/20 at 2:53 P.M., Review of CNA (Certified Nurses Assistant) Shower Sheets submitted by DON B dated 9/2/20 indicated Extremely Excoriated buttocks on the body diagram. This document included CNA S's signature, an illegible charge nurse signature and an incomplete section for charge nurse assessment. A second CNA Shower Sheet dated 9/4/20 indicated no findings on the body diagram and no charge nurse assessment. DON B reported that if Resident #103 had a pressure ulcer, it would have been documented on the CNA Shower Sheet. Requested nursing skin assessments or progress notes indicating that Resident #103's pressure ulcers had resolved, none received prior to exit. During an interview on 9/23/20 at 3:08 P.M., CNA S reported to regularly care for Resident #103 and stated, .I don't remember if she had a pressure ulcer . During an interview on 9/23/20 at 2:58 P.M., LPN N reported that skin assessments are completed by the nurses and documented weekly. LPN N could not recall Resident #103's skin status and stated, .if a wound was identified on an admission assessment, then I would expect it to trigger weekly wound rounds and a weekly skin assessment in our orders . During an interview on 9/23/20 at 2:44 P.M., Certified Nursing Assistant (CNA) G reported to regularly work on Resident #103's hall, but does not recall Resident #103. During an interview on 9/23/20 at 2:46 P.M., LPN T reported to regularly work on Resident #103's hall, but does not recall Resident #103. During an interview on 9/23/20 at 2:56 P.M., LPN CC reported to regularly work on Resident #103's hall, but does not recall Resident #103. Review of Nurse Practioner Note dated 8/25/20 at 6:00 P.M. revealed, .Physical Exam: .Skin: warm and dry, afebrile . This note did not include an assessment of Resident #103's pressure ulcer. Review of Physician Note dated 8/20/20 at 11:00 A.M. revealed, .Physical Exam: .Skin: warm and dry, no rashes erythems noted . This note did not include an assessment of Resident #103's pressure ulcer. Review of Resident #103's Skilled Note dated 8/28/2020 at 14:12 (2:12 P.M.) revealed, .Resident is alert and oriented x 2 with call light in reach and able to make her needs known. She is pleasant and cooperative with care. Review of Resident #103's Skilled Note dated 8/29/2020 at 04:09 (4:09 A.M.) revealed, alert, oriented x 2-3. cooperative with staff.

This citation pertains to Intakes: MI 42, MI 759, and MI 707. Based on observation, interview and record review the facility failed to prevent resident neglect for 3 out of 6 residents (Resident #105, #102, and #101), reviewed for abuse and neglect resulting in Residents #101, #102 and #105 not provided showers on a weekly basis due to low staffing, and Resident #101 was left wet and soiled and staff refused to enter the room to meet his needs. Findings include: Resident #105 Review of a Face Sheet revealed Resident #105 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 5/13/20 revealed a Brief Interview for Mental Status (BIMS) score of 8 which indicated Resident #105 was cognitively impaired. During an observation on 7/28/20 at 3:15 p.m., observed Resident #105 hollering out for staff from her room. This surveyor was located outside Resident #105's room for approximately 5 minutes. Resident #105 continued to call out of help. This surveyor entered Resident #105's room, once Resident #105 saw this surveyor, was called me in. Resident #105's call light was on the floor out of her reach. Resident #105 stated could you help me get to the toilet, I (Resident #105) really have to pee (urinate). This surveyor prompted Resident #105 to use the call light, Resident #105 replied (after looking around herself) I don't know where it's at, but I have to go to the bathroom. This surveyor noticed Resident #105 becoming increasingly agitated. (Resident #105's) roommate turned the call light on for Resident #105 (by this time approximately 10 minutes had passed). Certified Nurse Aide (CNA) W entered Resident #105's room in a rushed manner, asking Resident #105 what she needed. Resident #105 did not answer CNA W for some reason. CNA W turned the call light off, and was about to walk out of the room, when Resident #105 yelled wait I have to pee. CNA W swiftly turned around, grabbing Resident #105's wheelchair, swinging her (Resident #105) around, CNA W was trying to get into the bathroom, when CNA W got Resident #105's left foot stuck between the foot pedal on the wheelchair and the door to the adjoining resident room. Resident #105 hollered out ouch, that hurt CNA W continued the transfer from Resident #105's wheelchair to the toilet. CNA W assisted Resident #105 with pulling her pants down. Resident #105 stated ohhh God that stinks, how come it smells like that (Resident #105 was in a standing position, with her pants pulled down to knees) Resident #105 questioned multiple times why her (Resident #105's) peri-area (genital) smelled so bad. CNA W did not answer Resident #105, nor did CNA W assist Resident #105 with cleaning her peri-area, or calling for assistance from another staff to help clean Resident #105's peri-area. CNA W assisted Resident #105 with a gait belt to a standing position after Resident #105 urinated in the toilet. CNA W rushed the entire encounter, the whole-while Resident #105 was expressing discomfort with the way the gait belt was positioned under her (Resident #105) breasts, lifting her shirt. During an interview on 7/28/20 at 3:35 p.m., CNA W reported she didn't mean to rush during Resident #105's care. CNA W indicated the facility is so short staffed, CNA W stated its frustrating. CNA W reported residents are missing out on their showers, call lights are taking longer than usual, and staff that was hired, have all quit. CNA W reported management is aware that the CNA's needs help. Resident #102 Review of a Face Sheet revealed Resident #102 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 5/12/20 revealed a Brief Interview for Mental Status (BIMS) score of 14 meaning Resident #102 was cognitively intact During an interview on 7/28/20 at 4:00 p.m., Resident #102 reported she was completely dependant on staff to assist her with her toileting needs. Resident #102 reports she has been left wet and soiled for over an hour, especially on evening and night shifts. Resident #102 reported the staff are so rushed, they don't listen to us, when the do my care when they get to it it is rough and they (staff) say I gotta go, I'm too busy right now when I (Resident #102) asks for something. Resident #102 stated they (staff and management) are tough on us, there are unspoken looks, or attitudes, I (Resident #102) have tried to interact with them, it's like walking on eggshells every day, they (staff) say you're not the only patients. Resident #102 reported she cannot recall the last time she actually had a real shower Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/18/20 revealed a Brief Interview for Mental Status (BIMS) score of 99 meaning Resident #101 was unable to complete the assessment, Resident #101 was severely cognitively impaired. During an interview on 7/28/20 at 4:30 p.m., Family Member (FM) JJ reported he has been in to see (Resident #101) and found him to be in the same clothes from 2 days prior which were soiled. FM JJ reports he has attending care conferences and neglect and lack of staffing have been a topic in the meeting (Care Conference) in late February or early March. FM JJ reported that the Nursing Home Administrator (NHA) at the time of the Care Conference was interim Regional Vice Resident (RVP) C, the Director of Nursing (DON) B, Social Services Assistant H, and Licensed Practical Nurse (LPN) V along with the local Ombudsman (Omb) U were in attendance. FM JJ stated at the meeting many concerns for (Resident #101) were brought up, but also other residents not getting showers, staffing so short it took over an hour for some residents to get their care completed. During an interview on 7/29/20 at 11:10 a.m., LPN BB reported the facility has struggled to keep staff. LPN BB reported that staff is short, that many times showers or baths are not being done according to individual residents schedules. LPN BB reported for (Resident #101) many staff are not trained to deal with his behaviors, so certain staff wont even answer his call light, or he (Resident #101) yells out to come here. During an interview on 7/29/20 at 2:30 p.m., DON B reported the facility staffing has been a challenge to keep and retain new hires after they go through the training portion of orientation. DON B reported there are staff that are afraid of (Resident #101) due to his behaviors. During an interview on 7/29/20 at 6:10 p.m., Regional Vice President (RVP) C reported he was surprised the facility even admitted him (Resident #101), I don't think this is the right placement for him. RVP C reported conversations about (Resident #101) and his behaviors are brought up daily. RVP C reported there were some concerns with (Resident #101's) behaviors, and staffing. RVP C reported he was the acting NHA at that time earlier in the year around the end of February/March 2020. RVP C when a care conference meeting was held with (FM JJ) and the (OMB U) were involved, RVP C reported he does not recall what the concerns were. During an interview on 7/30/20 at 2:11 p.m., Social Services Assistant (SSA) H reported he has known (Resident #101) since his admission in 2018. SSA H stated I did not try to find placement for (Resident #101), it was not in my pay grade. SSA H stated we were told to sit on it, and we are not going to do anything SSA H reported that came from upper management about a year ago. SSA H reported many of the staff were afraid to care for (Resident #101) due to his behaviors. During an interview on 7/30/20 at 4:00 p.m., CNA I reported there is no doubt that Resident #101 has been neglected. CNA I reported staff wont even go in his room, because they are afraid of him, and his behaviors. CNA I reported many residents are not getting their showers. CNA I stated. There are not enough staff on 2nd shift to complete the showers, as well as answer call lights in a timely manner. CNA I reported she has a good working relationship with (Resident #101). CNA I indicated she works with him a lot, but also other staff members could learn the approach needed with (Resident #101), but they choose not too, so when she (CNA I) is off, showers for (Resident #101) probably don't get done. During an interview on 8/4/20 at 11:40 a.m., CNA R staff on 2nd shift are unable to give showers because they don't have enough staff to complete the showers. CNA R reported there are certain staff that will not go into (Resident #101's) room to care for him, because they are afraid of him. CNA R reported that she has a good working rapport with (Resident #101) but if she is assigned somewhere else, and not on that unit, or his room. The staff who were assigned to (Resident #101) often times will just assume she (CNA R) will pick him up and do his care, because of the relationship she has with (Resident #101). CNA R reported she has talked with the management team about this. CNA R states they just say we're working on it. During an interview on 8/4/20 at 12:45 p.m., Resident #101's private paid Companion (CMP) II reported she was at the facility 5 days a week for approximately 3-4 hours in the afternoon. CMP II reported during her time in the afternoons with (Resident #101) when staff would come in (staff that rushed or demanded things of (Resident #101)-) would escalate his behaviors. CMP II reported everyone knew his cognition was that of a 5-6-year-old. CMP II reported those staff were very impatient, complained about him in front of him, rush through his care, sometimes force him to change or make threats to take something away he cared about. CMP II reported despite the fact he had behaviors at the facility, he liked it there. CMP II reported she felt as if staff and management neglected to care for (Resident #101) but also other residents in the facility. CMP II indicated call lights took a very long time, especially on 2nd shift. During a telephone interview on 8/4/20 at 1:35 p.m., Ombudsman (OMB U) reported (Resident #101) has been discussed on almost every visit she has made to the facility . OMB U reported on numerous occasions she has made suggestions, given community resources, but over the last year it has been out of control . OMB U reported when RVP C was acting as NHA last year (Fall 2019-March 2020) many conversations were had with him and others (RVP C, DON B, FM JJ, & OMB U) and reported there was a Care Conference early March 2020 with complaints of neglect, cold food, no showers, among other issues at the facility OMB U reported (RVP C), would always minimize the issues, or say we're working on it. OMB U stated The facility knew (Resident #101's) needs when they admitted him in 2018. The main [DIAGNOSES REDACTED]. OMB U stated (Resident #101) had behaviors but in reality many behaviors are a reaction to the neglect and lack of care/[MEDICATION NAME] for him (Resident #101). OMB U reported when she has been in the facility the staff approach (Resident #101) as a problem vs person. During an interview on 8/4/20 at 3:50 p.m., Activity Assistant (AA) K reported she has heard some residents complain about not getting their showers, and call lights taking long. During an interview on 8/5/20 at 10:40 a.m., Maintenance Director (Mtn) D stated he has heard CNA's and many nurses say thinks like I'll feed, change and transfer him, but I'm not about to spend any extra time with him (Resident #101). Mtn D reported (Resident #101) was a funny guy, playful, but if staff rushed or went into his room, without knocking or the right approach he would go off on them (staff). Mtn D explained (Resident #101) was like having a little kid, he (Resident #101) would one minute be playful and happy, and the next he (Resident #101) would be upset, and behaviors would escalate, typically with staff he wasn't fond of. Mtn D reported he (Mtn D) has known (Resident #101) since his admission, and reported there haven't been many if any special training's offered by the facility to assist the staff with dealing with his (Resident #101's) type of behaviors. Mtn D reported there has been a push to get him (Resident #101) out of the facility. Mtn D reported I think much of (Resident #101's) behaviors stems from not having enough staff, and a revolving door of staff. Mtn D reported when (Resident #101) has staff that have gone that extra mile to get to know him (Resident #101), his routine, his likes and dislikes, he (Resident #101) does pretty well with those staff. Review of a facility Policy revised 1/21/19 revealed: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents medical symptoms. Residents must not be subjected to abuse by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the representative, friends, or any other individuals. It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation.

This citation pertains to Intakes: MI 42 and MI 759. Based on interview and record review, the facility failed to: 1.) prevent a facility initiated discharge and, 2.) document in the medical record a reason for the discharge that meets the federal requirements for discharge in 1 of 6 sampled residents (Resident #101) reviewed for transfer and discharge, resulting in feelings of sustained confusion, anger, frustration for Resident #101 and the resident representative when Resident #101 was discharged to a out of State Psychiatric Hospital. Findings include: Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/18/20 revealed a Brief Interview for Mental Status (BIMS) score of 99 meaning Resident #101 was unable to complete the assessment, Resident #101 was severely cognitively impaired. Review of a Communication document revealed on 5/9/2020 18:01 COMMUNICATION (Resident #101) - Family Member (FM) (name omitted-FM JJ). Note Text: received call from (FM JJ) he stated that he did not receive any calls about (Resident #101) daily update since Tuesday. (FM JJ) requested that (FM JJ) needs to be called daily basis. Review of an email correspondence from the Nursing Home Administrator (NHA A) wrote regarding Resident #101 revealed, This again was not an involuntary transfer or discharge as indicated on previous email. dated Thursday, June 25, 2020 11:41 AM. Further review of the email revealed: Thursday, June 25, 2020 2:00 PM., (NHA A) I have never been a part of an appeal for an emergency transfer due to the medical evaluation and treatment that was required per a provider. The transfer was for medical evaluation and treatment. During an interview on 7/28/20 at 4:30 p.m., Family Member (FM) JJ reported on June 12th, 2020, he received a phone call regarding (Resident #101) having increased behaviors and ultimately had inadvertently kicked a Certified Nurse Aide (CNAR) in the face striking her nose. FM JJ indicated he was told that (CNA R) and Registered Nurse (RN) NN had Resident #101 in a Hoyer lift being transferred into his bed. FM JJ reported (CNA R) and he had spoken after the incident. FM JJ reported (CNA R) told him she and (RN NN) were transferring Resident #101 from his broda (high back wheelchair) to bed. FM JJ indicated the report that was given to him about the incident was Resident #101 was not happy with the nurse (RN NN). FM JJ reported he and his family have close relationships with a handful of staff members that have worked extremely well with (Resident #101). FM JJ reported he (FM JJ) believes the facilities Interdisciplinary Team (IDT- Managers) were planning on discharging the resident long before the incident with (CNA R). FM JJ reported he feels there was an ongoing pattern of staff and management that continued to treat him (Resident #101) as a competent male. FM JJ reported between himself, a privately paid companion (CMP II) and a select few staff members at the facility were working diligently on Resident #101's behaviors prior to the incident with (CNA R). FM JJ reported (Resident #101) was being followed closely by the local Community Mental Health (CMH) for over 2 years. FM JJ reported CMH OBRA (Omnibus Budget Reconciliation Act of 1987 or OBRA ' 87.) Coordinator/Social Worker (CMH-SW) KK had been coming (pre-Covid 19) to see him (Resident #101) on a weekly basis and behavioral specialists at CMH completed 2 (2018 &2019) extensive behavioral care plans which went in great detail on what to do, how to approach him (Resident #101), along with extensive interventions based on the in depth assessment completed by CMH OBRA Coordinator/Social Worker (CMH-SW) KK, and CMH's Behavioral Specialists, and Psychologists/Psychiatrists for (Resident #101's). FM JJ reported these care plans were very detailed and were a tool to be used by staff (at the facility) on how to redirect any negative behaviors, refusals of care/medications for (Resident #101). FM JJ reported when (Resident #101) was agitated the majority staff were not thoroughly trained, including but not limited to the Medical Director (MD OO). FM JJ reports it's has been an ongoing process of communication breakdown between the facility management team and (Resident #101's) advocates such as myself (FM JJ), the Ombudsman, as well as many highly educated, and trained behavioralist at CMH, and (CMH-SW) KK weekly visits. FM JJ reported the leadership team at the facility failed to utilize the CMH Care Plans as well as failed to train their staff on how to approach him (Resident #101). FM JJ stated it's a simple as that. FM JJ stated, The next thing I knew on June 17th, 2020, a staff member told me they (upper management) were shipping (Resident #101) out of the facility. FM JJ reported on June 17th, 2020 Registered Nurse (RN) F assisted Psychologist LL who wrote the Clinical Certification for (Resident #101) to be hospitalized for [REDACTED]. FM JJ stated I was not notified of it on paper, nor did Psychologist LL reach out to me (FM JJ). FM JJ indicated he had called the facility and asked if any of the nursing staff, the Director of Nursing (DON) B or Social Services (SS) H had spoken to (CMH-SW) KK. FM JJ stated They (facility management team) did not reach out to me like I've (FM JJ) asked numerous times for them to do. FM JJ reported (Resident #101) should have had the right to see his own personal psychiatrist at CMH. FM JJ reported on June 18th he (FM JJ) got the call that the facility was transferring (Resident #101) in the early afternoon for an emergency psychiatric evaluation because of the staff (CNA R) being injured (on 6/12/20- 6 days previously). FM JJ reported he spoke with Ombudsman (Omb) U who then notified NHA A that this transfer was not an emergent transfer, since the incident happened over a week ago. FM JJ stated I don't understand why this was so emergent, and or facility initiated, because (Resident #101) hit another resident a week or so prior to kicking (CNA R) in the face. FM JJ indicated the facility should have started the process then, or the other numerous times (Resident #101) had behaviors. FM JJ reported he was also contacted by a (Confidential Informant-(CI)) EE on June 18, 2020 that Region Vice President (RVP) C, NHA A Director of Nursing (DON) B, Social Services Assistant (SSA H) had been discussing how to get him (Resident #101) moved somewhere else for a long time. FM JJ reported when they called him on the 17th to inform him (FM JJ) of their plan to send (Resident #101) out, FM JJ immediately requested a second opinion which the facility denied. FM JJ reported they lied to me, they (the facility staff/management) did not contact me and tell me it was a petition and cert (certification) for a psychiatric inpatient hospital in another state. FM JJ. asked for the paperwork to appeal from the facility. FM JJ reported he did not receive notice of a bed hold or any form of paperwork when he arrived at the facility when (Resident #101) was being transported out via ambulance. FM JJ reported the facilities petition failed to establish a clinical need, imminent harm to himself or others. FM JJ stated, The Region Vice President (RVP) C, NHA A Director of Nursing (DON) B, Social Services Assistant (SSA) H and Medical Director (MD) OO were trying to base an acute episode into a something that it was not. The fact of the matter is that (Resident #101) has had the same behaviors that he has had since day 1 in this facility. FM JJ reported they (Region Vice President (RVP) C, NHA A Director of Nursing (DON) B, Social Services Assistant (SSA) H and Medical Director (MD) OO, among other staff and legal department at the facility) are claiming in that Emergency Transfer or discharge transfer was due to the fact he had hit the (CNA R) FM JJ stated, If this were really the case why did they not do this a week or so before when he (Resident #101) hit the resident who wandered into his room? FM JJ indicated (Resident #101's) behaviors have been overall the same since admission. FM JJ reported they just did not want to deal with him (Resident #101) anymore. FM JJ stated, They sent him (Resident #101) to a different State, away from family, myself, his Companion (CMP II), the staff who worked and cared for him . FM JJ reported the facility made no attempts to face time, call or communicate with his caseworker at CMH, (CMH/SW KK) who saw him on a weekly basis until Covid-19. FM JJ stated (Resident #101) is now in a psychiatric hospital in a completely different State, so lethargic I cannot even talk to him on the phone, he's so drugged up. He (Resident #101) is not able to see anyone he knows, I am sure he (Resident #101) is extremely scared, anxious, and the staff there are probably giving him medications to keep him asleep. I have no resources now to work with as he (Resident #101) is in a completely different State and all the resources he's had were here in Michigan. FM JJ stated (Resident #101) likely feels very abandoned. During an interview on 7/29/20 at 11:10 a.m., Licensed Practical Nurse (LPN) BB reported (Resident #101) had behaviors including hitting, kicking, swatting, swearing, and refusal of medications at times. LPN BB reported (Resident #101's) behaviors were consistent since he had admitted . LPN BB reported it was well-known that management wanted him (Resident #101) out of the facility and that staff have not been trained on how to care for someone with (Resident #101's) diagnoses. LPN BB' reported a few times CMH staff came and went over some approaches to use when (Resident #101) is having behaviors, but that most staff do not use those approaches, and many times when (Resident #101) is having a behavior, it's because that staff is rushing him, or walks into his room without using a softer approach. LPN BB reported there have been multiple times (Resident #101) has made physical contact with other residents, behaviors of hitting, scratching, throwing things, and lashing out at staff. LPN BB reported she was not sure why (Resident #101) would not have been transferred out for psych services long before his discharge in June 2020. During an interview on 7/29/20 at 12:02 p.m., LPN V reported (Resident #101) was childlike with his behaviors like a child throwing a tantrum. LPN V indicated his cognitive status/age was about the age of a 5-year-old. LPN V reported CMH/SW KK, and (Resident #101's) personal companion (CMP II) visited frequently before Covid-19 ad that (Resident #101's) family member (FM JJ) was highly involved in (Resident #101's) care and was (Resident #101's) guardian. LPN V reported (Resident #101) responded better to certain staff, especially staff who had a gentle approach. LPN V reported she is unsure why the transfer discharge happened almost a week after the incident with (CNA R), and why (Resident #101) has not been emergently or involuntary transferred in the past with the same amount of behaviors (Resident #101) has had, including at times resident to resident altercations. LPN V reported another resident was hit by (Resident #101) about a week before (CNA R) was kicked in the face. LPN V reported (Resident #101) has had behaviors since his admission in 2018 and, There is not enough time, or ink in the pen to document all of (Resident #101's) behaviors. LPN V indicated the behaviors have not necessarily escalated as of late, but the facility management team including NHA A, DON B, RVP C, SS H, Social Services Director (SSD) O and corporate consultants have been talking about taking it to the next level, and pursuing it (LPN V reported -meaning transfer and or discharge Resident #101). LPN V indicated she was aware of an incident with (Resident #101) and another female resident last October 2019 where (Resident #101) was being pushed down the hall by (FM JJ) and (Resident #101) reached out and swatted, making contact with the other residents arm. LPN V reported she was not sure why (Resident #101) would not have been transferred out for psychiatric services at that time. LPN V stated when (CNA R) got hurt, we (staff) finally had (NHA A) who was willing to go the distance, went to the next level and pursued it. (indicated the transfer/discharge of Resident #101). During an interview on 7/29/20 at 2:30 p.m., DON B reported the facility management team has been discussing behaviors of (Resident #101) every week, and many daily reports. DON B reported (Resident #101's) behaviors have been consistent since she (DON B) started working at the facility approximately 10 months ago. DON B stated With (CNA R's) injuries we had to find a way to keep staff safe. DON B reported (Resident #101's) hitting could have had intent to it, or it could have been sporadic due to his [DIAGNOSES REDACTED]. DON B reported she was unsure why (Resident #101) was not sent out for psychiatric evaluations when he had made physical contact with other residents, staff, and the MD OO when she alleged he (Resident #101) assaulted her on initial consultation. DON B stated once (CNA R) was injured, the NHA (A) finally got support from above (meaning corporate) and the decision was made to transfer (Resident #101) out. During an interview on 7/29/20 at 4:45 p.m., NHA A reported that on June 12th, 2020 (CNA R) came to her (NHA A) to report that (Resident #101) kicked her in the nose during a transfer with a hoyer lift from (Resident #101's) wheelchair to bed. NHA A reported she sent (CNA R) to the emergency room (ER), NHA A reported CNA R drove herself to the ER. NHA A stated, We did not petition (Resident #101) on that afternoon (June 12th, 2020 a Friday) because we did not know the magnitude of the injuries to (CNA R). NHA A reported the petition and cert was completed on June 17th, and (Resident #101) was transferred on June 18th, 2020. (nearly a week after the incident). NHA A reported speaking with the local Ombudsman U about the transfer for Resident #101. NHA A reported she was unsure if (CMH-SW) KK was notified of Resident #101's transfer. During an interview on 7/29/20 at 6:10 p.m., Regional Vice President (RVP) C reported he was surprised the facility even admitted him (Resident #101), I don't think this is the right placement for him. RVP C reported conversations about (Resident #101) and his behaviors are brought up daily. RVP C reported there were some concerns with (Resident #101's) behaviors and what the facility needed to do assist with interventions and he was the acting NHA at that time earlier in the year around the end of February/March 2020. RVP C when a care conference meeting was held with (FM JJ) and the (OMB U) were involved, RVP C reported he does not recall what the concerns were. RVP C stated, We were looking to send him (Resident #101) out because he broke the nose of an employee (CNA R) who also sustained a concussion. During a telephone interview on 7/30/20 at 12:30 p.m., Registered Nurse (RN) F reported she assisted SSA H with filling out the petition/certification for hospitalization . RN F reported (Resident #101) always had behaviors of yelling out, swearing, hitting, or tugging at staff while they were providing care. RN F indicated overall (Resident #101's) behaviors are the same behaviors he's had since admission; some days are better than others. During an interview on 7/30/20 at 2:11 p.m., Social Services Assistant (SSA) H reported he has known (Resident #101) since his admission in 2018. SSA H reported at no time during the last 2 years did he initiate an alternative placement that could meet the behavioral needs of (Resident #101). SSA H reported it was talked about often with the IDT team, but it never went anywhere. SSA H stated I did not try to find placement for (Resident #101), it was not in my pay grade. SSA H stated We were told to sit on it, and we are not going to do anything SSA H reported that came from upper management about a year ago. SSA H reported he felt it was the injury to (CNA R) that crossed a line. During an interview on 7/30/20 at 4:00 p.m., CNA I reported she had a good rapport with (Resident #101) often coming in on off hours to de-escalate (Resident #101's) behaviors. CNA I reported she was not working when the facility transferred (Resident #101) out. CNA I reported (Resident #101) had behaviors, and there is no question about that. CNA I stated, There have been plenty of opportunities for staff to learn his (Resident #101's) approach according to his care plan.It really did come down to following the care plan and building trust and [MEDICATION NAME] for (Resident #101). CNA I indicated his (Resident #101's) behaviors did escalate slightly with the passing of his father recently, as well as being more isolated due to Covid-19. CNA I reported (Resident #101) could or should have been transferred out a long time ago if the case was he was a danger to himself or others. CNA I stated I have a very good working relationship with (Resident #101) as well as with his family and (FM JJ). I cannot imagine how this transfer affected (Resident #101), I am sure he is very frightened. During an interview on 8/4/20 at 11:40 a.m., CNA R reported she and LPN DD were going to do care on (Resident #101) on June 12th. CNA R reported (Resident #101's) legs were up, and she (CNA R) was helping LPN DD turn (Resident #101) attention towards her because she (CNA R) was one of the staff (Resident #101) was easily re-directed by. CNA R stated, (Resident #101) was swatting his arms at (LPN DD) and somehow while I was bending over, I was kicked in the face. (CNA R) reported (Resident #101) did not intentionally try to kick me, while he was in the hoyer his leg went up with momentum and all of a sudden crack I felt that feeling like salt water in my nose, and I don't recall anything after that. CNA R reported she was told by LPN DD to go report the incident, and then she (CNA R) drove herself to the emergency room . CNA R stated I feel horrible, I know he (Resident #101) would never have intentionally kicked me to hurt me, I cannot imagine what he is going through right now, I am very sad about this. I was unable to say good bye to him, and also whenever (Resident #101) did have behaviors, he always would apologize to the staff and say I'm sorry, I'm sorry, did I hurt you?, I'm sorry many of his behaviors of grabbing were because he (Resident #101) was afraid of the hoyer lift and would say 'I fall, I fall, I hurt, I hurt' he really was just like a little kid. CNA R reported she does not believe his behaviors were any worse that day, than they were another other day since she has known him. CNA R indicated the staff that were successful with (Resident #101) were the staff that took the time to get to know him, stay consistent with re-direction, and treat him with respect. CNA R reported she thinks moving him (Resident #101) was devastating to him, and he was probably very afraid, agitated, and alone at the out of state psychiatric hospital. During an interview on 8/4/20 at 12:45 p.m., Resident #101's private paid Companion (CMP) II reported she was at the facility 5 days a week for approximately 3-4 hours in the afternoon. CMP II reported she would play games, listen to music, take him (Resident #101) out for walks prior to the Covid-19 pandemic. CMP II reported she has been unable to see Resident #101 since March 2020. CMP II reported during her time in the afternoons with (Resident #101) when staff would come in, staff that rushed or demanded things of (Resident #101) would escalate his behaviors. CMP II reported everyone knew his cognition was that of a 5-6-year-old. CMP II reported staff that were very impatient, complained about him in front of him, rush through his care, sometimes force him to change or made threats to take something away he cared about. CMP II reported despite the fact he had behaviors at the facility, he liked it there. CMP II reported (Resident #101) was very playful and joked around a lot. CMP II stated it devastates me to hear he was moved to another facility, especially a psychiatric hospital in another State. It appalls me that (facility name omitted) would transfer him for the incident that happened. I believe they wanted him out of there for a long time, and this was the incident that broke the camel's back if you will. During a telephone interview on 8/4/20 at 1:35 p.m., local Ombudsman (OMB U) reported (Resident #101) has been discussed on almost every visit she has made to the facility. OMB U reported on numerous occasions she has made suggestions, given community resources, but over the last year it has been out of control. OMB U reported when RVP C was acting as NHA last year (fall 2019-March 2020) many conversations were had with him, the DON at the time, and FM JJ. OMB U reported RVP C, would always minimize the issues, or say we're working on it OMB U stated, The facility knew (Resident #101's) needs when they admitted him in 2018. The main [DIAGNOSES REDACTED]. OMB U stated (Resident #101) had behaviors, but in reality it's a reaction to the neglect and lack of care for him. OMB U reported when she has been in the facility the staff approach (Resident #101) as a problem vs person, the catalyst in this case is that there was an injury to a staff member, who also reported it was not intentional but an accident. During an interview on 8/4/20 at 3:50 p.m., Activity Assistant (AA) K reported (Resident #101's) behaviors stay consistent throughout the 2 years he was a resident. AA K indicated he had good days and bad days. AA K reported that (Resident #101) preferred certain staff members, and those staff worked very well with him. AA K reported he also had a companion who came in daily for a few hours in the afternoon. AA K stated when (Resident #101) was discharged /transferred it seemed very abrupt and sudden. During an interview on 8/5/20 at 10:40 a.m., Maintenance Director (Mtn) D stated he has heard CNA's and many nurses say thinks like Ill feed, change and transfer him, but I'm not about to spend any extra time with him (Resident #101). Mtn D reported (Resident #101) was a funny guy, playful, but if staff rushed or went into his room, without knocking or the right approach he would go off on them (staff). Mtn D explained (Resident #101) was like having a little kid, he (Resident #101) would one minute be playful and happy, and the next he (Resident #101) would be upset, and behaviors would escalate, typically with staff he wasn't fond of. Mtn D reported he (Mtn D) has known (Resident #101) since his admission, and reported there haven't been many if any special training's offered by the facility to assist the staff with dealing with his (Resident #101's) type of behaviors. Mtn D reported there has been a push to get him (Resident #101) out of the facility. Mtn D reported I think much of (Resident #101's) behaviors stems from not having enough staff, and a revolving door of staff. Mtn D reported when (Resident #101) has staff that have gone that extra mile to get to know him (Resident #101), his routine, his likes and dislikes, he (Resident #101) did pretty well with those staff. Review of a Communication noted signed by Social Services Director (SSD) CC revealed on 6/17/2020 16:20 Psychosocial Note Text: SW along with Executive Director (NHA A) called guardian/(FM JJ) to inform him that a petition had been completed for (Resident #101) to receive inpatient psychiatric care. (SSD CC) explained that (Resident #101) was a danger to himself/others and so an evaluation was going to take place. Guardian (FM JJ) did verbalize his disagreement with this decision and felt that having a telephone conversation with ombudsman (Omb U) and CMH would better serve his brother (Resident #101). Guardian (FM JJ) was informed that ombudsman (Omb U) would be notified of this discharge. Ombudsman (Omb U) was notified of decision that facility was seeking inpatient psychiatric care for resident. Review of a Communication noted signed by Social Services Director (SSD) CC revealed on 6/17/2020 18:05 COMMUNICATION - with Family/NOK/POA Note Text: SW and Executive Director spoke with guardian/(FM JJ) and informed him that at this time facility was unable to secure evaluation at psychiatric hospital. SW shared that (Name omitted) Hospital, which guardian (FM JJ) preferred was unable to accept (Resident #101). (Name omitted) Hospital also unable to accept. Guardian (FM JJ) remains frustrated over situation. Guardian (FM JJ) does not feel that his brother (Resident #101) warrants hospitalization . Review of a Communication noted signed by Licensed Practical Nurse revealed: (LPN) DD 6/15/2020 18:13 COMMUNICATION - spoke with Family Member (FM) JJ .and gave him update . (Resident #101) behavior, he (FM JJ) was asking if we (facility staffing/nursing/SS) have called CMH/SW KK and (FM JJ) said they (CMH) should be able to help with his behavior and (Resident #101) needs more attention when he does not get it, the behavior starts etc .he (FM JJ) also said Certified Nurse Aide (CNA) I (CNA I is one of Resident #101's favorite CNA's at the facility) will be in tomorrow everything should go back to normal. Review of Resident #101's progress notes revealed: Social Services Director CC 6/17/2020 16:20 Psychosocial Note Text: SW along with Executive Director- (Nursing Home Administrator-NHA A) called guardian/ (FM JJ) to inform him that a petition had been completed for resident to receive inpatient psychiatric care. SW explained that resident was a danger to himself/others and so an evaluation was going to take place. Guardian/ (FM JJ) did verbalize his disagreement with this decision and felt that having a telephone conversation with ombudsman and CMH would better serve his brother. Guardian/ (FM JJ) was informed that ombudsman would be notified of this discharge. Ombudsman was notified of decision that facility was seeking inpatient psychiatric care for resident. Review of Resident #101's progress notes revealed: Social Services Director CC 6/17/2020 18:05 COMMUNICATION - and Executive Director (Nursing Home Administrator-NHA A) spoke with guardian/(FM JJ) and informed him that at this time facility was unable to secure evaluation at psychiatric hospital . Guardian/ (FM JJ) remains frustrated over situation. Guardian/ (FM JJ) does not feel that his brother (Resident #101) warrants hospitalization . Guardian/ (FM JJ) does acknowledge that resident is physically aggressive. Conversation concluded that this writer and ED would remain in touch with guardian/ (FM JJ) as needed regarding evaluation and perhaps subsequent psychiatric hospitalization . During an interview on 8/5/20 at 2:50 p.m., CMH-SW KK reported: because of (Resident #101's) developmental disability it was determined that Community Mental Health would collaborate behavioral interventions with the facility staff and management in treating (Resident #101's) diagnosis. CMH-SW KK reported the Behavioral Specialist (BS) PP completed assessments in 2018, & 2019 for (Resident #101). CMH-SW KK reported (BS PP) revised the 1st one due to what the staff told her on his response was to some of these interventions for Resident #101. CMH-SW KK reported she typically met with (Resident #101) weekly, to provide visits but also for training with his behaviors especially during difficulty with medication pass, toileting, etc. CMH-SW KK indicated there was a struggle (at the facility) they (staff) would define him a violent, and sexually inappropriate. CMH-SW KK indicated (Resident #101) would make some gestures most likely from learned from TV. CMH-SW KK stated I don't think he (Resident #101) knew what that meant, over the years he would do these mostly out of entertainment. When he (Resident #101) would grab me, I would ask do you want to arm wrestle, and he (Resident #101) would then do that. He (Resident #101) was mentally disabled, but could talk to him, and work your way through that. It is different from dementia. CMH-SW KK reported she was surprised that when (FM JJ) called to say he was going to be admitted to a psychiatric hospital out of State. CMH-SW KK stated I asked why, because these behaviors were baseline, and that was on (Resident #101's) admission paperwork, and my (CMH-SW KK.) OBRA Screening for 2018 &2019. CMH-SW KK reported (Resident #101) has never verbalized not liking anyone, there would be some staff that would approach his door and I (CMH-SW KK) would see eye rolls, when I (CMH-SW KK) would walked by, you could just tell by they way they (certain staff/nurses/management) looked at him (Resident #101), it was unfavorable look CMH-S KK stated I would considered that abusive CMH-SW KK reported staffing pretty much got widdled down. (Resident #101) had a good strong circle, that really cared for his (Resident #101) spirit and who he was, you could tell they were happy to provide that care, even when he (Resident #101) was difficult . When I (CMH-SW KK) was with him, I would convey to staff and (Resident #101) I (CMH-SW KK) would help with meds, brief changes, whatever I could I would do, or I (CMH-SW KK) would sit there with him, distract him, and prep him for what staff would be coming to do, and that would go well The Behavioral Plan our specialist (Behavior Specialist at CMH PP) who specializes in Developmental Disabilities put into place was basically one to how to develop a relationship with him (Resident #101) We had a meeting with Medical Director (MD) OO, FM JJ, DON B, LPN V, RVP C and myself (CMH-SW KK) this was in February 2020 the meeting was at the facility in the NHA office- (FM JJ) did a nice job of addressing his concerns with care for (Resident #101), staffing shortages, and approaching (Resident #101) CMH-SW KK reported we did talk about the 'Behavioral Care Plan the (Ombudsman-Omb U), was on speaker and she asked if they (facility staff) were using the Care Plan from CMH, they (MD OO, FM JJ, DON B, LPN V, RVP C) all looked around and someone said . one of the nurses was using one of the steps . CMH-SW KK reported (RVP) C was focused on let's move forward Review of an Annual Resident Assessment from Community Mental Health dated 6/5/19 revealed, Presenting problem: This annual reside nt review was requested by the staff of (facility name omitted) on behalf of (Resident #101) and his guardian (FM JJ). The 3877 identifies staff have identified that (Resident #101) has a [DIAGNOSES REDACTED]. Subjective evaluation.(Resident #101) was approached in his room where he was found sitting calmly in a chair, looking forward and not at the TV that was slightly off and in front of him. (Resident #101) The OBRA social worker (CMH-SW KK), stood outside of his (Resident #101) door, greeting him, and asking permission to enter. He (Resident #101) smiled and motion with his hand for the social worker (CMH-SW KK), to enter and said come here. He (Resident #101) asked the social worker (CMH-SW KK), politely for a (Resident #101) dollar, fake money he is able to earn for desired behaviors and reimbursement for pop. He (Resident #101) was given one. (Resident #101) was asked how he (Resident #101) was and respon (TRUNCATED)

This citation pertains to Intakes: MI 42, MI 759. Based on interview and record review the facility failed to prevent a discharge that was chaotic, causing much anxiety a resident and a durable power of attorney (DPOA)/family member in 1 of 6 residents (Resident #101) reviewed for discharge, resulting in increased anxiety, fear and the potential for increase in isolation/inability to communicate with family members during a global pandemic. Findings include: Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/18/20 revealed a Brief Interview for Mental Status (BIMS) score of 99 meaning Resident #101 was unable to complete the assessment, Resident #101 was severely cognitively impaired. Review of a Communication noted signed by (LPN) DD on 6/15/2020 18:13 COMMUNICATION - spoke with Family Member (FM) JJ .and gave him update . (Resident #101) behaviors, he (FM JJ) was asking if we (facility staffing/nursing/SS) has called CMH/SW KK and (FM JJ) said they (CMH) should be able to help with his behavior and (Resident #101) needs more attention when he does not get it, the behavior starts etc .he (FM JJ) also said (CNA I) is one of (Resident #101's) favorite CNA's at the facility will be in tomorrow everything should go back to normal. During an interview on 8/4/20 at 11:40 a.m., CNA R reported she and LPN DD were going to do care on (Resident #101) on June 12th. CNA R reported (Resident #101's) legs were up, and she (CNA R) was helping (Licensed Practical Nurse - LPN DD) turn his (Resident #101) attention towards her because she was one of the staff he (Resident #101) was easily re-directed by. CNA R stated (Resident #101) was swatting his arms at LPN DD and somehow while I was bending over, I was kicked in the face. (CNA R) reported (Resident #101) did not intentionally try to kick me, while he was in the hoyer his leg went up with momentum and all of a sudden crack I felt that feeling like salt water in my nose, and I don't recall anything after that. CNA R reported she was told by LPN DD to go report the incident, and then she (CNA R) drove herself to the emergency room . CNA R stated, I feel horrible, I know he (Resident #101) would never have intentionally kicked me to hurt me, I cannot imagine what he is going through right now, I am very sad about this. I was unable to say good bye to him, and also whenever (Resident #101) did have behaviors, he always would apologize to the staff and say 'I'm sorry, I'm sorry, did I hurt you?, I'm sorry'. Many of his behaviors of grabbing were because he (Resident #101) was afraid of the hoyer lift and would say 'I fall, I fall, I hurt, I hurt'. He really was just like a little kid. CNA R reported she does not believe his behaviors were any worse that day, than they were another other day since she has known him. CNA R indicated the staff that were successful with (Resident #101) were the staff that took the time to get to know him, stay consistent with re-direction, and treat him with respect. CNA R reported she thinks moving him (Resident #101) was devastating to him, and he was probably very afraid, agitated, and alone at the psychiatric hospital in (bordering state). Review of Resident #101's progress notes revealed: Social Services Director CC 6/17/2020 16:20 Psychosocial Note Text: SW along with Executive Director- (Nursing Home Administrator-NHA A) called guardian/ (FM JJ) to inform him that a petition had been completed for resident to receive inpatient psychiatric care. SW explained that resident was a danger to himself/others and so an evaluation was going to take place. Guardian/ (FM JJ) did verbalize his disagreement with this decision and felt that having a telephone conversation with ombudsman and CMH (community mental health) would better serve his brother. Guardian/ (FM JJ) was informed that ombudsman would be notified of this discharge. Ombudsman was notified of decision that facility was seeking inpatient psychiatric care for resident. Review of Resident #101's progress notes revealed: Social Services Director CC 6/17/2020 18:05 COMMUNICATION - with Family/NOK/POA Note Text: SW and Executive Director (Nursing Home Administrator-NHA A) spoke with guardian/(FM JJ) and informed him that at this time facility was unable to secure evaluation at psychiatric hospital . Guardian/ (FM JJ) remains frustrated over situation. Guardian/ (FM JJ) does not feel that his brother (Resident #101) warrants hospitalization . Guardian/ (FM JJ) does acknowledge that resident is physically aggressive. Conversation concluded that this writer and ED would remain in touch with guardian/ (FM JJ) as needed regarding evaluation and perhaps subsequent psychiatric hospitalization . During an interview on 7/28/20 at 4:30 p.m., Family Member (FM) JJ reported on June 12th, 2020, he received a phone call regarding (Resident #101) having increased behaviors and ultimately had inadvertently kicked a Certified Nurse Aide (CNAR) in the face striking her nose. FM JJ indicated he was told that (CNA R) and Registered Nurse (RN) NN had Resident #101 in a Hoyer lift being transferred into his bed. FM JJ reported (CNA R) and himself had spoken after the incident. FM JJ reported (CNA R) told him she and (RN NN) were transferring Resident #101 from his broda (high back wheelchair) to bed. FM JJ indicated the report that was given to him about the incident was Resident #101 was not happy with the nurse (RN NN). FM JJ reported between himself, a privately paid companion (CMP II) and a select few staff members at the facility were working diligently on Resident #101's behaviors prior to the incident with (CNA R). FM JJ stated, The next thing I knew on June 17th, 2020, a staff member told me they (upper management) were shipping (Resident #101) out of the facility. FM JJ reported on June 17th, 2020 Registered Nurse (RN) F assisted Psychologist LL who wrote the Clinical Certification for (Resident #101) to be hospitalized for [REDACTED]. FM JJ stated I was not notified of it on paper, nor did Psychologist LL reach out to me (FM JJ). FM JJ reported on June 18th he (FM JJ) got the call that the facility was transferring (Resident #101) in the early afternoon for an emergency psychiatric evaluation because of the staff (CNA R) being injured. FM JJ reported he spoke with the local Ombudsman (Omb) U who then notified Nursing Home Administrator A that this transfer was not an emergent transfer, since the incident happened over a week ago. FM JJ stated I don't understand why this was so emergent because (Resident #101) hit another resident a week or so prior to kicking (CNA R) in the face. FM JJ reported when they called him on the 17th to inform him (FM JJ) of their plan to send (Resident #101) out, FM JJ immediately requested a second opinion which the facility denied. FM JJ reported they lied to me, they (the facility staff/management) did not contact me and tell me it was a petition and cert (certification) for a psychiatric inpatient hospital in another state. FM JJ asked for the paperwork to appeal, with no avail, from the facility. FM JJ reported the facilities petition failed to establish a clinical need, imminent harm to himself or others. FM JJ indicated (Resident #101's) behaviors have been overall the same since admission. FM JJ asked why didn't they transfer him back then?. FM JJ stated they sent him (Resident #101) to (bordering state) away from family, myself- (FM JJ), his Companion (CMP II), the staff who worked and cared for him. FM JJ stated (Resident #101) is now in a psychiatric hospital in a completely different State, so lethargic I cannot even talk to him on the phone, he's so drugged up. He (Resident #101) is not able to see anyone he knows, I am sure he (Resident #101) is extremely scared, anxious, and the staff there are probably giving him medications to keep him asleep. I have no resources now to work with as he (Resident #101) is in a completely different State. FM JJ stated (Resident #101) most likely feels very abandoned. FM JJ expressed extreme frustration with the entire situation. During an interview on 7/29/20 at 2:30 p.m., DON B reported she was unsure why (Resident #101) was not sent out for psychiatric evaluations when he had made physical contact with other residents, staff, and the MD OO when she alleged he (Resident #101) assaulted her on initial consultation. DON B stated once (CNA R) was injured (broken nose/concussion) NHA A finally got support from above (meaning corporate), the decision was made to transfer (Resident #101) out. During an interview on 7/29/20 at 12:02 p.m., LPN V reported she is unsure why the transfer discharge happened almost a week after the incident with (CNA R), and why (Resident #101) has not been emergently or involuntary transferred in the past with the amount of behaviors (Resident #101) has had, including at times resident to resident altercations. LPN V reported another resident was hit by (Resident #101) about a week before (CNA R) was kicked in the face. LPN V reported (Resident #101) has had behaviors since his admission in 2018. LPN V stated when (CNA R) got hurt, we (staff) finally had (NHA A) who was 'willing to go the distance, went to the next level and pursued it'. (meaning the transfer/discharge of Resident #101 to a psychiatric hospital in another State) During an interview on 7/29/20 at 4:45 p.m., NHA A reported on June 12th, 2020 (CNA R) came up to her (NHA A) to report that (Resident #101) kicked her in the nose during a transfer with a hoyer lift. NHA A reported We did not petition (Resident #101) on that afternoon (June 12th, 2020 a Friday) because we did not know the magnitude of the injuries to (CNA R). NHA A reported the petition and cert was completed on June 17th, and (Resident #101) was transferred on June 18th, 2020. (nearly a week after the incident-June 12th, 2020). During an interview on 7/30/20 at 2:11 p.m., Social Services Assistant (SSA) H reported he has known (Resident #101) since his admission in 2018. SSA H reported at no time during the last 2 years did he initiate an alternative placement that could meet the behavioral needs of (Resident #101). SSA H reported it was talked about often with the IDT team, but it never went anywhere. SSA H stated I did not try to find placement for (Resident #101), it was not in my pay grade. SSA H stated we were told to sit on it, and we are not going to do anything SSA H reported that came from upper management about a year ago. SSA H reported he felt it was the injury to (CNA R) that crossed a line. During an interview on 7/30/20 at 4:00 p.m., CNA I reported she had a good rapport with (Resident #101) often coming in on off hours to de-escalate (Resident #101's) behaviors. CNA I reported she was not working when the facility transferred (Resident #101) out. CNA I reported (Resident #101) had behaviors, and there is no question about that. CNA I stated there have been plenty of opportunities for staff to learn his (Resident #101's) approach according to his care plan. CNA I stated it really did come down to following the care plan and building trust and [MEDICATION NAME] for (Resident #101). CNA I indicated his (Resident #101's) behaviors did escalate slightly with the passing of his father recently, as well as being more isolated due to Covid-19. CNA I reported (Resident #101) could or should have been transferred out a long time ago if the case was he was a danger to himself or others. CNA I stated I have a very good working relationship with (Resident #101) as well as with his family and (FM JJ) I cannot imagine how this transfer affected (Resident #101), I am sure he is very frightened. During an interview on 8/4/20 at 3:50 p.m., Activity Assistant (AA) K stated when (Resident #101) was discharged /transferred it seemed very abrupt and sudden. During an interview on 8/5/20 at 2:50 p.m., CMH-S KK reported: because of (Resident #101's) developmental disability it was determined that Community Mental Health would collaborate behavioral interventions with the facility staff and management in treating Resident #101's diagnosis. CMH-SW KK reported the Behavioral Specialist (BS) PP completed assessments in 2018, & 2019 for Resident #101. CMH-SW KK reported BS PP revised the 1st one due to what the staff told her on his response was to some of these interventions for Resident #101. CMH-SW KK reported she typically met with Resident #101 weekly, to provide visits but also for training with his behaviors especially during difficulty with medication pass, toileting, etc. CMH-SW KK indicated there was a struggle (at the facility) they (staff) would define him a violent, and sexually inappropriate. CMH-SW KK indicated Resident #101 would make some gestures most likely from learned from TV. CMH-SW KK stated I don't think he (Resident #101) knew what that meant, over the years he would do these mostly out of entertainment. When he (Resident #101) would grab me, I would ask do you want to arm wrestle, and he (Resident #101) would then do that. He (Resident #101) was mentally disabled, but could talk to him, and work your way through that. It is different from dementia. CMH-S KK reported she was surprised that when (FM JJ) called to say he was going to be admitted to a psychiatric hospital out of State. CMH-S KK stated I asked why, because these behaviors were baseline, and that was on admission. Review of facility meeting minutes that were provided to this surveyor on a word document, typed, undated from Director of Nursing (DON) B revealed: We had a resident by the name of (Resident #101) who was sent on an Emergent Transfer due to progressive behaviors that included daily hitting, biting, and scratching of staff; hit a resident who entered his room, and gave a broken nose with a concussion to an aide (CNA R) who was caring for him.Guardian (FM JJ) was not happy with the transfer and asked us to change our mind about sending him out . This surveyor was made aware this document was for the facilities legal department by Confidential Informant (CI) QQ. Review of a facility Policy titled Transfers and Discharges with a revision date of 6/3/20 revealed: Policy: As members of the interdisciplinary team, social services and nursing staff will participate in all transfers and discharges. Transfers and discharges will be handled appropriately to ensure proper notification and assistance to residents and families in accordance with federal and state specific regulations. The facility will provide equal care regardless of diagnosis, severity of condition, or payment source. Transfer and discharge policies are the same for residence regardless of payer source. Further review of this policy revealed the facility may not transfer a discharge the resident while the appeal is pending unless the failure to discharge her transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

This citation pertains to Intakes: MI 42, MI 759, MI 958 Based on interview and record review, the facility failed to follow the facility policy and procedure regarding care planning for behavioral management for 1 out of 6 residents (Resident #101) reviewed for comprehensive care plans, resulting in the potential for impaired physical, mental, and psychosocial well-being. Findings include Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/18/20 revealed a Brief Interview for Mental Status (BIMS) score of 99 meaning Resident #101 was unable to complete the assessment, Resident #101 was severely cognitively impaired. During an interview on 7/28/20 at 4:30 p.m., Family Member (FM) JJ reported on June 12th, 2020, he received a phone call regarding (Resident #101) having increased behaviors FM JJ reported (Resident #101) was being followed closely by the local Community Mental Health (CMH) for over 2 years. FM JJ reported CMH OBRA Coordinator/Social Worker (CMH-SW) KK had been coming (pre-Covid 19) to see him (Resident #101) on a weekly basis and a behavioral specialists at CMH completed 2 (2018 & 2019) extensive behavioral care plans which were in great detail on what to do, how to approaching him (Resident #101) along with extensive interventions based on the in depth assessment. FM JJ reported these care plans were very detailed and were a tool to be used by staff (at the facility) on how to redirect any negative behaviors, refusals of care/medications for (Resident #101). FM JJ indicated this has been going on for a while. FM JJ reported staff and higher management do not follow the care plan. FM JJ stated, We (RVP C, Ombudsman (OMB U), CMH-SW KK, Director of Nursing (DON B), and other staff) had a conference which was held early part of the year before Covid-19 where we discussed concerns with neglect, lack of showers, short staffing, residents being left wet and soiled. FM JJ reported nothing has changed, its just gotten worse, for (Resident #101). Review of a Community Mental Health-Behavior Plan-(Care Plan)-Date of Functional Analysis 6/5/19 revealed: Challenging Behavior In Functional Analysis: Physical Aggression-Hitting, spitting, biting, scratching, pulling another person toward him and then hitting, spiting, scratching or biting. Pushing Bed Alarm at Night-Consists of purposefully setting off the bed alarm with his foot or rolling onto the safety air mattress at night. Unbuckling in Wheelchair-Consists of unbuckling his support belt in his wheelchair and slumping down to the point where he could fall to the ground. Sexually Inappropriateness-Consists of using sexual language, grabbing himself in the private area or exposing himself while not in his room. Verbal Aggression-Yelling profanities at another person, making threats of harm to another person, name calling. Desired Behavior: Requests attention, needs and wishes in an appropriate manner. Improve sleep hygiene. Maintain safe behavior in wheelchair. Increase appropriate social language. Increase appropriately expressing feelings. Goal: To be happy. Proactive Measures: Staff will praise (Resident #101) for all positive social interactions. Staff will provide (Resident #101) with as much consistency and predictability as possible. When you need to any care with (Resident #101) a calm, nice and engaging approach should be used for example.Hey (Resident #101) can I talk to you for a minute? or Hey I have a question for you. this helps (Resident #101) feel as though he is in control of the conversation. (Resident #101) can do his favorite activities in his room, however it is important for him to be involved in daily activities that get him out of his room in a safe manner. Provide the scheduled and on a regular basis to aid in gaining consistency in his schedule. Appropriate social touch and affection are important to (Resident #101), however if holding hands make a staff uncomfortable, staff should find a way to give (Resident #101) that positive interaction on their own comfort level. for example a pat or run on the back, or high fives. Provide as much concrete information with (Resident #101) as possible. In the nursing home setting it is understandable that emergencies arise, however try to stick to a plan with (Resident #101) as much as possible. Give (Resident #101) choices when possible. It may be best to limit 2-3 to prevent him from being overwhelmed .Staff should provide (Resident #101) with as much exercise as possible that will be safe for him to complete. (Resident #101) enjoys movement and has a lot of energy .While physical exercise ins important, different ways to keep (Resident #101) mentally stimulated would be beneficial for him as well Different incentive items may be beneficial to keep one item from losing it's motivational power such as different foods that would be a treat, fake dollar, creativity can be used to find different items he would like. (Resident #101) wants to stay in control of his situations. Keeping interactions positive will help build a better relationship and create less defiance using not getting to do something or get something will likely increase stubbornness to comply. Staff should do their best to focus spinning all requests in a positive manner and focus on what he can do and can earn etc . For example telling (Resident #101) I wont take you on a walk if you hit/bite while I change you. Will be less effective than stating, I will talk you on a walk if we get you changed without hitting/biting.It is staffs responsibility to maintain a positive environment for (Resident #101), regardless if (Resident #101) is being positive and pleasant or not. (Resident #101) will feed off of negative from staff. During an interview on 7/29/20 at 11:10 a.m., Licensed Practical Nurse (LPN) BB reported a few times CMH staff came and went over some approaches to use when (Resident #101) is having behaviors. LPN BB reported most staff do not use those approaches, and many times when (Resident #101) is having a behavior, it's because that staff is rushing him, or walks into his room without using a softer approach. During an interview on 7/29/20 at 12:02 p.m., LPN V reported (Resident #101) was childlike with his behaviors like a child throwing a tantrum. LPN V indicated his cognitive status/age was about the age of a 5-year-old. LPN V reported (CMH/SW KK) visited often, and Resident #101's behaviors were easily re-directed by herself (LPN V), and (CMH/SW KK), along with a few other staff, including (Certified Nurse Aide/CNA I) During an interview on 7/29/20 at 2:30 p.m., DON B reported the facility management team has been discussing behaviors of (Resident #101) every week, and many daily reports. DON B reported (Resident #101's) behaviors have been consistent since she (DON B) started working at the facility approximately 10 months ago. DON B reported she did not reach out to CMH since Covid-19, or update/implement any new approaches for (Resident #101's) Facility Care Plan which has very little of the extensive CMH Care Plan and assessment done in 2018 & updated in 2019 . During a telephone interview on 7/30/20 at 12:30 p.m., Registered Nurse (RN) F reported (Resident #101) always had behaviors of yelling out, swearing, hitting, or tugging at staff while they were providing care. RN F indicated overall (Resident #101's) behaviors are the same behaviors he's had since admission; some days are better than others. it depends on who is taking care of him, and how they approach him. During an interview on 7/30/20 at 2:11 p.m., Social Services Assistant (SSA) H reported he has not updated (Resident #101's) care plan recently. SSA H reports he did no go back to CMH's extensive care plan and look into any interventions or information that would have been helpful for (Resident #101). During an interview on 7/30/20 at 4:00 p.m., CNA I reported she had a good rapport with (Resident #101) often coming in on off hours to de-escalate (Resident #101's) behaviors. CNA I stated there have been plenty of opportunities for staff to learn his (Resident #101's) approach according to his care plan. CNA I stated it really did come down to following the care plan and building trust and [MEDICATION NAME] for (Resident #101). CNA I reported CMH staff came in a few times for training and answered questions the staff had in relation to de-escalating behavior of (Resident #101). CNA I reported the training was great, but the staff trained either forgot about those approaches, don't try, or quit the job. CNA I reported she does not believe anyone has updated (Resident #101's) care plan for behaviors, and new individualized interventions in quiet a while During an interview on 8/4/20 at 11:40 a.m., CNA R indicated the staff that were successful with (Resident #101) were the staff that took the time to get to know him, stay consistent with re-direction, and treat him with dignity and respect, and follow the care plan. During an interview on 8/4/20 at 12:45 p.m., Resident #101's private paid Companion (CMP) II reported during her time in the afternoons with (Resident #101) when staff would come in they rushed or demanded things of (Resident #101) that would escalate his behaviors. CMP II reported everyone knew his cognition was that of a 5-6-year-old. CMP II reported those staff were very impatient, complained about him in front of him, rush through his care, sometimes force him to change or make threats to take something away he cared about. CMP II reported despite the fact he had behaviors at the facility, he liked it there. During a telephone interview on 8/4/20 at 1:35 p.m., OMB U reported (Resident #101) has been discussed on almost every visit she has made to the facility. OMB U reported on numerous occasions she has made suggestions, given community resources, but over the last year it has been out of control. OMB U reported when RVP C was acting as NHA last year (Fall 2019-March 2020) many conversations were had with him (RVP C, DON B, FM JJ, & OMB U) reported there was a Care Conference early March 2020 with complaints of neglect, cold food, no showers, among other issues at the facility. OMB U reported RVP C would always minimize the issues, or say we're working on it OMB U stated The facility knew (Resident #101's) needs when they admitted him in 2018. During an interview on 8/5/20 at 10:40 a.m., Maintenance Director (Mtn) D sreported he has known (Resident #101) since admission, and reported there haven't been many if any special training's offered by the facility to assist the staff with dealing with his type of behaviors. Mtn D reported there may have been a training done through CMH, but he (Mtn D) cannot recall when. Mtn D reported no in-services, emails, notes on (Resident #101's) door on how to approach. Review of a Communication noted signed by Licensed Practical Nurse revealed: (LPN) DD 6/15/2020 18:13 COMMUNICATION - spoke with Family Member (FM) JJ .and gave him update . (Resident #101) behavior, he (FM JJ) was asking if we (facility staffing/nursing/SS) have called CMH/SW KK and (FM JJ) said they (CMH) should be able to help with his behavior and (Resident #101) needs more attention when he does not get it, the behavior starts etc .he (FM JJ) also said Certified Nurse Aide (CNA) I (CNA I is one of Resident #101's favorite CNA's at the facility) will be in tomorrow everything should go back to normal. During an interview on 8/5/20 at 2:50 p.m., CMH-S KK reported: because of (Resident #101's) developmental disability it was determined that Community Mental Health would collaborate behavioral interventions with the facility staff and management in treating Resident #101's diagnosis. CMH-SW KK reported the Behavioral Specialist (BS) PP completed assessments in 2018, & 2019 for Resident #101. CMH-SW KK reported BS PP revised the 1st one due to what the staff told her on his response was to some of these interventions for Resident #101. CMH-SW KK reported she typically met with Resident #101 weekly, to provide visits but also for training with his behaviors especially during difficulty with medication pass, toileting, etc. CMH-SW KK indicated there was a struggle (at the facility) they (staff) would define him a violent, and sexually inappropriate. CMH-SW KK reported he (Resident #101) was mentally disabled, but you could talk to him, and work your way through that, It is different from dementia CMH-SW KK stated As things progressed there lots of meeting, his brother (FM JJ), nursing staff, CNA's, Activities, RVP C . (FM JJ) also spent a lot of time there, he (FM JJ) understood it was unique situation, he (FM JJ) also provided a lot of staff training, and ensuring they (staff) weren't startled from him (Resident #101) CMH-SW KK reported we spoke about the fact that nursing staff was NOT using the behavior plan and interventions, they (the management team) sort of ignored it. The nursing staff did NOT reach out for help. I (CMH-SW KK) made it clear that we were available. CMH-SW KK reported during Covid -19 she had reached out the new Social Services Director (SSD) O to bring her up to speed. CMH-SW KK stated, I left her a messages, she (SSD O) did not return the messages. I am unsure why we did not connect. CMH-SW KK reported she had called the facility with no return calls. CMH-SW KK indicated Social Services Assistant (SSA) H has not reached out. Review of an Annual Resident Assessment from Community Mental Health dated 6/5/19 revealed. Presenting problem: This annual resident review was requested by the staff of (facility name omitted) on behalf of (Resident #101) and his guardian (FM JJ). The 3877 identifies staff have identified that (Resident #101) has a [DIAGNOSES REDACTED]. Subjective evaluation. (Resident #101) was approached in his room where he was found sitting calmly in a chair, looking forward and not at the TV that was slightly off and in front of him. (Resident #101) The OBRA social worker (CMH-SW KK), stood outside of his (Resident #101) door, greeting him, and asking permission to enter. He (Resident #101) smiled and motion with his hand for the social worker (CMH-SW KK), to enter and said come here. He (Resident #101) asked the social worker (CMH-SW KK), politely for a (Resident #101) dollar, fake money he is able to earn for desired behaviors and reimbursement for pop. He (Resident #101) was given one. (Resident #101) was asked how he (Resident #101) was and responded by asking if the social worker (CMH-SW KK), was working tomorrow. When she said yes, she was working, but not at the facility, he (Resident #101) asked where and she said she did not know. When asked if he (Resident #101) could go, she said no and he (Resident #101) laughed. He (Resident #101) complemented the social workers (CMH-SW KK), appearance in a polite way and smiled. He (Resident #101) then asked if he could hold the social workers hand. He (Resident #101) was told he could shake it and when the hand was offered, he (Resident #101) grabbed her (CMH-SW KK), fingers in a pinching manner. He (Resident #101) was asked to be gentle he continued to pinch. The social worker (CMH-SW KK), removed her hands from him and he (Resident #101) stated F**k You and asked the social worker (CMH-SW KK), to leave which she did. Objective evaluation. (Resident 101) has exhibited a number of behavioral issues with varying intensity since he was admitted to the facility including hitting, kicking, and spitting, rolling himself out of bed, smearing feces, and using sexually inappropriate language .The behaviorist (CMH Behaviorist PP) through CMH has noted that nursing facility staff have not engaged consistently when she (CMH Behaviorist PP) has offered interventions. Staff were concerned about being able to meet his (Resident 101) behavioral needs and questions in the nursing facility setting was the most appropriate place for him. (Resident 101) has a strong inner circle of caregivers at the facility staff reports good days and bad days in which he is verbally and physically aggressive .He (Resident 101) has 3 caregivers who his brother pays for, that present 5 days per week for 2 hours per day to provide one to one (1:1) attention and socialization for him (Resident 101) .His brother named (LPN V) and (CNA I) as facility staff who are specially committed to caring for his brother (Resident 101) and have good relationships with him .(CNA I) is assigned to (Resident 101) often who has a great relationship with him (Resident 101) and presents as understanding how to approach him (Resident 101), manage his negative behaviors and engage him (Resident 101) in pro-social behaviors .She (CNA I) has attempted to share her approaches and other interventions with colleagues with minimal success . (FM JJ) has expressed concerns related to short staffing. Staff from the Ombudsman office has been in contact with (CMH-SW KK), the guardian (FM JJ), and nursing facility staff regarding these and other care concerns and treatment of [REDACTED]. The guardian indicated there has been a lot of change over in the staff at the several last months including administration, social worker, nursing, and CNA's. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.17.1, Chapter 2: Assessments for the Resident Assessment Instrument (RAI), revealed .Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan . Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.17.1, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care . Review of Fundamentals of Nursing (Potter and Perry) 8th edition revealed, If the patient's status has changed and the nursing [DIAGNOSES REDACTED]. An out of date or incorrect care plan compromises the quality of nursing care. Review and modification enable you to provide timely nursing interventions to best meet the patient's needs .It is necessary to revises related factors and the patient's goals, outcomes, and priories. Date any revisions. Revise specific interventions that correspond to the new nursing [DIAGNOSES REDACTED]. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 257-258 the requisite knowledge to complete an accurate assessment .Review of the MDS 3.0 RAI Manual v1.16, Chapter 3 Section N: Medications, revealed .The intent of the items in this section is to Revisions need to reflect the patient's present status. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 257-258

This citation pertains to Intakes: MI 42, MI 759, MI 707. Based on observation, interview and record review the facility failed to ensure there was sufficient skilled and competent nursing staff to provide nursing and related services for 4 of 6 sampled residents (Resident #101, Resident #102 and #105 & Resident #106) reviewed for sufficient staffing, resulting in: 1.) a lack of sufficent staff to prevent a resident to resident incident for Residents #101 & #106, 2.) neglect, psychosocial harm, increased behaviors and agitation for Resident #101, and 3.) lack of activities of daily living assistance for Resident #102 and Resident #105. Findings include: Resident #106 Review of a Face Sheet revealed Resident #106 was a [AGE] year old female originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sheet ((MDS) dated [DATE] revealed Resident #106 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated Resident #106 was severely cognitively impaired. Review of Resident #106's progress notes revealed: Registered Nurse (RN) F documented on 5/30/2020 17:43 Behavior Note Text: (Resident #106) was observed going into (Resident #101's room) and this writer tried redirection and education related to (r/t) (Resident #101's) behaviors. She (Resident #106) started down the hallway and next thing she (Resident #106) is observed sitting in his (Resident #101's) room closer this time, while (Resident #101's) was yelling at her to go, and tried kicking her. Educated again r/t safety and not being in their room. She stated that 'he called me to come in'. Educated about safety and that she could be hurt if she continued to go into that room and that this writer does not want to see that happen and pleaded that she please stay out of his room. Review of Resident #106's progress notes revealed: Registered Nurse (RN) F documented on 6/4/2020 08:38 Behavior Note Text: Observed (Resident #106) in Room (room # omitted) going through another resident's bed side dresser. Education provided as these were not her belongings and that her (Resident #106's) room was (room # omitted) and that was where her belongings were. Resident (Resident #106) was assisted out of (room # omitted) and into the hallway where she was observed heading to her room. Review of Resident #106's progress notes revealed Registered Nurse (RN) F documented on 6/4/2020 12:48 Behavior Note Text: Observed (Resident #106) sitting in room (room # omitted). educated that she (Resident #106) was in the wrong room and this writer requested that she come out into the hall r/t (Room # omitted) not wanting people in their area. She (Resident #106) remarked that she (Resident #106) is their friend. Informed that while she (Resident #106) may be, that resident is not in there and requested again that she (Resident #106) come out into the hallway. She (Resident #106) obliged then wandered down the hall. Review of Resident #106's progress notes revealed Registered Nurse (RN) F documented on 6/4/2020 18:18 Behavior Note Text: (Resident #106) was escorted out of and educated r/t (Resident #101's) room and not going into their room r/t safety. She (Resident #106) continued to wheel into his (Resident #101's) doorway and into his room. She (Resident #106) just stared blankly at this writer during education. She (Resident #106) would then go down the hall in her WC into another resident's room and needed redirection from there. Reported from other hall nurse that (Resident #106) was found sitting in room (Room #omitted) while male residents were in the room and unaware that she (Resident #106) was in the room. She (Resident #106) was redirected back to her room. She (Resident #106) then requested assistance to get ready for bed. Education was provided r/t time of request and that staff was assisting other residents at this time with eating their dinner and as soon as meal was over that they would assist her. She (Resident #106) just sat and stared blankly again at this writer and restated well are you coming? reeducated r/t statement just made to her. She (Resident #106) headed down to her room and staff was notified of her request as soon as meals were over. Review of Resident #106's progress notes revealed RN RR documented on 6/5/2020 15:08 Infection Note Text: Nurse went in resident (Resident #101's room) after called to come in and observed 2 residents one sitting in w/c (Resident #106) and other sitting in geri-chair (Resident #101), no one was talking, staff reported to nurse that (Resident #101) just hit the other resident (Resident #106) on left thigh. immediately removed (Resident #106) away from other (Resident #101) then assessed (Resident #106) no skin mark noted, (Resident #106) denies pain. Review of Resident #106's progress notes revealed: Licensed Practical Nurse (LPN) DD documented on 6/7/2020 15:37 Health Status Note Text: (Resident #106) moved the chair which was in front of (Resident #101's room) and came into residents' room this writer was giving meds to (Resident #101). Review of Resident #106's progress notes revealed RN QQ documented on 6/7/2020 22:47 Behavior Note Text: (Resident #106) Res moved the chair and entered (Resident #101's room) times three tonight. (Resident #106) was educated on respecting other people's privacy and not entering their rooms without their permission. (Resident #106) stated understanding and agreed with me that she (Resident #106) should not be entering other residents' room. Review of Resident #106's progress notes revealed Registered Nurse (RN) F documented on 6/8/2020 16:07(Resident #106) was reported and observed to be in and out of numerous resident rooms. Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/18/20 revealed a Brief Interview for Mental Status (BIMS) score of 99 meaning Resident #101 was unable to complete the assessment, Resident #101 was severely cognitively impaired. Review of the facility reported incident (FRI) dated 6/5/20 revealed, On the afternoon of 6/5/2020 at 1:21 P.M., (Resident #106) wandered into (Resident #101) room and (Resident #101) made physical contact with a closed fist to (Resident #106) left side of thigh. CNA immediately separated residents and notified nurse of the encounter. Pain and skin assessment were completed for both residents; pain was at baseline for both residents and no skin alteration were noted. (Resident #101) is not mobile in the facility at this time and room is next to nurse station, to prevent further occurrence facility placed a removable chair to help set boundaries and limit (Resident #106) from wandering into the room until further evaluation and pending investigation outcome. Summary of the Event: CNA reported while redirecting (Resident #106) from sitting next to (Resident #101) inside his room, (Resident #101) reached out and hit (Resident #106) on her left thigh. CNA immediately separated (Resident #106) and (Resident #101) and reported to nurse. Nurse assessed both residents for pain and skin alterations and noted both residents were at baseline. Initial interventions noted placing a removable chair in front of (Resident #101) room which (Resident #106) continued to attempt to remove the chair with staff redirecting her attempts. During an interview on 7/28/20 at 4:30 p.m., Family Member (FM) JJ reported (Resident #101) has had multiple episodes of being left wet and soiled for long periods of time. FM JJ reported that certain staff do not attend to (Resident #101's) needs because they are afraid of him. FM JJ indicated if the staff was trained according to the Community Mental Health behavioral care plan, it would help them (staff) with (Resident #101's) cares. During an interview on 8/5/20 at 10:40 a.m., Maintenance Director Mtn D reported I think much of (Resident #101's) behaviors stems from not having enough staff, and a revolving door of staff. Mtn D reported when (Resident #101) has staff that have gone that extra mile to get to know him (Resident #101), his routine, his likes and dislikes, he (Resident #101) does pretty well with those staff. During an interview on 8/5/20 at 11:40 a.m., LPN DD indicated the progress notes for (Resident #101) on 6/7/20 and (Resident #106) are from a evening she (LPN DD) worked and there were not enough staff to properly supervise the residents. LPN DD reported the facility is in dire need for CNA's During an interview on 7/29/20 at 12:02 p.m., LPN V reported there is a struggle to get and keep CNA's right now. During a phone interview on 7/30/20 at 12:30 p.m., Registered Nurse (RN) F staffing at the facility is very short, especially 2nd shift. RN F states it is hard to hire and keep good CNA's. RN F reported some nurses are put on the schedule but when they come to work they are assigned CNA duties/work load instead of medication pass. During an interview on 8/5/20 at 2:50 p.m., Community Mental Health/Social Worker (CMH-SW) KK reported the facility staffing has been short as long as she has been coming to the facility since 2018. During an interview on 7/29/20 at 11:10 a.m., LPN BB reported it the facility has struggled to keep staff. LPN BB reported that staff is short, that many times showers or baths are not being done according to individual residents schedules. LPN BB reported for (Resident #101) many staff are not trained to deal with his behaviors, so certain staff wont even answer his call light, or he (Resident #101) yells out to come here. During an interview on 7/29/20 at 2:30 p.m., DON B reported the facility staffing has been a challenge to keep and retain new hires after they put them through the training portion of orientation. DON B reported there are staff that are afraid of (Resident #101) due to his behaviors. During an interview on 8/4/20 at 12:45 p.m., Resident #101's private paid Companion (CMP) II reported she was at the facility 5 days a week for approximately 3-4 hours in the afternoon. CMP II reported when staff would come in always in a rush. CMP II reported afternoon shift for CNA's, its like a ghost town at the facility. CMP II indicated call lights took a very long time, especially on 2nd shift. Resident #102 Review of a Face Sheet revealed Resident #102 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 5/12/20 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #102 was cognitively intact. During an interview on 7/28/20 at 4:00 p.m., Resident #102 reported she was completely dependant on staff to assist her with her toileting needs. Resident #102 reports she has been left wet and soiled for over an hour, especially on evening and night shifts. Resident #102 reported, The staff are so rushed, they don't listen to us. When the do my care, when they get to it, it is rough and they (staff) say 'I gotta go, I'm too busy right now' when I ask for something. Resident #102 stated, They (staff and management) are tough on us, there are unspoken looks, or attitudes. I have tried to interact with them, it's like walking on eggshells every day. They (staff) say 'you're not the only patient'. Resident #102 reported she cannot recall the last time she actually had a real shower Resident #105 Review of a Face Sheet revealed Resident #105 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 5/13/20 revealed a Brief Interview for Mental Status (BIMS) score of 8 meaning Resident #105 was unable to complete the assessment, Resident #105 was cognitively impaired. During an observation on 7/28/20 at 3:15 p.m., observed Resident #105 hollering out for staff from her room. This surveyor was located outside Resident #105's room for approximately 5 minutes. Resident #105 continued to call out of help. This surveyor entered Resident #105's room, once Resident #105 saw this surveyor and called me in. Resident #105's call light was on the floor out of her reach. Resident #105 stated could you help me get to the toilet, I (Resident #105) really have to pee (urinate). This surveyor prompted Resident #105 to use the call light, Resident #105 replied (after looking around herself) I don't know where it's at, but I have to go to the bathroom. This surveyor noticed Resident #105 becoming increasingly agitated the longer it took for staff to come in. (Resident #105's) room-mate turned the call light on for Resident #105 (by this time approximately 10 minutes had passed). Certified Nurse Aide (CNA) W entered Resident #105's room in a rushed manner, asking Resident #105 what she needed. Resident #105 could not answer CNA W for some reason. CNA W turned the call light off, and was about to walk out of the room, when Resident #105 yelled wait I have to pee. CNA W swiftly turned around, grabbing Resident #105's wheelchair, swinging her (Resident #105) around, CNA W was trying to get into the bathroom, when CNA W got Resident #105's left foot stuck between the foot pedal on the wheelchair and the door to the adjoining resident room. Resident #105 hollered out ouch, that hurt CNA W continued without saying much to Resident #105 during the transfer from Resident #105's wheelchair to the toilet. CNA W assisted Resident #105 with pulling her pants down. Resident #105 stated ohhh God that stinks, how come it smells like that (Resident #105 was in a standing position, with her pants pulled down to knees) Resident #105 questioned multiple times why her (Resident #105's) peri-area (genital) smelled so bad. CNA W did not answer Resident #105, nor did CNA W assist Resident #105 with cleaning her peri-area, or calling for assistance from another staff to help clean Resident #105's peri-area. CNA W assisted Resident #105 with a gait belt to a standing position after Resident #105 urinated in the toilet. CNA W rushed the entire encounter, the whole-while Resident #105 was expressing discomfort with the way the gait belt was positioned under her (Resident #105) breasts, lifting her shirt. During an interview on 7/28/20 at 3:35 p.m., CNA W reported she didn't mean to rush during Resident #105's care. CNA W indicated the facility is so short staffed, CNA W stated its frustrating. CNA W reported residents are missing out on their showers, call lights are taking longer than usual, and staff that was hired, have all quit. CNA W reported management is aware that the CNA's needs help, and that (managers) have nurses put on the schedule and the nurses get her and they are assigned CNA duties. During an interview on 8/5/20 at 1:00 p.m., CNA EE reported management does not help on the floor, everyone that works at the facility knows how badly the shortage of staff is. CNA EE reported staff barely has time to do complete care on their assigned group of residents. CNA EE indicated a lot of staff are afraid of management, and/or if they continue working at this facility they will lose their license or something bad is going to happen. Burnout is the condition that occurs when perceived demands outweigh perceived resources (Potter et al., 2013a). It is a state of physical and mental exhaustion that often affects health care providers because of the nature of their work environment. Over time, giving of oneself in often intense caring environments sometimes results in emotional exhaustion, leaving a nurse feeling irritable, restless, and unable to focus and engage with patients (Potter et al., 2013b) .[MEDICATION NAME] fatigue impacts the health and wellness of nurses and the quality of care provided to patients .When a nurse experiences ongoing stressful patient relationships, he or she often disengages (Slatten et al., 2011) .It is not uncommon for nurses who are experiencing [MEDICATION NAME] fatigue to become angry or cynical and have difficulty relating with patients and co-workers (Young et al., 2011). Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations 1671-1672). Elsevier Health Sciences. Kindle Edition. During a telephone interview on 8/4/20 at 1:35 p.m.,Ombudsman (OMB U) reported the facility is extremely short staffed, especially for CNA's. During an interview on 8/4/20 at 3:50 p.m., Activity Assistant (AA) K reported she has heard some residents complain about not getting their showers, and call lights taking long. During an interview on 7/30/20 at 4:00 p.m., CNA I stated. There are not enough staff on 2nd shift to complete the showers, as well as answer call lights in a timely manner. CNA I indicated staffing is very low in the facility, so low that nurses are being hired to do CNA work. During an interview on 8/4/20 at 11:40 a.m., CNA R reported there are not enough staff at the facility, its been an ongoing problem.

This citation pertains to Intakes: MI 42, MI 759, MI 958 Based on interview and record review, the facility failed to provide consistent mental health services to assist in prevention and treatment of [REDACTED].#101) reviewed for behavioral symptoms, resulting in the involuntary discharge to a out of State Psychiatric Hospital, unmet mental health needs and decline in mental health status. Findings include: Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 2/11/20 revealed Resident #101 was unable to complete the assessment and was severely cognitively impaired. The MDS indicated, Section E: Behavior. E200: Behavioral Symptom and Frequency: Physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing .) -- occurred 4 to 6 days, but less than daily. Verbal behavioral symptoms directed towards others -- occurred 4 to 6 days, but less than daily. Other behviroal symptoms not directed toward others -- behavior occurred 1 to 3 days. E800. Rejection of Care- Presence & Frequency: behavior occurred 4 to 6 days but less than daily. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 5/12/20 revealed a Brief Interview for Mental Status (BIMS) score of 99 meaning Resident #101 was unable to complete the assessment and was found to be severely cognitively impaired. The MDS indicated, Section E: Behavior. E200: Behavioral Symptom and Frequency: Physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing .) -- behavior occurred daily. Verbal behavioral symptoms directed towards others -- occurred 4 to 6 days, but less than daily. Other behviroal symptoms not directed toward others -- behavior occurred 1 to 3 days. The MDS revealed under E500 and E600 that the behaviors exhibited did not have any impact on the resident (no risk for physical illness or injury, did not interfere with care, did not significanlty interfere with social interactions) nor did the behaviors have any impact on others (did not put others at risk for physical injury, did not intrude on privacy of others, did not significanlty significantly disrupt care or living environment). The MDS indicated, E800. Rejection of Care- Presence & Frequency: behavior occurred 1 to 3 days. The MDS indicated an increase in behaviors that worsened but did not negatively impact the resident or others in the facility. Review of a Communication LPN DD documentation revealed on 5/9/2020 18:01 COMMUNICATION (Resident #101) - Family Member (FM) name omitted (FM JJ) Note Text: received call from (FM JJ) he stated that he did not receive any calls about (Resident #101) daily update since Tuesday. (FM JJ) requested that (FM JJ) needs to be called daily basis. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/18/20 revealed Resident #101 was unable to complete the assessment and was severely cognitively impaired. The MDS indicated, Section E: Behavior. E200: Behavioral Symptom and Frequency: Physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing .) -- behavior occurred daily. Verbal behavioral symptoms directed towards others -- -- behavior occurred daily. Other behviroal symptoms not directed toward others -- -- behavior occurred daily. E800. Rejection of Care- Presence & Frequency: -- behavior occurred daily. The MDS indicated Resident #101's behaviors increased since the previous assessment in May 2020. Review of a Community Mental Health-Behavior Plan-(Care Plan)-Date of Functional Analysis 6/5/19 revealed: Challenging Behavior In Functional Analysis: Physical Aggression-Hitting, spitting, biting, scratching, pulling another person toward him and then hitting, spiting, scratching or biting. Pushing Bed Alarm at Night-Consists of purposefully setting off the bed alarm with his foot or rolling onto the safety air mattress at night. Unbuckling in Wheelchair-Consists of unbuckling his support belt in his wheelchair and slumping down to the point where he could fall to the ground. Sexually Inappropriateness-Consists of using sexual language, grabbing himself in the private area or exposing himself while not in his room. Verbal Aggression-Yelling profanities at another person, making threats of harm to another person, name calling. Desired Behavior: Requests attention, needs and wishes in an appropriate manner. Improve sleep hygiene. Maintain safe behavior in wheelchair. Increase appropriate social language. Increase appropriately expressing feelings. Goal: To be happy. Proactive Measures: Staff will praise (Resident #101) for all positive social interactions. Staff will provide (Resident #101) with as much consistency and predictability as possible. When you need to do any care with (Resident #101) a calm, nice and engaging approach should be used for example.Hey (Resident #101) can I talk to you for a minute? or Hey I have a question for you. this helps (Resident #101) feel as though he is in control of the conversation. (Resident #101) can do his favorite activities in his room, however it is important for him to be involved in daily activities that get him out of his room in a safe manner. Provide the scheduled and on a regular basis to aid in gaining consistency in his schedule. Appropriate social touch and affection are important to (Resident #101), however if holding hands make a staff uncomfortable, staff should find a way to give (Resident #101) that positive interaction on their own comfort level. for example a pat or run on the back, or high fives. Provide as much concrete information with (Resident #101) as possible. In the nursing home setting it is understandable that emergencies arise, however try to stick to a plan with (Resident #101) as much as possible. Give (Resident #101) choices when possible. It may be best to limit 2-3 to prevent him from being overwhelmed. Staff should provide (Resident #101) with as much exercise as possible that will be safe for him to complete. (Resident #101) enjoys movement and has a lot of energy. While physical exercise is important, different ways to keep (Resident #101) mentally stimulated would be beneficial for him as well. Different incentive items may be beneficial to keep one item from losing it's motivational power such as different foods that would be a treat, fake dollar, creativity can be used to find different items he would like. (Resident #101) wants to stay in control of his situations. Keeping interactions positive will help build a better relationship and create less defiance using not getting to do something or get something will likely increase stubbornness to comply. Staff should do their best to focus spinning all requests in a positive manner and focus on what he can do and can earn etc . For example telling (Resident #101) I wont take you on a walk if you hit/bite while I change you. Will be less effective than stating, I will talk you on a walk if we get you changed without hitting/biting. It is staffs responsibility to maintain a positive environment for (Resident #101), regardless if (Resident #101) is being positive and pleasant or not. (Resident #101) will feed off of negative from staff. During an interview on 8/5/20 at 2:50 p.m., CMH-SW KK reported: because of (Resident #101's) developmental disability it was determined that Community Mental Health would collaborate behavioral interventions with the facility staff and management in treating (Resident #101's) diagnosis. CMH-SW KK reported the Behavioral Specialist (BS) PP completed assessments in 2018, & 2019 for (Resident #101). CMH-SW KK reported (BS PP) revised the 1st one due to what the staff told her on his response was to some of the original interventions. CMH-SW KK reported she typically met with (Resident #101) weekly to provide visits but also for training with his behaviors especially during difficulty with medication pass, toileting, etc. CMH-SW KK indicated there was a struggle (at the facility) they (staff) would define him a violent, and sexually inappropriate. CMH-SW KK stated, I don't think he (Resident #101) knew what that meant. He (Resident #101) was mentally disabled, but could talk to him, and work your way through that. CMH-SW KK reported she was surprised that when (FM JJ) called to say he was going to be admitted to a psychiatric hospital out of State. CMH-SW KK stated I asked why, because these behaviors were baseline, and that was on (Resident #101's) admission paperwork, and my (CMH-SW KK.) OBRA Screening from 2018 &2019. The Behavioral Plan our specialist (Behavior Specialist at CMH PP), who specializes in Developmental Disabilities, put into place was basically designed for staff to use to learn how to develop a relationship with him (Resident #101). We had a meeting with (Medical Director (MD) OO), (FM JJ), (Director of Nursing (DON) B), (Licensed Practical Nurse (LPN) V), (Regional Vice President (RVP) C) and myself (CMH-SW KK) in February 2020 were we talked about the Behavioral Care Plan put in place by CMH. The (Ombudsman-Omb U), was on speaker and she asked if they (facility staff) were using the Care Plan from CMH. They (MD OO, FM JJ, DON B, LPN V, RVP C) all looked around and someone said 'one of the nurses was using one of the steps .'. CMH-SW KK reported she typically met with Resident #101 weekly, to provide visits but also for training with his behaviors especially during difficulty with medication pass, toileting, etc. CMH-SW KK reported she has called the facility numerous times and left messages for SSA U, DON 'B and SSD O with no return call during the Covid-19 pandemic. CMH-SW KK stated, I have heard via FM JJ that the facility had discharged (Resident #101) out of State to a psychiatric hopsital. CMH-SW KK stated, I was sick to my stomach, why someone from the facility didn't reach out to me, or return my phone calls. CMH-SW KK reported having had no contact, in person or electronically, with Resident #101 since the beginning of the Covid-19 pandemic. CMH-SW KK reported no staff attempted to reach out to her to provide assistance with Resident #101's escalating behaviors which were likely due to the change in his routine. During an interview on 7/29/20 at 2:30 p.m., DON B reported the facility management team has been discussing behaviors of (Resident #101) every week, and many daily reports. DON B reported (Resident #101's) behaviors have been consistent since she (DON B) started working at the facility approximately 10 months ago. DON B reported she did not reach out to CMH since Covid-19, or update/implement any new approaches for (Resident #101's) Facility Care Plan which had very little of the extensive CMH Care Plan and assessment done in 2018 & updated in 2019 . During an interview on 7/28/20 at 4:30 p.m., Family Member (FM) JJ reported between himself, a privately paid companion (CMP II) and a select few staff members at the facility were working diligently on Resident #101's. FM JJ reported (Resident #101) was being followed closely by the local Community Mental Health (CMH) for over 2 years. FM JJ reported CMH OBRA Coordinator/Social Worker (CMH-SW) KK had been coming (pre-Covid 19) to see him (Resident #101) on a weekly basis and behavioral specialists at CMH completed 2 (2018 &2019) extensive behavioral care plans which were in great detail on what to do, how to approach (Resident #101) along with extensive interventions based on the in-depth assessment completed by CMH OBRA Coordinator/Social Worker (CMH-SW) KK, and CMH's Behavioral Specialists, and Psychologists/Psychiatrists for (Resident #101's). FM JJ reported these care plans were very detailed and were a tool to be used by staff (at the facility) on how to redirect any negative behaviors, refusals of care/medications for (Resident #101). FM JJ reported when (Resident #101) was agitated the majority staff were not thoroughly trained, including but not limited to the Medical Director (MD OO). FM JJ reports it's has been an ongoing process of communication breakdown between the facility management team and (Resident #101's) advocates such as myself (FM JJ), the local Ombudsman (Long Term Care Advocacy Agency), as well as many highly educated, and trained behavioralist at CMH, and (CMH-SW) KK weekly visits. FM JJ reported the leadership team at the facility failed to utilize the CMH Care Plans as well as failed to train their staff on how to approach him (Resident #101). FM JJ stated it's a simple as that. FM JJ stated the next thing I knew on June 17th, 2020, a staff member told me they (upper management) were shipping (Resident #101) out of the facility. FM JJ reported on June 17th, 2020 Registered Nurse (RN) F assisted Psychologist LL who wrote the Clinical Certification for (Resident #101) to be hospitalized for [REDACTED]. FM JJ stated I was not notified of it on paper, nor did Psychologist LL reach out to me (FM JJ). FM JJ indicated he had called the facility and asked if any of the nursing staff, or the Director of Nursing (DON) B or Social Services (SS) H had spoken to (CMH-SW) KK. FM JJ further stated they had not reached out to CMH, and they (facility management team) did not reach out to me like I've (FM JJ) asked numerous times for them to do. Review of a Communication noted signed by Licensed Practical Nurse revealed: (LPN) DD 6/15/2020 18:13 COMMUNICATION - spoke with Family Member (FM) JJ .and gave him update . (Resident #101) behavior, he (FM JJ) was asking if we (facility staffing/nursing/SS) have called CMH/SW KK and (FM JJ) said they (CMH) should be able to help with his behavior and (Resident #101) needs more attention when he does not get it, the behavior starts etc .he (FM JJ) also said Certified Nurse Aide (CNA) I (one of Resident #101's favorite CNA's at the facility) will be in tomorrow everything should go back to normal. During an interview on 7/29/20 at 12:02 p.m., LPN V reported (Resident #101) responded better to certain staff, especially staff who had a gentle approach as mentioned in (Resident #101's) care plan. LPN V reported she has not reached out to (CMH/SW KK) during Covid-19 to address his behaviors. During an interview on 7/29/20 at 2:30 p.m., DON B reported she has not reached out to the local Community Mental Health and/or the case worker (CMH/SW KK), who was doing weekly visits with Resident #101 prior to Covid -19. During an interview on 7/29/20 at 4:45 p.m., NHA A reported she has not reached out to the local Community Mental Health and/or the case worker (CMH/SW KK), who was doing weekly visits with Resident #101 prior to Covid -19. During a telephone interview on 7/30/20 at 12:30 p.m., Registered Nurse (RN) F reported she she has not reached out to the local Community Mental Health and/or the case worker (CMH/SW KK), who was doing weekly visits with Resident #101 prior to Covid -19. During an interview on 7/30/20 at 2:11 p.m., Social Services Assistant (SSA) H reported he has not reached out to CMH or (CMH/SW KK) in regards to (Resident #101's) behaviors, since her (CMH/SW KK) last visit pre-Covid-19. During an interview on 8/4/20 at 11:40 a.m., CNA R reported she does not believe Resident #101 has had any contact with his (CMP II) or (CMH/SW KK). CNA R reported the facility management and social workers haven't updated or changed anything for his (Resident #101's) behaviors. During an interview on 7/29/20 at 11:10 a.m., Licensed Practical Nurse (LPN) BB reported it was well-known that management wanted him (Resident #101) out of the facility. LPN BB reported, staff have not been trained on how to care for someone with (Resident #101's) diagnosis. LPN BB' reported a few times that CMH staff came and went over some approaches to use when (Resident #101) is having behaviors. LPN BB reported most staff do not use those approaches, and many times when (Resident #101) is having a behavior, it's because that staff is rushing him, or walks into his room without using a softer approach. During an interview on 7/30/20 at 4:00 p.m., CNA I stated there have been plenty of opportunities for staff to learn his (Resident #101's) approach according to his care plan.CNA I stated it really did come down to following the care plan and building trust and [MEDICATION NAME] for (Resident #101). During an interview on 8/4/20 at 12:45 p.m., Resident #101's private paid Companion (CMP) II reported during her time in the afternoons with (Resident #101) when staff would come in (staff that rushed or demanded things of (Resident #101)-) would escalate his behaviors. CMP II reported, Everyone knew his cognition was that of a 5-6-year-old. CMP II reported those staff were very impatient, complained about him in front of him, rush through his care, sometimes force him to change or make threats to take something away he cared about. During a telephone interview on 8/4/20 at 1:35 p.m., Ombudsman (OMB U) reported (Resident #101) has been discussed on almost every visit she has made to the facility. OMB U reported on numerous occasions she has made suggestions, given community resources, but over the last year it has been out of control. OMB U reported when RVP C was acting as NHA last year (fall 2019-March 2020) many conversations were had with him, the DON at the time, and FM JJ. OMB U reported RVP C, would always minimize the issues, or say we're working on it. OMB U stated, The facility knew (Resident #101's) needs when they admitted him in 2018. The main [DIAGNOSES REDACTED]. During an interview on 8/5/20 at 10:40 a.m., Maintenance Director (Mtn) Dstated he has heard CNA's and many nurses say thinks like 'I'll feed, change and transfer him, but I'm not about to spend any extra time with him (Resident #101)'. Mtn D reported (Resident #101) was a funny guy, playful, but if staff rushed or went into his room, without knocking or the right approach he would go off on them. Mtn D reported he thinks much of (Resident #101's) behaviors stem from not having enough staff, and a revolving door of staff, because when (Resident #101) has staff that have gone that extra mile to get to know him, his routine, his likes and dislikes, he did pretty well with those staff. Review of Resident #101's progress notes revealed: Social Services Director CC 6/17/2020 16:20 Psychosocial Note Text: SW along with Executive Director- (Nursing Home Administrator-NHA A) called guardian/ (FM JJ) to inform him that a petition had been completed for resident to receive inpatient psychiatric care. SW explained that resident was a danger to himself/others and so an evaluation was going to take place. Guardian/ (FM JJ) did verbalize his disagreement with this decision and felt that having a telephone conversation with ombudsman and CMH would better serve his brother. Guardian/ (FM JJ) was informed that ombudsman would be notified of this discharge. Ombudsman was notified of decision that facility was seeking inpatient psychiatric care for resident.

This citation pertains to Intakes: MI 42, MI 759, MI 958 Based on observation, interview, and record review, the facility failed to administer its policies, practices and procedures in a manner that displayed effective and efficient use of its resources to ensure the achievement and maintenance of the highest practicable physical, mental and psychosocial well-being of each resident, as evidenced by the following: Findings include: 1. Based on observation, interview and record review the facility failed to implement their abuse and neglect policy and procedures for 3 out of 6 residents (#101, #102 and #105) reviewed for abuse and neglect, resulting in neglect for 3 residents (#101, #102 and #105) when they were not provided showers on a weekly basis. 2. Based on interview and record review, the facility failed to: 1.) prevent a facility initiated discharge and, 2.) document in the medical record a reason for the discharge that meets the federal requirements for discharge, and 3.) provide written notification upon transfer of the facility bed hold and return policy in 1 of 6 sampled residents (Resident #101) reviewed for transfer and discharge with documentation, resulting in feelings of sustained confusion, anger, frustration for Resident #101 and the resident representative when Resident #101 was discharged to a out of State Psychiatric Hospital. 3. Based on interview and record review, the facility failed to follow implement comprehensive, person centered care plans for behavioral management for 1 out of 6 residents (Resident #101) reviewed for comprehensive care plans, from a total sample of 1 residents, resulting in the potential for impaired physical, mental, and psychosocial well-being. 4. Based on observation, interview, and record review the facility failed to ensure adequate supervision to prevent a resident to resident incident for 2 of 2 sampled residents (Resident #101 and Resident #106) reviewed for incidents, resulting the potential for resident to resident abuse to go undetected. 5. Based on observation, interview and record review the facility failed to ensure there was sufficient skilled and competent nursing staff to provide nursing and related services for 4 of 6 sampled residents (Resident #101, Resident #102 and #105 & Resident #106) reviewed for sufficient staffing, resulting in: 1.) a lack of sufficient staff to prevent a resident to resident incident for Residents #101 & #106, 2.) neglect, psychosocial harm, increased behaviors and agitation for Resident #101, and 3.) lack of activities of daily living assistance for Resident #102 and Resident #105. 6. Based on interview and record review, the facility failed to provide mental health services to treat behaviors for one (R#101) of 6 sampled residents reviewed for behavioral symptoms, resulting in the involuntary discharge to a out of State Psychiatric Hospital potential for unmet mental health needs and decline in mental health status. 7. Based on observation, interview, and record review the facility failed to provide resident choices, palatable and visually appealing food for 1 residents (Resident #102) out of 2 residents reviewed for palatable food from a total sample of 6 residents resulting in resident dissatisfaction and frustration. 8. Based on observation, interview and record review the facility failed to effectively implement infection control standards of practice for and resident using a sit to stand, or hoyer lift who required transmission based precautions, failed to properly 1.) Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/18/20 revealed a Brief Interview for Mental Status (BIMS) score of 99 meaning Resident #101 was unable to complete the assessment, Resident #101 was severely cognitively impaired. During an interview on 7/28/20 at 4:30 p.m., Family Member (FM) JJ reported (Resident #101) has had multiple episodes of being left wet and soiled for long periods of time. FM JJ reported that certain staff do not attend to (Resident #101's) needs because they are afraid of him. FM JJ indicated if the staff were trained according to the Community Mental Health behavioral care plan, it would help them (staff) with (Resident #101's) cares. Resident #102 Review of a Face Sheet revealed Resident #102 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 5/12/20 revealed a Brief Interview for Mental Status (BIMS) score of 14 meaning Resident #102 was cognitively intact. During an interview on 7/28/20 at 4:00 p.m., Resident #102 reported she was completely dependent on staff to assist her with her toileting needs. Resident #102 reports she has been left wet and soiled for over an hour, especially on evening and night shifts. Resident #102 reported, The staff are so rushed, they don't listen to us. When the do my care, when they get to it, it is rough and they (staff) say 'I gotta go, I'm too busy right now' when I ask for something. Resident #102 stated, They (staff and management) are tough on us, there are unspoken looks, or attitudes. I have tried to interact with them, it is like walking on eggshells every day. They (staff) say 'you're not the only patient'. Resident #102 reported she cannot recall the last time she actually had a real shower. Resident #105 Review of a Face Sheet revealed Resident #105 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 5/13/20 revealed a Brief Interview for Mental Status (BIMS) score of 8 meaning Resident #105 was unable to complete the assessment, Resident #105 was cognitively impaired. During an observation on 7/28/20 at 3:15 p.m., observed Resident #105 hollering out for staff from her room. This surveyor was located outside Resident #105's room for approximately 5 minutes. Resident #105 continued to call out of help. This surveyor entered Resident #105's room, once Resident #105 saw this surveyor and called me in. Resident #105's call light was on the floor out of her reach. Resident #105 stated could you help me get to the toilet, I (Resident #105) really have to pee (urinate). This surveyor prompted Resident #105 to use the call light, Resident #105 replied (after looking around herself) I don't know where it's at, but I have to go to the bathroom. This surveyor noticed Resident #105 becoming increasingly agitated the longer it took for staff to come in. (Resident #105's) room-mate turned the call light on for Resident #105 (by this time approximately 10 minutes had passed). Certified Nurse Aide (CNA) W entered Resident #105's room in a rushed manner, asking Resident #105 what she needed. Resident #105 could not answer CNA W for some reason. CNA W turned the call light off, and was about to walk out of the room, when Resident #105 yelled wait I have to pee. CNA W swiftly turned around, grabbing Resident #105's wheelchair, swinging her (Resident #105) around, CNA W was trying to get into the bathroom, when CNA W got Resident #105's left foot stuck between the foot pedal on the wheelchair and the door to the adjoining resident room. Resident #105 hollered out ouch, that hurt CNA W continued without saying much to Resident #105 during the transfer from Resident #105's wheelchair to the toilet. CNA W assisted Resident #105 with pulling her pants down. Resident #105 stated ohhh God that stinks, how come it smells like that (Resident #105 was in a standing position, with her pants pulled down to knees) Resident #105 questioned multiple times why her (Resident #105's) peri-area (genital) smelled so bad. CNA W did not answer Resident #105, nor did CNA W assist Resident #105 with cleaning her peri-area, or calling for assistance from another staff to help clean Resident #105's peri-area. CNA W assisted Resident #105 with a gait belt to a standing position after Resident #105 urinated in the toilet. CNA W rushed the entire encounter, the whole-while Resident #105 was expressing discomfort with the way the gait belt was positioned under her (Resident #105) breasts, lifting her shirt. During an interview on 7/28/20 at 3:35 p.m., CNA W reported she didn't mean to rush during Resident #105's care. CNA W indicated the facility is so short staffed, CNA W stated its frustrating. CNA W reported residents are missing out on their showers, call lights are taking longer than usual, and staff that was hired, have all quit. CNA W reported management is aware that the CNA's needs help, they (managers) have nurses put on the schedule and the nurses get her and they are assigned CNA duties. 2.) Review of an email correspondence revealed: Nursing Home Administrator (NHA) wrote: This again was not an involuntary transfer or discharge as indicated on previous email. dated Thursday, June 25, 2020 11:41 AM. Further review of the email revealed: Thursday, June 25, 2020 2:00 PM., (NHA A) I have never been a part of an appeal for an emergency transfer due to the medical evaluation and treatment that was required per a provider. The transfer was for medical evaluation and treatment. Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/18/20 revealed a Brief Interview for Mental Status (BIMS) score of 99 meaning Resident #101 was unable to complete the assessment, Resident #101 was severely cognitively impaired. During an interview on 7/28/20 at 4:30 p.m., Family Member (FM) JJ reported on June 12th, 2020, he received a phone call regarding (Resident #101) having increased behaviors and ultimately had inadvertently kicked a Certified Nurse Aide (CNAR) in the face striking her nose. FM JJ indicated he was told that (CNA R) and Registered Nurse (RN) NN had Resident #101 in a Hoyer lift being transferred into his bed. FM JJ reported (CNA R) and himself had spoken after the incident. FM JJ reported (CNA R) told him she and (RN NN) were transferring Resident #101 from his broda (high back wheelchair) to bed. FM JJ indicated the report that was given to him about the incident was Resident #101 was not happy with the nurse (RN NN). FM JJ reported he and his family have close relationships with a handful of staff members that have worked extremely well with (Resident #101). FM JJ reported he (FM JJ) believes the facilities Interdisciplinary Team (IDT- Managers) was planning on discharging the resident long before the incident with (CNA R). FM JJ reported he feels there was an ongoing pattern of staff and management that continued to treat him (Resident #101) as a competent male. FM JJ reported between himself, a privately paid companion (CMP II) and a select few staff members at the facility were working diligently on Resident #101's behaviors prior to the incident with (CNA R). FM JJ reported (Resident #101) was being followed closely by the local Community Mental Health (CMH) for over 2 years. FM JJ reported CMH OBRA (Omnibus Budget Reconciliation Act of 1987 or OBRA ' 87.) Coordinator/Social Worker (CMH-SW) KK had been coming (pre-Covid 19) to see him (Resident #101) on a weekly basis and behavioral specialists at CMH completed 2 (2018 &2019) extensive behavioral care plans which were in great detail on what to do, how to approaching him (Resident #101) along with extensive interventions based on the in depth assessment completed by CMH OBRA Coordinator/Social Worker (CMH-SW) KK, and CMH's Behavioral Specialists, and Psychologists/Psychiatrists for (Resident #101's). FM JJ reported these care plans were very detailed and were a tool to be used by staff (at the facility) on how to redirect any negative behaviors, refusals of care/medications for (Resident #101). FM JJ reported when (Resident #101) was agitated the majority staff were not thoroughly trained, including but not limited to the Medical Director (MD OO). FM JJ reports it's has been an ongoing process of communication breakdown between the facility management team and (Resident #101's) advocates such as myself (FM JJ), the local Ombudsman (Long Term Care Advocacy Agency), as well as many highly educated, and trained behavioralist at CMH, and (CMH-SW) KK weekly visits. FM JJ reported the leadership team at the facility failed to utilize the CMH Care Plans as well as failed to train their staff on how to approach him (Resident #101). FM JJ stated it's a simple as that. FM JJ stated the next thing I knew on June 17th, 2020, a staff member told me they (upper management) were shipping (Resident #101) out of the facility. FM JJ reported on June 17th, 2020 Registered Nurse (RN) F assisted Psychologist LL who wrote the Clinical Certification for (Resident #101) to be hospitalized for [REDACTED]. FM JJ stated I was not notified of it on paper, nor did Psychologist LL reach out to me (FM JJ). FM JJ indicated he had called the facility and asked if any of the nursing staff, the Director of Nursing (DON) B or Social Services (SS) H had spoken to (CMH-SW) KK. FM JJ further stated They (facility management team) did not reach out to me like I've (FM JJ) asked numerous times for them to do. FM JJ reported (Resident #101) should have had the right to see his own personal psychiatrist at CMH. FM JJ reported on June 18th he (FM JJ) got the call that the facility was transferring (Resident #101) in the early afternoon for an emergency psychiatric evaluation because of the staff (CNA R) being injured. FM JJ reported he spoke with the local Ombudsman (Omb) U who then notified Nursing Home Administration A that this transfer was not an emergent transfer, since the incident happened over a week ago. FM JJ stated I don't understand why this was so emergent, and or facility initiated, because (Resident #101) hit another resident a week or so prior to kicking (CNA R) in the face. FM JJ indicated the facility should have started the process then, or the other numerous times (Resident #101) had behaviors. FM JJ reported he was also contacted by a (Confidential Informant-(CI) EE on June 18, 2020 that management (Region Vice President (RVP) C, NHA A Director of Nursing (DON) B, Social Services Assistant (SSA H) have been discussing how to get him (Resident #101) moved somewhere else for a long time. FM JJ reported when they called him on the 17th to inform him (FM JJ) of their plan to send (Resident #101) out, FM JJ immediately requested a second opinion which the facility denied. FM JJ reported they lied to me, they (the facility staff/management) did not contact me and tell me it was a petition and cert (certification) for a psychiatric inpatient hospital in another state. FM JJ. asked for the paperwork to appeal, with no avail, from the facility. FM JJ reported he did not receive notice of a bed hold or any form of paperwork when he arrived at the facility when (Resident #101) was being transported out via ambulance. FM JJ reported the facilities petition-Cert failed to establish a clinical need, imminent harm to himself or others FM JJ stated the facilities management team Region Vice President (RVP) C, NHA A Director of Nursing (DON) B, Social Services Assistant (SSA) H and Medical Director (MD) OO are trying to base an acute episode into a something that it is not. FM JJ further stated The fact of the matter is that (Resident #101) has had the same behaviors that he has had since day 1 in this facility. FM JJ reported they (Region Vice President (RVP) C, NHA A Director of Nursing (DON) B, Social Services Assistant (SSA) H and Medical Director (MD) OO, among other staff and legal department at the facility) are claiming in that Emergency Transfer or discharge transfer was due to the fact he had hit the (CNA R) FM JJ stated if this were really the case why did they not do this a week or so before when he (Resident #101) hit the resident who wandered into his room. FM JJ indicated (Resident #101's) behaviors have been overall the same since admission. FM JJ asked why didn't they transfer him back then? . FM JJ reported they just did not want to deal with him (Resident #101) anymore . FM JJ indicated he asked for that information and was denied any correspondence.FM JJ stated they sent him (Resident #101) to a different State, away from family, myself- (FM JJ), his Companion (CMP II), the staff who worked and cared for him . FM JJ reported the facility made no attempts to face time, call or communicate with his caseworker at CMH, (CMH/SW KK) who saw him on a weekly basis until Covid-19 FM JJ stated (Resident #101) is now in a psychiatric hospital in a completely different State, so lethargic I cannot even talk to him on the phone, he's so drugged up. He (Resident #101) is not able to see anyone he knows, I am sure he (Resident #101) is extremely scared, anxious, and the staff there are probably giving him medications to keep him asleep. I have no resources now to work with as he (Resident #101) is in a completely different State. FM JJ stated (Resident #101) most likely feels very abandoned. Review of facility meeting minutes that were provided to this surveyor on a word document, typed, undated 2nd bullet point down from DON B revealed: We had a resident by the name of (Resident #101) who was sent on an Emergent Transfer due to progressive behaviors that included daily hitting, biting, and scratching of staff; hit a resident who entered his room, and gave a broken nose with a concussion to an aide (CNA R) who was caring for him.Guardian (FM JJ) was not happy with the transfer and asked us to change our mind about sending him out . This surveyor was made aware this document was for the facilities legal department by Confidential Informant (CI) QQ. During an interview on 7/28/20 at 4:30 p.m., Family Member (FM) JJ reported: FM JJ on June 18th he (FM JJ) got a call that the facility was transferring (Resident #101) in the early afternoon for an emergency psychiatric evaluation because of the staff (CNA R) being injured. (FM) JJ reported he did not receive a bed hold policy, or anything from the facility at the time of (Resident #101's) discharge on 6/18/20. FM JJ reported he was at the facility at the time of discharge for (Resident #101). During an interview on 7/30/20 at 2:11 p.m., Social Services Assistant (SSA) H reported he was unsure if a bed hold was given to (Resident #101) when he discharged to a Psychiatric facility on 6/18/20. SSA H reported he would look and get that information to this surveyor. During a phone interview on 8/4/20 at 1:35 p.m., local Ombudsman (OMB U) reported no required paperwork on discharged residents have been sent in to her (OMB U) from the (Facility name omitted) since December of 2019. OMB U reported the facility has been without a licensed 'Social Services Director (SSD) for some time, but a new (SSD CC) started recently. During an interview on 8/5/20 at 4:00 p.m., SSA H and Nursing Home Administrator (NHA) A reported they would have the bed hold, and the notification of discharges to this surveyor by 4:30 p.m., on 8/5/20. At 5:30 p.m., on 8/5/20 this surveyor had not received any further documentation from LPN V', DON B, SSA H, SSD CC or NHA 'A. 3.) Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/18/20 revealed a Brief Interview for Mental Status (BIMS) score of 99 meaning Resident #101 was unable to complete the assessment, Resident #101 was severely cognitively impaired. Review of a Community Mental Health-Behavior Plan-(Care Plan)-Date of Functional Analysis 6/5/19 revealed: Challenging Behavior In Functional Analysis: Physical Aggression-Hitting, spitting, biting, scratching, pulling another person toward him and then hitting, spiting, scratching or biting. Pushing Bed Alarm at Night-Consists of purposefully setting off the bed alarm with his foot or rolling onto the safety air mattress at night. Unbuckling in Wheelchair-Consists of unbuckling his support belt in his wheelchair and slumping down to the point where he could fall to the ground. Sexually Inappropriateness-Consists of using sexual language, grabbing himself in the private area or exposing himself while not in his room. Verbal Aggression-Yelling profanities at another person, making threats of harm to another person, name calling. Desired Behavior: Requests attention, needs and wishes in an appropriate manner. Improve sleep hygiene. Maintain safe behavior in wheelchair. Increase appropriate social language. Increase appropriately expressing feelings. Goal: To be happy. Proactive Measures: Staff will praise (Resident #101) for all positive social interactions. Staff will provide (Resident #101) with as much consistency and predictability as possible. When you need to any care with (Resident #101) a calm, nice and engaging approach should be used for example.Hey (Resident #101) can I talk to you for a minute? or Hey I have a question for you. this helps (Resident #101) feel as though he is in control of the conversation. (Resident #101) can do his favorite activities in his room, however it is important for him to be involved in daily activities that get him out of his room in a safe manner. Provide the scheduled and on a regular basis to aid in gaining consistency in his schedule. Appropriate social touch and affection are important to (Resident #101), however if holding hands make a staff uncomfortable, staff should find a way to give (Resident #101) that positive interaction on their own comfort level. for example a pat or run on the back, or high fives. Provide as much concrete information with (Resident #101) as possible. In the nursing home setting it is understandable that emergencies arise, however try to stick to a plan with (Resident #101) as much as possible. Give (Resident #101) choices when possible. It may be best to limit 2-3 to prevent him from being overwhelmed .Staff should provide (Resident #101) with as much exercise as possible that will be safe for him to complete. (Resident #101) enjoys movement and has a lot of energy .While physical exercise ins important, different ways to keep (Resident #101) mentally stimulated would be beneficial for him as well Different incentive items may be beneficial to keep one item from losing it's motivational power such as different foods that would be a treat, fake dollar, creativity can be used to find different items he would like. (Resident #101) wants to stay in control of his situations. Keeping interactions positive will help build a better relationship and create less defiance using not getting to do something or get something will likely increase stubbornness to comply. Staff should do their best to focus spinning all requests in a positive manner and focus on what he can do and can earn etc . For example telling (Resident #101) I wont take you on a walk if you hit/bite while I change you. Will be less effective than stating, I will talk you on a walk if we get you changed without hitting/biting.It is staffs responsibility to maintain a positive environment for (Resident #101), regardless if (Resident #101) is being positive and pleasant or not. (Resident #101) will feed off of negative from staff. During an interview on 8/5/20 at 2:50 p.m., Community Mental Health-Social Worker (CMH-SW) KK reported: because of (Resident #101's) developmental disability it was determined that Community Mental Health would collaborate behavioral interventions with the facility staff and management in treating Resident #101's diagnosis. CMH-SW KK reported the Behavioral Specialist (BS) PP completed assessments in 2018, & 2019 for Resident #101. CMH-SW KK reported BS PP revised the 1st one due to what the staff told her on his response was to some of these interventions for Resident #101. CMH-SW KK reported she typically met with Resident #101 weekly, to provide visits but also for training with his behaviors especially during difficulty with medication pass, toileting, etc. CMH-SW KK indicated there was a struggle (at the facility) they (staff) would define him a violent, and sexually inappropriate. CMH-SW KK reported when he (Resident #101) would grab me I (CMH-SW KK) would ask do you want to arm wrestle, and he (Resident #101) would then do that CMH-SW KK reported he (Resident #101) was mentally disabled, but you could talk to him, and work your way through that, It is different from dementia CMH-SW KK stated As things progressed there lots of meeting, his brother (FM JJ), nursing staff, CNA's, Activities, RVP C . (FM JJ) also spent a lot of time there, he (FM JJ) understood it was unique situation, he (FM JJ) also provided a lot of staff training, and ensuring they (staff) weren't startled from him (Resident #101) CMH-SW KK reported we spoke about the fact that nursing staff was NOT using the behavior plan and interventions, they (the management team) sort of ignored it. The nursing staff did NOT reach out for help. I (CMH-SW KK) made it clear that we were available . They (staff/management) would hint that this is not the most appropriate place for him (Resident #101) .(CMH-SW KK) reported this was all happening around New Year Jan/[DATE] before Covid-19. CMH-SW KK reported the Ombudsman was also notified of these concerns for (Resident #101). I (CMH-SW KK) have heard Upper Corporate say to the brother (FM JJ) if you don't like it you can take him elsewhere. CMH-SW KK reported during Covid -19 she called to all of her nursing homes in (county name omitted) county. CMH-SW KK reported she had reached out the new Social Services Director (SSD) O. I (CMH-SW KK) wanted to bring her up to speed, I (CMH-SW KK) left her a messages, she (SSD O) did not return the messages. I (CMH-S KK) am unsure why we did not connect. CMH-SW KK reported she had called the facility with no return calls. CMH-SW KK indicated Social Services Assistant (SSA) H has not reached out. CMH-SW KK stated I would think he was extremely overwhelmed with the job. During an interview on 7/29/20 at 2:30 p.m., Director of Nursing (DON) B reported the facility management team has been discussing behaviors of (Resident #101) every week, and many daily reports. DON B reported (Resident #101's) behaviors have been consistent since she (DON B) started working at the facility approximately 10 months ago. DON B reported she did not reach out to CMH since Covid-19, or update/implement any new approaches for (Resident #101's) Facility Care Plan which has very little of the extensive CMH Care Plan and assessment done in 2018 & updated in 2019. 4.) Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/18/20 revealed a Brief Interview for Mental Status (BIMS) score of 99 meaning Resident #101 was unable to complete the assessment, Resident #101 was severely cognitively impaired. Resident #106 Review of a Face Sheet revealed Resident #106 was a -year-old female, originally admitted to the facility on , with pertinent [DIAGNOSES REDACTED].#106, with a reference date of revealed a Brief Interview for Mental Status (BIMS) score of 99 meaning Resident #106 was unable to complete the assessment, Resident #106 was cognitively impaired During an interview on 7/28/20 at 4:30 p.m., Family Member (FM) JJ reported on June 5th he (FM JJ) received informing him (FM JJ also Durable Power of Attorney/Guardian) that (Resident #101) had hit another resident. FM JJ reported, he had asked what happened, and (Registered Nurse-RN RR) informed that the other resident (Resident #106) wandered into his (Resident #101's) room. FM JJ reported he asked how did he hit her? (RN RR) reported (Resident #106) wandered into (Resident #101's) room which is a private room (RN RR) was in there shortly thereafter the resident had no signs of abuse. I asked how this happened when resident is completely immobile, I was told she wandered in there as she has known wandering behaviors. Review of Resident #106's progress notes revealed: Registered Nurse (RN) F documented on 5/30/2020 17:43 Behavior Note Text: (Resident #106) was observed going into room [ROOM NUMBER] and this writer tried redirection and education related to (r/t) (Resident #101's) behaviors. She (Resident #106) started down the hallway and next thing she (Resident #106) is observed sitting in his (Resident #101's) room closer this time, while (Resident #101's) was yelling at her to go, and tried kicking her. Educated again r/t safety and not being in their room. She stated that he called me to come in. Educated about safety and that she could be hurt if she continued to go into that room and that this writer does not want to see that happen and pleaded that she please stay out of his room. Review of Resident #106's progress notes revealed: Registered Nurse (RN) F documented on 6/4/2020 08:38 Behavior Note Text: Observed (Resident #106) in Room (room # omitted) going through another resident's bed side dresser. Education provided as these were not her belongings and that her (Resident #106's) room was (room # omitted) and that was where her belongings were. Resident (Resident #106) was assisted out of (room # omitted) and into the hallway where she was observed heading to her room. Review of Resident #106's progress notes revealed: Registered Nurse (RN) F documented on 6/4/2020 12:48 Behavior Note Text: Observed (Resident #106) sitting in room (room # omitted). educated that she (Resident #106) was in the wrong room and this writer requested that she come out into the hall r/t (Room # omitted) not wanting people in their area. She (Resident #106) remarked that she (Resident #106) is their friend. Informed that while she (Resident #106) may be, that resident is not in there and requested again that she (Resident #106) come out into the hallway. She (Resident #106) obliged then wandered down the hall. Review of Resident #106's progress notes revealed: Registered Nurse (RN) F documented on 6/4/2020 18:18 Behavior Note Text: (Resident #106) was escorted out of and educated r/t (Resident #101's) room and not going into their room r/t safety. She (Resident #106) continued to wheel into his (Resident #101 (TRUNCATED)

This citation pertains to Intake #MI 812. This citation has two Deficiency Practice Statements, A & B. Deficiency Practice Statement A Based on observation, interview, and record review, the facility failed to effectively respond to a door alarm and provide adequate supervision to prevent an elopement and ensure safety in 1 of 6 residents (Resident #100) reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 6/9/20 and 6/11/20, Resident #100 exited the facility, unbeknownst to facility staff, and was returned to the facility by off duty facility staff. This deficient practice placed 9 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of the facility policy Unsafe Wandering and Elopement, last reviewed 4/15/19, revealed .Residents will be assessed for unsafe wandering and elopement indicators upon admission, readmission, change in condition, quarterly and with any unsafe wandering or elopement event utilizing the Risk of Elopement/Wandering Review form .A specific system will be implemented to notify staff that exit doors have been opened in areas accessible to residents and may include but not be limited to .Documented and routine testing of door alarms .Documented and routine testing of staff's response to alarms .Monitoring practices when door alarms are disabled or during instances of higher traffic such as holidays, special events or tours .Monitoring practices for exits that are not visible to staff but readily accessible to residents. Residents and/or family members will receive education on signing the resident in and out when leaving facility at time of admission and as indicated thereafter. Residents and/or family members will receive education on the resident's unsafe wandering and elopement management care plan and provided opportunity for feedback. All associates will be provided unsafe wandering and elopement training upon hire, annually and as indicated by the Unsafe Wandering and Elopement Performance Improvement Plans (PIPs). Elopement drills will be conducted at least quarterly. Identifying Residents Potential Unsafe Wandering and Elopement Accurate and thorough assessment of the resident is fundamental in determining indicators for unsafe wandering and elopement. Not all residents exhibit unsafe wandering behaviors or verbalize the desire to leave facility unplanned .A system of identification for Residents identified with potential for unsafe wandering and elopement will be in place, including but not limited to .Identification bracelets on wrist or ankle .Identification on or in the Resident's clothing .Current photographs of residents .Current responsible party contact information . It was noted that the policy did not include expectations for responding to a door alarm. Resident #100 Review of an Admission Record revealed Resident #100 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 6/14/20 revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated Resident #100 was severely cognitively impaired. Review of the Functional Status revealed that Resident #100 required supervision during locomotion on and off the unit with a physical assist of 1 person. Review of Behaviors revealed that Resident #100 had wandering behavior occur daily. Review of a Care Plan revealed, FOCUS: (Resident #100) At risk for elopement. History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly Date Initiated: 06/09/2020 .INTERVENTIONS: Add resident to the Elopement Book. Date Initiated: 06/09/2020 .Frequent monitoring of (Resident #100's) whereabouts in the facility. Date Initiated: 06/09/2020 .When awake one on one Date Initiated: 06/12/2020 .FOCUS: (Resident #100) has a potential for falls r/t decreased cognition/confusion, left eye [MEDICAL CONDITION]. Date Initiated: 06/09/2020. Review of Resident #100's Hospital Report dated 3/26/20 revealed, .was hit by a car on 3/7/20. He was walking across (highway) for an unknown reason. He sustained multiple injuries including right femur fracture, left fibular fracture . Review of an Incident Report dated 6/9/20 at 15:10 (3:10 P.M.) revealed, staff reported that while outside in her car by the garbage can she saw (Resident #100) come walking by and immediately got out from her car to get him when she asked what he was doing and resident said he was just going for walk, staff brought him in the facility .Immediate Action Taken: started 15 minute checks .No witnesses found Review of an Incident Report dated 6/12/20 at 01:34 (1:34 A.M.) (written for the incident that occurred on 6/11/20) revealed, .(Resident #100) on every 15 checks. Resident last saw at 1840 (6:40 P.M.) by this nurse. Then at 1850 (6:50 P.M.) resident was attempting to get outside by therapy. CENA attempted to redirect, per CENA, resident stated that he was going to hit her. CENA then went to notify 70's hall nurse. During this time resident exited the building. Nurse notified, resident's assigned nurse, at this time multiple staff started a room to room search. Staff also started outside search. Received call from (local gas station) employee that resident was there. During the time staff went to pick up resident. When staff arrived resident not on premises. Off duty staff member recognized resident and returned back to facility .No witnesses found . In an observation and interview on 6/17/20 at 9:49 A.M., Resident #100 observed walking slow and unsteady within his room. Dietary Aide (DA) D observed outside of Resident #100's room and reported to be providing 1:1 supervision. DA D reported that Resident #100 was very easy going and sleepy lately. In an interview on 6/17/20 at 11:35 a.m., Registered Nurse (RN) F reported Resident #100 eloped from the building on 6/11/20 around dinner time, while she was working on the Woods unit. RN F reported .I was in the middle of shift change and we had just had a resident fall .I heard the alarm go off and I checked the box (panel above nurses station that indicates which door alarm is sounding), when I turned around to head to check the door I saw a CNA that was closer. I yelled down to have the CNA check the door .Within a few minutes she came back to me to say he was trying to get out the door and he was being aggressive. I radioed up front for assistance and I got halfway and got pulled into a room due to a safety issue . RN F reported the alarm stopped sounding at that point and she continued her assignment. RN F reported the nurse from the Bridge unit came shortly after to ask where Resident #100 was, and at that point we began to search for the resident. RN F reported she was on the phone with 911 dispatch when she was notified he was back in the facility. RN F stated .I was told by the Supervisor on nights that an off-duty nurse was driving through the neighborhood and happened to see him . In an interview on 6/18/20 at 2:13 P.M., CNA N reported that on the 6/11/20 she was in a resident's room, assisting with the dinner meal, when she heard repeated banging in the hall and when it did not stop she went to check to see where it was coming from. CNA N reported that Resident #100 was pounding on the double doors separating the 2 units (Bridge and Woods) , which were located in close proximity to the Pond exit door. CNA N reported that Resident #100 stated to her that he was trying to go outside. CNA N reported that she informed him that the exit door was not working and then Resident #100 seemed agitated. CNA N then walked to the nurses' station on Woods unit to get someone to help with Resident #100, as she was not familiar with him. CNA N reported that she informed Registered Nurse (RN) F that Resident #100 was trying to go outside and RN F phoned Resident #100's nurse on Bridge unit. CNA N then walked back down to where she had last observed Resident #100, saw he was no longer in the area, and .figured that someone had come and taken care of him. CNA N reported that she did not check outside of the Pond exit door, because she did not hear a door alarm sounding. CNA N reported that she was not aware that Resident #100 was missing until she noticed a staff member performing room searches. CNA N reported that she did not participate in the resident search because she was assisting another resident. In an interview on 6/18/20 at 2:47 P.M., Licensed Practical Nurse (LPN) G reported that on 6/11/20 she had last laid eyes on Resident #100 at approximately 6:40 P.M. and at that time he was in his room. LPN G reported that RN F phoned her to .come and get . Resident #100 at approximately 6:50 P.M. because he was trying to go outside. LPN G reported that she did not hear a door alarm nor did she immediately check the Pond exit doors where Resident #100 was reported to be trying to exit. LPN G reported that she walked around facility .did a full circle . and was not able to locate Resident #100. LPN G reported that she then went through and checked all the rooms and when she still couldn't find him, she went back through a second time and checked all the bathrooms. LPN G reported that following the room search, RN F announced over the intercom that we needed all hands on deck to search for Resident #100 and at that point some facility staff went outside to search. LPN G reported that during the search, the facility received a call from (local gas station) employee who reported that Resident #100 was spotted in the area. Dining Room Manager (DRM) Y drove there to get Resident #100, but when DRM Y arrived in the area, Resident #100 was not there. LPN G reported that Resident #100 was then returned to the facility later by an unknown off-duty facility staff member. LPN G was not able to recall what the time was when Resident #100 was returned to the facility. In an interview on 6/18/20 at 11:05 A.M. Receptionist (REC) T reported that on 6/11/20 she was not aware that a resident was missing until she observed a nurse was searching all the rooms in the front lobby area. REC T reported that she received a phone call from an off-duty nurse that had seen Resident #100 when she was driving down the highway. REC T stated, I asked her to stop and make sure he was OK and bring him back, and she did. REC T was not able to recall what the time was or what time Resident #100 returned to the facility. In an interview on 6/23/20 at 10:15 A.M., Housekeeping Director (HSK-D) JJ reported that on 6/9/20 at approximately 2:00 P.M. she was headed outside to wash a chair when she heard the door alarm at the Pond exit sounding and visualized that the door was not latched all the way. HSK-D JJ reported that she deactivated the door alarm and proceeded to her task of washing the chair. HSK-D JJ reported that she did not search for residents nor did she alert facility staff that she had come upon a door that was alarming. HSK-D JJ reported that she reentered the building approximately 30 minutes later, she was informed by DRM Y that Resident #100 was found walking in the parking lot. HSK-D JJ reported that she could not recall having received education regarding elopements or responding to a door alarm. In an interview on 6/18/20 at 3:27 P.M., DRM Y reported that on 6/9/20 at approximately 3:10 P.M., she was on break and sitting in her car when she saw Resident #100 walking through the parking lot. DRM Y reported that Resident #100 was observed unsupervised, walking slowly and rocked as he ambulated. DRM Y reported that he was easily redirected back into the facility. DRM Y reported that on 6/11/20 she was on break and sitting in her car when she noticed another facility staff member outside .looking for (Resident #100) . DRM Y reported that she entered the facility and helped to search the rooms. DRM Y reported that the facility received a call that Resident #100 was identified at (local gas station), therefore DRM Y drove to pick him up. DRM Y reported that when she arrived at (local gas station) Resident #100 was not there, but that a customer had seen him walking down the highway. DRM Y reported .a couple minutes . later HSK-D JJ phoned and reported that Resident #100 was returned to the facility by an off-duty nurse. DRM Y reported that she had not received education regarding elopements during her employment until today. In an interview on 6/19/20 at 8:37 A.M., LPN FF reported that she was off-duty on 6/11/20, was stopped at the light on the highway (0.6 miles from the facility) when she observed Resident #100 unsupervised, in his pajamas and no shoes, .wobbly, but on the move . walking across an intersection between the gas station and the hospital. LPN FF reported that she phoned the facility at 7:04 P.M. to inform them that she had observed Resident #100. LPN FF reported that she then turned around to go back and try to pick him up. LPN FF reported that Resident #100 was pleasant and willingly entered her car. LPN FF reported that about 15 minutes had passed between the time she first observed Resident #100 and when she returned him to the facility. LPN FF reported that she had worked at least one shift since Resident #100's elopement on 6/11/20, and had not received any education nor had she spoken to anyone about the incident until this surveyor entered the facility on 6/17/20. LPN FF reported that on 6/17/20 she gave a statement regarding the incident over the phone to someone from the facility. In an observation on 6/23/20 at 1:29 P.M., the highway and intersection where Resident #100 was found during his elopement on 6/11/20, was observed with heavy multi-directional traffic and a 35 mph speed limit. In an interview on 6/17/20 at 3:20 p.m., Unit Manager P reported she was contacted on 6/11/20 at 7:06 p.m. and notified by staff that Resident #100 was not able to be located within the building or around the perimeter. Unit Manager P reported she told staff to call 911, and when she called back at 7:18 p.m. Resident #100 was back in the building. Unit Manager P stated .we are still in the process of completing the investigation. I haven't talked to everyone that was here that night . Review of Progress Note dated 6/9/2020 at 15:03 (3:03 P.M.) revealed, (Resident #100) alert and oriented to his name wandering on facility ground, staff redirect resident to his room, no injury, family and NP notify for wandering nurse intervention to start every 15 min check, nursing care continue. Review of Progress Note dated 6/9/2020 at 15:10 (3:10 P.M.) revealed, Event Note staff reported that while outside in her car by the garbage can she sow (sic) (Resident #100) come walking by and immediately got out from her car to get him when she asked what he was doing and resident said he was just going for walk, staff brought him in the facility. Nurse assessed resident no injury noted skin remain dry intact, denies any discomfort, initiate 15 min check, will notify np and family. Review of Progress Note dated 6/10/2020 at 03:28 (3:28 A.M.) Behavior Note: (Resident #100) roaming the halls of bridge unit at 01:15. All staff on unit kept eyes on him. Resident is on q 15min checks d/t elopement earlier today. While resident was roaming the halls he sat himself on the floor next to nurses station and chatted with staff. No complaint of pain; stated he just wanted to walk. finally resident went back to his room and laid down. resident is currently in his bed sleeping. Will continue to monitor. Review of Progress Note dated 6/11/2020 at 19:11 (7:11 P.M.) revealed, Behavior Note CNA reported that (Resident #100) was at the Pond Exit Door trying to push on the door sounding the alarm. She stated that she tried to redirect him from the door and he was becoming physically threatening to her. Instructed to attempt to redirect him again. Assistance to Bridge unit called to come assist staff. Review of Progress Note dated 6/12/2020 at 02:03 (2:03 A.M.) revealed, Event Note (Resident #100) on every 15 checks. Resident last saw at 1840 (6:40 P.M.) by this nurse. Then at 1850 (6:50 P.M.) resident was attempting to get outside by therapy. CENA attempted to redirect, per CENA, resident stated that he was going to hit her. CENA then went to notify 70's hall nurse. During this time resident exited the building. Nurse notified , residents assigned nurse , at this time multiple staff started a room to room search. Staff also started outside search. Received call from (local gas station) employee that resident was there. During the time staff went to pick up resident. When staff arrived resident not on premises. Off duty staff member recognized resident and returned back to facility. Review of 15-Minute Check Log initiated following Resident #100's elopement on 6/9/20 at 3:00 P.M. revealed, unidentified staff initials documented on 6/11/20 from 2:00 P.M. through 6:30 P.M., no staff initials from 6:45 P.M. through 8:30 P.M., and Hosp documented from 8:45 P.M. through 10:00 P.M. In an interview on 6/24/20 at 2:52 P.M., NHA A reported that she was .still trying to determine . which staff member was assigned to 15 minute checks for Resident #100 on 6/11/20 from 2:00 P.M. through 8:30 P.M., the time frame within which Resident #100 eloped from the facility. In an interview on 6/17/20 at 11:22 A.M., Certified Nurse Assistant (CNA) EE was working on Bridge hall and assigned to Resident #100, reported that Resident #100 had tried to exit the facility in the past, but that she was not aware of any actual elopements. CNA EE reported that she had received written education regarding elopements, but has not had time to read it. CNA EE reported that Resident #100 is the only resident in the facility at risk for elopement. In an interview on 6/17/20 at 12:21 p.m., Assistant Director of Nursing (ADON) M reported Resident #100 had several previous stays at the facility, and stated .this was the first time elopement was a significant risk. He is mobile and has a tendency to push on doors and wander . ADON M reported Resident #100 had a history of [REDACTED].I have not heard any reports of aggression now . In an interview on 6/17/20 at 11:24 a.m., CNA J reported there have been no elopement drills that she can recall in the past three years. In an interview on 6/23/20 at 1:56 P.M., CNA II reported to have heard a door alarm on 6/11/20, but was in a resident's room on Wood unit providing care. CNA II reported that she had not been aware of an elopement until later that evening when another facility staff had mentioned that Resident #100 had been found in the community. CNA II reported that prior to 6/11/20, she does not remember receiving training on elopement. In an interview on 6/23/20 at 9:13 A.M., Nursing Home Administrator NHA A reported that on 6/9/20 facility staff were not aware that Resident #100 had exited the facility until DRM Y reportedly found Resident #100 walking in the parking lot, while she was sitting in her car on break. NHA A could not recall if a door alarm sounded or if a resident search had been initiated prior to Resident #100 returning to the facility on [DATE]. NHA A reported that the only information available was the statement from the facility staff that found Resident #100 in the parking lot. NHA A reported that on 6/11/20 facility staff failed to redirect Resident #100, and respond appropriately to the door alarm, which lead to a significant elopement. NHA A reported that on 6/11/20, when Resident #100 exited the facility the door alarm at the Pond exit sounded and was deactivated, but she had not determined who had deactivated the door alarm. NHA A reported that she expected facility staff would have responded to the door alarm by first checking outdoors for residents and then assuring that all residents were accounted for. NHA A reported that the Elopement Binders are intended to alert staff to residents at risk for elopement, so that we make sure that we are watching for them. NHA A reported that if a resident were to exit the facility, she would expect that staff utilize the Elopement Binder to help identify residents. NHA A reported that the facility does not have a policy in regard to how staff are expected to respond to a door alarm, or how often elopement drills and training are performed, but that Maintenance Director (MD) E performs these periodically. NHA A reported that the facility did not have record of an elopement drill or training specific to responding to a door alarm, prior to 6/12/20. During an interview on 6/19/20 at 9:13 A.M., MD E reported that he was not made aware that he was supposed to be performing elopement drills for the facility until after Resident #100's elopement on 6/11/20. MD E reported that he had no record of when the last elopement drill was performed, prior to the one that he participated in on 6/18/20. MD E reported that his current expectation from staff during an elopement drill was .to get to the door that was alarming, turn the alarm off as soon as possible .take 10 steps out the door and go back to work. MD E could not recall how to determine that all residents were accounted for in the facility. MD E reported that he could not recall receiving any training regarding elopements, until after Resident #100 eloped on 6/11/20. Review of the Elopement Risk Binders on 6/17/20 at 12:20 P.M. revealed, Bridge and Wood unit binders located at the nurses' stations did not include a photo of Resident #100 or indicate the resident as an elopement risk. In an interview on 6/17/20 at 12:30 P.M., RN C at Bridge unit reported that the only way she knows which residents that are at risk for elopement is by knowing her residents. RN C reported that she did not have a list of all residents at risk for elopement. In an interview on 6/17/20 at 12:40 P.M., LPN GG at Wood unit reported that she was not aware of an Elopement Risk Binder. This surveyor presented the Elopement Risk Binder to LPN GG and she could not recall having seen it prior to that time, but confirmed that the residents indicated in the binder were all of the residents that were currently at risk for elopement. It was noted that this binder did not include Resident #100. In an interview on 6/17/20 at 12:40 P.M. Social Services (SS) H at Wood unit reported that the Elopement Risk Binder would indicate all residents at risk for elopement and wandering. SS H reported that the binder was implemented by the previous NHA and is no longer being used. On 6/17/20, the Nursing Home Administrator (NHA) A was notified of an Immediate Jeopardy that began on 6/9/20 when Resident #100, who was identified as an elopement risk, eloped from the facility unbeknownst to facility staff. On 6/24/20, this surveyor verified the facility completed the following to remove the Immediate Jeopardy. 1. On 6/9/2020 .The resident was returned by Dining Room Manager who intercepted in the parking lot at 3:10 PM. Resident skin and pain was assessed and was at baseline. Nursing team implement 15-minute checks on resident on 6/9/2020. Care plan was updated to reflect this intervention on 6/9/2020. 2. At the time of the incident on 6/11/2020, after safe return of the resident, the facility assessed the situation to determine the causative factor, noting that the door alarm activated upon exit, the staff responded appropriately to the alarm and attempted to redirect the resident. 3. The Unit Manager interviewed and provided education to staff that were scheduled for this day on how to effectively redirect the resident and to maintain visual sight of resident while out of the facility. 4. The resident was sent to theER on [DATE] and was assessed for any injuries and no injuries were found. Upon return to the facility the resident was immediately placed on a 1:1 on 6/11/2020 and has remained on 1:1 to date. 5. Elopement Drill was completed on 6/12/2020, 6/18/2020, and 6/22/2020 and education was provided to the Elopement/Wandering policy as well as searching tips. 6. All residents are assessed at admission, quarterly, and if there is a change in condition for elopement risk. All 90 residents were reassessed for elopement risk 6/17/2020 and any residents that were identified to be at risk for exit seeking their care plans were reviewed and interventions were deemed appropriate. No resident needed an updated intervention to add as an elopement risk. 7. All 90 residents house wide were reassessed by ADON on 6/17/20 for elopement risk. One resident whose care plan was updated was previously on elopement risk list, but due to clinical/physical condition deterioration, she is no longer physically able to physically open doors, stand, etc. 8. All door alarms checked and found to be in working order on 6/11/2020 and 6/18/2020. There is a system for checking the door alarms routinely checked and previously the door was last checked on 6/6/2020. 9. Signs placed on doors to remind associates and visitors to ensure no residents followed them out. All doors were noted to have a sign as of 6/17/2020. The receptionist has a copy of the elopement book and the receptionist desk. 10. The door alarms were not a factor in this incident, the door alarms functioned properly at the time the event and continued to function properly as evidence by ongoing inspections. 11. Upon receipt of the immediate jeopardy notification on 6/17/2020 at 3:40 pm, the nursing management staff provided education on resident elopement to all facility staff currently on duty that were scheduled for 2nd, 3rd shift for 6/17/2020 and 1st shift on 6/18/2020. 12. The facility has educated 61 staff. The facility will continue to educate all employees upon their next scheduled shift and will not be allowed to work until education is completed. We continue to educate regarding Abuse and Neglect and have re-educated on 6/18/2020. 48 staff have been re-educated and will continue through this process. The education provided to all staff includes: Elopement precautions Alarming door process Searching procedures 13. Medical Director notified of Immediate Jeopardy on 06/17/2020 and agrees with above plan 14. Elopement Drill was completed on 6/12/2020 and 6/16/2020 for 1st and 2nd shift, 6/18/2020 for 3rd shift, and 6/22/2020 on 2nd shift. Mass communication was sent on 6/19/2020 regarding the policy and educating key points for Wandering and Elopement Risk. Education was provided and documented. Although the immediate jeopardy was removed on 6/17/20, the facility remained out of compliance with a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to all staff had not received the inservice education and sustained compliance had not yet been verified by the state agency. Deficiency Practice Statement B Based on interview, and record review, the facility failed to provide adequate supervision and implement care plan interventions for elopement risk in 1 of 6 residents (Resident #101) reviewed for supervision/elopement, resulting in an elopement from the facility and the potential for injury. Findings include: Review of the policy and procedure Unsafe Wandering and Elopement, reviewed 4/15/19, revealed .Purpose .To promote Resident safety and reduce unsafe wandering and elopements by proactively identifying, care planning and monitoring of Resident wandering and elopement indicators .Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so .a resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle .Facility policies that clearly define the mechanisms and procedures for assessing or identifying, monitoring and managing residents at risk for elopement can help to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision .In addition, the resident at risk should have interventions in their comprehensive plan of care to address the potential for elopement .Residents will be assessed for unsafe wandering and elopement indicators upon admission, readmission, change in condition, quarterly and with any unsafe wandering or elopement event .During the admission and readmission process, a care plan will be initiated by the admitting nurse on any residents assessed with [REDACTED].A system of identification for Residents identified with potential for unsafe wandering and elopement will be in place, including but not limited to .Current photographs of residents . Resident #101 Review of an Admission Record revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 3/11/20, revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a a total possible score of 15, which indicated severe cognitive impairment. Further review of this MDS assessment, with a reference date of 3/11/20, revealed Resident #101 wandered daily, was sometimes understood, and rarely/never understands others. Review of an Elopement Risk Assessment for Resident #101, dated 3/4/20, revealed Summary of Findings .Resident is at risk for elopement at this time? (any yes answer would indicate that this resident is a potential for elopement) .Yes .Wandering/Elopement Interventions .Add resident to the Elopement Book .Frequent monitoring observe as walking past room, room next to nurses station . Noted check marks beside .Interventions have been initiated, reviewed, or modified .If appropriate physician orders have been requested/obtained .Family/Responsible Party/Resident have been notified .Care plan has been updated . to indicate that these tasks were complete. Review of a Care Plan for Resident #101 revealed the focus .At risk for elopement . initiated 3/5/20, with interventions which included .Add resident to the Elopement Book .Complete Elopement Risk Assessment .Encourage to participate in activities to divert from exit seeking .Frequent monitoring observe as walking past room, room next to nurses station .Provide for safe wandering - resident is an elopement risk . all initiated 3/5/20. Review of a Progress Note for Resident #101, dated 3/6/20 at 12:54 a.m., revealed .Nurse pulled medication for resident at (7:08 p.m.) on 3/5/2020. When nurse went to residents room, resident was not there. A different resident stated they just saw him in the lobby. Nurse went to lobby, asked receptionist if she had seen resident, receptionist stated no. Nurse went back to find DON-this writer Alerted DON of situation and code green announced over head. This writer went room to room looking for resident. This writer went into every room on bridge unit and wood unit. When nurse returned to bridge unit DON stated resident was located. This writer canceled code green. DON stated that she would notify director. Director to notify state, family notified. Assessment done by ADON . Review of a Progress Note for Resident #101, dated 3/5/20 at 7:35 p.m., revealed .At (7:15 p.m.), alerted by receptionist that resident had walked out front door, following another visitor. Receptionist

Based on observation, interview and record review, the facility failed failed to follow and update the facility assessment to ensure resources needed to competently care for residents are provided in 11 of 24 sampled residents (Resident #'s 3, #258, #14, #51, #17, #62, #94, #45, #42, #85, #33), resulting in unmet care needs, short staffing, incomplete nursing competency assessments, physical and psychosocial harm for residents residing in the facility. Findings include: Review of the Facility Assessment last revised (MONTH) 2019 revealed the names of the Nursing Home Administrator and the Director of Nursing documented on the assessment were inaccurate. The Facility Assessment revealed, Our programs, series and facilities must be designed and operated with superior quality in order to satisfy the need of our customers .We believe our residents are our highest priority. We believe in the preservation of dignity, self-respect, and resident rights in a loving and caring environment. We believe int he resident-centered approach to care in which the total health needs of the resident are met . The Assessment indicated the facility Acuity, average monthly: Extensive services: average 1 resident or less per month; Special Care High: average 1 resident or less per month; Reduced Physical Function: average of 22 residents or less per month. The Assessment indicated General Care: Skin Integrity, Extensive wound care program that provides prevention, ongoing skin care, and wound care for wounds that are either surgical, received, and/or acquired .Provide person-centered/directed care, All requests are honored within reasonable accommodation. The physical/cognitive/spiritual care of the resident is person centered. If the resident is unable to make their own clinical decisions, legal representation and medical decision making is documented in their individual EMR. The Facility Assessment revealed, Infection prevention and Infection prevention, surveillance, and reporting is done and reported control through to the QAPI program. All new antibiotics meet the McGreer's criteria. An antibiotic stewardship program is in place. The assessment indicated, In order to ensure sufficiet staff for all clinical and business functions, the following is provided in terms of number of staff for all shifts - Licensed nurses providing direct care: 12. Review of the staffing sheets from [DATE]-[DATE] revealed on [DATE] there were 7 nurses assigned and a census of 114; on [DATE] there were 9 nurses assigned and a census of 114; on [DATE] there were 9 nurses assigned and a census of 114; on [DATE] there were 9 nurses assigned and a census of 114; and on [DATE] there were 11 nurses assigned and a census of 114. The facility has a total of 119 beds. Resident #3 Review of a Face Sheet revealed Resident #3 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #3's Progress Note dated [DATE] revealed, Seen today as she is not feeling good. She complains of nausea, diarrhea and decreased appetite. She has a temperature of 100.3 .White blood cells elevated. Ordered [MEDICATION NAME] 1g IMx7 days. Review of Resident #3's Event Note dated [DATE] revealed, Blood draw completed today due to resident being nauseous and having a fever as told to this writer in report. Blood work came back and NP on call (name omitted) notified. Gave new orders for [MEDICATION NAME] (antibiotic) IM (Intramuscular) 1gm (gram) daily x 7 days for increase in WBC's (White Blood Count). Review of a laboratory result dated [DATE] revealed, WBC 12.8 (normal range 4XXX,[DATE]). On the laboratory result a note was hand written [MEDICATION NAME] 1 gm daily x7 days per (NP EE). Review of Resident #3's laboratory results revealed no cultures for a wound, urine, or other source of infection. Review of Resident #3's Order dated [DATE] revealed, Keflex Capsule 500mg Give 500mg by mouth three times a day for infection prevention. Review of Resident #3's Progress note dated [DATE] revealed, Res (resident) continues on antibiotics for right stump incision. VS WNL (vital signs within normal limit). During an interview on [DATE] at 09:45 [NAME]M., Unit Manager (UM) M and Regional Consultant (RC) ZZ reported that McGreer Criteria was to be followed for all antibiotic use. During an interview on [DATE] at 03:12 P.M., RC ZZ reported that the reason [MEDICATION NAME] was ordered was empirically because she had an increase in her wbc and vital signs. RC ZZ reported there was no cultures obtained prior to, or after, the start of the antibiotic. Unknown source of infection. Review of the facility Infection Control' binder revealed no monthly calculations were performed. No correlations between staff call ins and resident illnesses., and antibiotics were prescribed for residents without cultures, testing, and or blood work. During an interview on [DATE] 12:08 PM., Assistant Director of Nursing (ADON) B reported she was new to the position of Infection Control Preventionist. ADON B indicated the Nurse Practitioner (NP) does not identify the organism from which an infection would be identified. ADON B indicated the NP has blood drawn for WBC (white blood count-identifier of possible infections). ADON B reported she does not collaborate with the pharmacy on the antibiotic use, and she has been in the position about 3 weeks. ADON B indicated the Director of Nursing (DON) may receive certain things for infection control, but ADON B has not see those collaborations. ADON B indicated her and the DON are taking an online course which has 17 modules to become a Certified Infection Control Preventionist. ADON B reported she is on the 4th module. ADON B reported when she took the position, she did not know much about infection control besides the basics. ADON B reported she was still learning, and as for surveillance she hasn't done much. ADON B reported for her training when hired, she did the facility orientation, and someone from another facility came over for a few days to teach her the Infection Control Program. ADON B indicated in that training, it was much like the orientation, and skills testing, nothing was covered about the Infection Control Program ADON B reported she was unaware she was to do monthly infection rate calculations, and had not noticed that the calculations in the facility Infection Control binder calculations for infections had not been done since (MONTH) 2019. ADON B reported she had no surveillance has been done on her part, she (ADON B) has not rounded, or audited hand hygiene. ADON B reported she clearly told the NHA A that she (ADON B) had not a clue about anything with infection control when she (ADON B) was hired. ADON B indicated she was in over her head with all the responsibility that comes with the program. Review of the Facility Assessment last revised (MONTH) 2019 revealed, Staff educator/Development-Employee Health This position is a R.N/DON (registered nurse/director of nursing) whose responsibilities include the planning, development, and coordination of new nurse/CENA (certified nursing assistant) orientation. Also, the organization, evaluation, tracking and in-services of mandatory education and competencies of the staff. Review of Licensed Practical Nurse (LPN) CC's employee file revealed no Nurse Orientation Skills Competency checklist completed. Review of LPN NN's employee file revealed Nurse Orientation Skills Competency checklist completed. Review of LPN QQ's employee file revealed Nurse Orientation Skills Competency checklist completed. During an interview on [DATE] at 12:00 P.M. Human Resource (HR) UU reported that the three employees (LPN CC, LPN NN, and LPN QQ) did not have orientation check lists completed in their employee files. During an interview on [DATE] at 03:44 P.M., HR UU reported that there was no Staff Educator on staff at the facility. HR UU reported that there had been no staff educator since approximately (MONTH) of 2019. Resident #258 Review of a Face Sheet revealed Resident #258 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #258, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #258 was cognitively impaired. During an interview on [DATE] at 1:48 PM., LPN P reported the staff was way understaffed on the night shift ([DATE]) prior to him being notified by CNA SS that Resident #258 was left wet and soiled to the point her brief was saturated through. LPN P reported CNA SS came to him and informed him of Resident #258's brief being so wet, it was falling apart as CNA SS tried to remove it from underneath Resident #258. LPN P reported he went down to Resident #258's room to assist CNA SS with changing Resident #258. LPN P reported as they changed Resident #258 the brief was falling apart, and looked like mashed potatoes on the floor. LPN P reported after he and CNA SS finished changing Resident #258 he immediately called Nursing Home Administrator (NHA) A because not only did he (LPN P) think Resident #258 was neglected but so did CNA SS which is why she (CNA SS) initially came to him. LPN P reported when speaking with NHA A she did not think it was a neglectful situation, and NHA A instructed LPN P to educated CNA SS on walking rounds. LPN P reported NHA A had him do education for CNA SS because NHA A indicated that she (CNA SS) should have done the walking rounds between the day and night shift, she (CNA SS) trusted the word night shift, when she (night shift CNA) said that (Resident #258) was cleaned up a little while ago. LPN P stated if we did that, staff would have to glove up, and feel everyone's brief that is not realistic. LPN P reported he (LPN P) and (CNA SS) wrote up statements and he (LPN P) placed both statements in NHA As personal mailbox. LPN P reported the next time he saw (NHA A) she asked if he (LPN P) did the education for (CNA SS), and (NHA A) also asked why there were statements were in her (NHA A) box. LPN P stated I said so you can do your investigation, she passively dismissed me, and Resident #258 was not able to say what happened due to her condition. Review of a facility Witness Statement Form dated [DATE] time of incident 8:40 AM., revealed: Resident #258's name on the top of the form. (CNA SS) reported to me (LPN P) that it appeared that the resident had not been changed at night due to her brief being saturated to the point that it completely disintegrating and look like a pile of mashed potatoes dropped on the floor. (CNA SS) also told me that the night shift CNA had told her that the resident was fine and she had believed her. I (LPN P) reported the incident to the ED (NHA A) who is also the abuse coordinator. She told me to educate my CNA about doing walking around and physically check each resident and change of shift rather than taking her word for it. This document was signed by LPN P. During an interview on [DATE] 02:06 PM Certified Nurse Aide (CNA) SS reported she came in at 6 am on [DATE] and about 8:30 AM., she checked on Resident #258. CNA SS stated that in shift report she was told that everyone (all the residents on CNA SS assignment) had been taken care of, and everything was fine. CNA SS reported she went in to get Resident # 258 up for the dining room. CNA SS reported she went to change (Resident #258) and her brief pulled out and it literally fell to the floor in pieces like mashed potatoes, it was disintegrated. CNA SS reported she remembers that the night shift ([DATE] going into [DATE]) only had 2 aides (CNA's) that night. CNA SS reported she immediately went to (LPN P) to report, and she (CNA SS) did use the word neglected. CNA SS reported LPN P came down and assisted with changing (Resident #258). CNA SS reported after that LPN P instructed her to write a statement up. CNA SS reported she wrote the statement, and gave it to LPN P. CNA SS reported after a while LPN P came down to her and told her (CNA SS) that (NHA A) wanted her (CNA SS) re-educated on walking rounds. CNA SS reported LPN P did education for walking rounds. CNA SS reported she (CNA SS and LPN P) both thought it was a neglectful situation. CNA SS stated if there were more than 2 aides, I doubt this would have happened. I do not think it was neglect on the night shift CNA's, I think it is a neglectful situation because of low staffing levels. CNA SS reported NHA A never followed up with her (CNA SS). CNA SS reported she did not believe an investigation was done, or any protocol followed as to retraining for neglect. Review of a facility Witness Statement Form dated [DATE] time of incident 8:40 AM., revealed: Resident #258's name on the top of the form. Statement I (CNA SS) went into the room. I was telling the resident what I was in there for. So I could get her up for breakfast. I went to get her up for breakfast and saw that she was wet. I started to clean her up when I picked up the brief it was disintegrating all over the floor. It look like a pile of mush. I went to get the nurse I told the nurse what the night CNA said she was fine. So I believed her because she had clothes on. this document was signed by CNA SS. Review of a Staffing Report revealed the facility had a census of 113 residents on [DATE]. During the Night Shift hours (10pm-6am), there were 16 worked hours for Registered Nurses (2 RN's), 16 worked hours of Licensed Practical Nurses (2 LPN's), and 37.5 (approximately 4 CNA's) worked hours for Certified Nurse Aides reported. On [DATE] during the Morning Shift hours (6am-2pm), there were 16 worked hours for Registered Nurses, 16 worked hours of Licensed Practical Nurses, and 62 worked hours for Certified Nurse Aides reported. Review of the Facility Nursing Staffing report dated [DATE] revealed there were 4 CNA's scheduled to work the Night Shift hours with one additional CNA listed as a trainee and was scheduled to work with one of the 4 CNA's. During an interview on [DATE] at 3:19 PM., Registered Nurse (RN) L reported on [DATE], she (RN L), LPN P and CNA SS all worked the day shift. RN L reported the 3rd shift from [DATE] was extremely short staffed. RN L stated there was a staffing issue that evening before, I don't know how many staff the facility was down off the top of my head, but I know it was a really rough night for them. The staffing here is really bad. RN L reported nurses work 6 am-6pm and tend to stay over to chart because its difficult to complete everything during the shift. RN L reported CNA's are showing signs of burnout they (CNA's) are frustrated. RN L reported many residents are complaining, sometimes about meals, and getting cold food. RN L reported the biggest complaint is the call light times taking too long. RN L reported there are CNA's that are suppose to be shower aides, and restorative aides, but they (CNA's) get pulled to the floor to do cares for the residents, and some (resident) have missed showers. Resident #14 Review of a facility Admissions Record revealed Resident #14 was a [AGE] year-old male originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of Resident #14's Minimum Data Set (MDS) assessment, revealed a Brief Inventory of Mental Status (BIMS) score was 15 or cognitively intact. In an interview on [DATE] at 4:50 PM, Nurse Practitioner EE (NP) indicated in (MONTH) ordered a series of test for Resident #14 because (Resident #14) was having increased pain in his left BKA stump, where he also had an infected pressure ulcer. NP EE indicated ordered an ultrasound, and an x-ray of the left BKA stump. The ultrasound results were inconclusive and suggested further testing, and a MRI was ordered. Review of Resident #14's printed order, sent to the facility that performed his MRI, dated [DATE], revealed From: (facility address and phone number) Fax: N/A .Ordered By: (NP EE and office address) . Order Date: [DATE] .Communication: Verbal .Order Summary: MRI (LEFT KNEE) ATTN: Stump w/ & w/o contrast one time only for Infected pressure ulcer to left stump for 1 Day .Ordered By Signature: (NP EE) . Review of Resident #14's MRI results, dated [DATE], revealed .Conclusion: .Open wound over the residual fibula with osteo[DIAGNOSES REDACTED] of the residual, fibular shaft .[MEDICAL CONDITION] (skin infection) around the open wound . Review of NP progress note dated [DATE], .Patient seen today per his request regarding follow-up MRI .Ordered an MRI over a month ago and did not receive any follow-up. Today nursing staff went through calendar and found out that he went to (MRI facility) on [DATE] for an MRI of his left BKA . a report was faxed to (facility) . In an interview and observation on [DATE] at 11:31 AM, Resident #14's was lying in bed, and his left stump with a pressure ulcer bandage was exposed. The bandage was signed and dated [DATE]. Resident #14 indicated has not had his left stump dressing changed since [DATE]. It was ordered to be done every day. Resident #14 indicated the nurses often tell him they are too busy to change his dressing on their shift, and pass the dressing off to the next shift, but those nurses were busy too and don't do it either. In an interview on [DATE] at 2:20 PM, Registered Nurse [NAME] (RN) indicated worked [DATE] day shift and noticed Resident #14's left stump dressing had not been changed in several days. RN [NAME] indicated did not change his dressing on the day shift because spent the entire shift passing medications. RN [NAME] indicated sometimes there was a third nurse scheduled to do skin assessments and dressing changes, but often that third nurse was pulled to a hall assignment due call ins. RN [NAME] indicated staffing has been an issue for nursing and with aides for the passed few months. On [DATE] at 9:00 AM, requested Licensed Practical Nurse FF (LPN) to observe Resident #14's left stump dressing change. LPN FF indicate would try to complete the dressing change on first shift. On [DATE] at 1:30 PM, asked LPN FF again to observe Resident #14's left stump dressing change. LPN FF indicated will not get to it this shift (ends at 2:00 PM) because was too busy passing medications and there was not a third nurse today to do dressing changes. LPN FF indicated would report to the oncoming nurse that Resident #14's dressing change needs to be done. During an interview and observation on [DATE] at 9:45 AM, Resident #14's was lying in bed, and his left stump with a bandage was exposed. The bandage was signed and dated [DATE]. Resident #14 indicated does not remember the staff changing his dressing the day before ([DATE]). Review of Resident #14's Treatment Administration Record (TAR) for October, on [DATE], revealed most current dressing order dated [DATE], .Left stump pressure wound: . No dressing change was completed on ,[DATE], ,[DATE], ,[DATE], or ,[DATE]. Review of Resident #14's (MONTH) TAR revealed multiple changes for his .Left stump pressure wound: . dressing orders and 8 missed dressing changes out of 30 possible days in September. Review of Resident #14's Skin Assessments' revealed no nursing skin assessments have been documented since [DATE]. During an observation and interview on [DATE] at 9:50 AM, RN L entered Resident #14's room and administered a pill. RN L indicated only removed a 5 MG [MEDICATION NAME] tablet from the medication cart; no [MEDICATION NAME] gel was requested. During an interview on [DATE] at 9:56 AM, UM M indicated would do Resident #14's dressing change now and did not need to delay the dressing change ,[DATE] minutes for any reason. During an observation on [DATE] at 9:59 AM, Assistant Director of Nursing B and UM M entered Resident #14's room to start his dressing change. No [MEDICATION NAME] gel was applied to Resident #14's wound. Resident #14 grimaced and indicated pressure to the stump was very painful. UM M cleansed the wound with normal saline and measured the depth of tunneling of the wound by inserting a cotton tipped swab into the wound. Resident #14 moaned, held his breath, grimaced and indicated that was extremely painful. UM M indicated the wound was deeper than last week, and it hurt a lot more than last week. The start and completion of Resident #14's dressing change occured less than 30 minutes from [MEDICATION NAME] administration and without the ordered [MEDICATION NAME] gel. During an observation and interview on [DATE] at 10:15 AM, Resident #14 indicated could not talk right then because he was in so much pain. Resident #14 indicated to come back in 20 to 30 minutes when the pain pill started to work. Resident #14 was holding his left leg behind the knee, with his eyes closed, and he was pursed lipped breathing, indicating pain. During an interview on [DATE] at 11:00 AM, Resident #14 indicated his dressing change are terribly painful. Resident #14 indicated when the staff used the [MEDICATION NAME] gel and allowed for his pain pill to work the dressing was tolerable. Resident #14 indicated when the staff were busy or short they do not wait long effect for my pain medication to take effect. Resident #14 indicated since his dressing changes have been frequently missed when the facility was low staffed, he does not stop them to ask for the [MEDICATION NAME] or to wait for the pain medication to work. Resident #14 indicated was afraid the nurse would not make time to come back later to do the dressing change. Resident #14's missed dressing changes and fear of not having dressing changes done when staff actually do come to change the dressing regardless of pain medication effectiveness indicated Resident #14 has been harmed by this facility practice which contributed to his infection of osteomylitis. In an interview on [DATE] at 3:00 PM, Unit Manager Y (UM) indicated Resident #14's unit has been without a unit manager for approximately 5 to 6 months. UM Y indicated the wound nurse then left in September. UM Y indicated the facility had to band together and cover Resident #14's unit and later cover wound care. UM Y indicated the lack of a manager coupled with a lack of staffing lead to things being missed like weights, restorative care, and wound care. Resident #51 Review of a facility Admissions Record, revealed Resident #51 was a [AGE] year-old male originally admitted to the facility on [DATE] with a pertinent [DIAGNOSES REDACTED]. Review of Resident #51's Minimum Data Set (MDS) assessment on [DATE], revealed The Brief Interview for Mental Status (BIMS) score was 15 or cognitively intact. In an interview on [DATE] at 10:40 AM, Resident #51 indicated was concerned with not receiving restorative therapy. Resident #51 indicated had been working with therapy and was released with a restorative program to follow three times a week. Resident #51 indicated the restorative aides ran this program and should have been working with him. Resident #51 indicated does not know when the last time the restorative aides helped him with his ordered exercises. Resident #51 indicated complained last week but nothing has been done. Review of Resident #14's MDS, Section O .O0500 Restorative Nursing Programs, dated [DATE], revealed .Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none of less than 15 minutes daily) .0 .Range of motion (active) .0 .Bed mobility . 0 . Transfer .0 . Walking . Review of Resident #51's Concern & Comment Form, dated [DATE] at 10:05 AM, revealed .Receptionist .Helped him fill out .Please describe your Concern .Restorative therapy told (Resident #51) they are too busy to work with him for the past month. He is very frustrated as he was up and walking with therapy for the past 3 months .Associate Receiving Concern . (Receptionist) . [DATE] .10:13 AM . No Facility Investigation and Response to Resident #51's concern until [DATE], 11 days later. In an interview on [DATE] at 10:31 AM, CNA D indicated was one of the two restorative aides for the facility. CNA D indicated has not been able to consistently complete a full day of restorative therapy in a long time. CNA D indicated has been pulled to the floor frequently and so has the other restorative CNA NNN. CNA D indicated was pulled today to the floor and will not be able to complete restorative tasks today. CNA D indicated pulling the restorative aide to cover staffing concerns in the facility started about 4 months ago. CNA D indicated the two restorative aides were supposed to be scheduled 7 days a week, one CNA on the floor and one CNA on restorative. On Monday's one CNA was scheduled to do residents weights and the other was to do restorative therapy. Restorative therapy hardly gets done and Monday weights are rarely done on Monday's anymore. CNA D indicated if they were not pulled to work the floor, would have to complete all the missing weights not done on Monday and restorative was pushed to another day. CNA D indicated used to complete a paper log to indicate who was seen or why they were not seen. CNA D indicated stopped using paper log because the log would say pulled to floor in almost every space (last log dated ,[DATE]). CNA D indicated residents have complained about not doing their exercises. CNA D indicated has voiced the resident's concerns to the UM, ADON, DON, and NH[NAME] CNA D indicated Resident #51 was on the current restorative therapy list and should have been participating for the last several months. CNA D indicated has not done restorative therapy with Resident #51 in at least a month and neither has CNA NNN because has been covering the floor. In an interview on [DATE] at 10:00 AM, Nursing Home Administrator A (NHA) indicated CNA D and CNA NNN were the two CNA's that ran the restorative program. NHA A indicated the facility staffed restorative aides everyday but often those aides were being pulled to work on the floor instead of doing restorative therapy. NHA A indicated has requested for those aides to not be pulled and to fill the empty the CNA spots with CNA volunteers. Resident #17 In an interview on [DATE] at 9:30 AM, Social Worker PP (SW) indicated when Resident #17 was admitted she was severely cognitively impaired, and her cognitive abilities have declined. SW PP indicated she was not competent on [DATE] to sign the Advanced Directive/Medical Decision form designating her code status. SW PP indicated Resident #17 has not been deemed incompetent either. SW PP indicated a family member has been designated as her responsible party but there was no paperwork in the facility that indicated her family member was legally her DPO[NAME] SW PP indicated Resident #17 should have been deemed incompetent upon admission based on her cognitive state (BIMS 03) or at the latest on the next quarterly MDS review ([DATE]). SW PP indicated once Resident #17 was deemed incompetent the DPOA paperwork should have been obtained and the DPOA should have signed a new Advanced Directive/Medical Decision form. SW PP indicated just started at the facility a few months ago and it has become apparent a some paperwork has not been updated or obtained. In an interview on[DATE] at 8:45 AM, Case Manager AAA (CM) indicated a resident's code status should be reviewed 48 hours after admission in an Interdisciplinary Team meeting (IDT) and then quarterly. CM AAA indicated at each IDT meeting they should review code status, care plans, and other pertinent information with the resident and/or responsible party. Review of a facility Admissions Record revealed Resident #17 was an [AGE] year-old female originally admitted to the facility on [DATE] with a pertinent [DIAGNOSES REDACTED]. Review of Resident #17's admission A Minimum Data Set (MDS) assessment was completed on [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 or severely cognitively impaired. Review of Resident #17's quarterly MDS assessment was completed on [DATE] revealed a BIMS score of 00 or severely cognitively impaired, denoting a decline in cognitive ability. Review of Resident #17's Face Sheet revealed, Resident #17 had a Durable Power of Attorney (DPOA) that was responsible for making her medical decision. Review of Resident #17's, medical record revealed no DPOA paperwork designating a responsible party for Resident #17 and no paperwork to deem Resident #17 incompetent. Review of Resident #17's Advance Directives/Medical Treatment Decisions form, dated [DATE], revealed Resident #17 signed the form herself and picked the code status Do Not Resuscitate, despite being severely cognitively impaired. Resident #62 Review of a Face Sheet revealed Resident #62 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #62, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #62 was cognitively moderately impaired. Review of an Advance Directives document for Resident #62 dated [DATE] and reviewed [DATE] revealed, Full Code (a person will allow all medical interventions needed to restore breathing or heart functioning). Review of Care Plan for Resident #62 revealed, DNR (Do Not Resuscitate) (do not perform CPR if breathing or heart stops) initiated [DATE]. Indicating a discrepancy with the resident's advance directives document. Review of Physician order [REDACTED]. Indicating a discrepancy with the resident's advance directives document. During an interview on [DATE] at 10:25 [NAME]M., Assistant Director of Nursing (ADON) B reported that DNR with comfort care measures is similar to an order for [REDACTED].>During an interview on [DATE] at 10:30 [NAME]M., SSA Q reported that Resident #62 did not have DNR paperwork Resident #94 Review of a Face Sheet revealed Resident #94 was a [AGE] year-old male, originally admitted to the facility on [DATE]. Review of a Care Plan revealed, Focus: (Resident #94) has an ADL self-care performance deficit r/t (related to) MS, tremors, muscle spasms. Goal: Will receive the staff assistance necessary to complete ADLs. Date Initiated: [DATE]. Interventions: Eating: Extensive assistance x1 Date Initiated: [DATE]. Toileting: Extensive assistance x1 Date Initiated: [DATE] Transfers: Extensive assistance x1 Date Initiated: [DATE] ·Showers twice weekly and prn (as needed) on 2nd shift Date Initiated: [DATE]. During an interview on [DATE] at 11:24 [NAME]M., Resident #94 reported that he didn't get his scheduled shower this morning, instead he received a bed bath, because of short staffing. Review of Bathing Task located in Resident #94's EHR revealed, Resident #94 preferred showers on Tuesday and Thursday. The record indicated that Resident #94 received a bed ba (TRUNCATED)

Based on observation, interview and record review, the facility failed to adequately prevent, assess, and treat residents with pressure ulcers in 3 of 24 sampled residents (Resident #14, Resident #93 and Resident #45) reviewed for pressure ulcers, resulting in the worsening of a facility acquired pressure ulcer for Resident #14 and the potential for further clinical compromise for Resident #93 and Resident #45. Findings include: Resident #93 Review of a Admission Record revealed Resident #93 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #93, with a reference date of 8/28/19 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #93's cognitive skills for daily decision making were intact. During an interview and observation on 10/07/19 at 12:35 PM, Resident #93 was in her room sitting in her recliner dressed for the day she reported that during the past few months she had not been getting (2) baths per week and would like to have (2) baths a week, she feels like her skin would not break down if she had them. Resident #93 reported that she had a sore on her bottom due to not getting her baths twice a week and went to the side of the bed and asked if she could show me the sore, lifted her skirt, removed her brief to show the surveyor a Stage II area 1 cm x 1 cm on her right buttock stating it hurts that they were putting cream on it but, if she had been getting her whirlpool baths it would not have come. During an observation on 10/08/19 at 11:31 AM, Resident #93 was sitting in her recliner dressed for the day, Certified Nursing Assistant (CNA) PPPcame in the room to do care. CNA PPP washed hands and gloved, assisted Resident #93 to the bed and turned on her right side, removed brief, cleaned buttock with soap and rinsed and dried area, then changed her gloves and applied [MEDICATION NAME] cream to the buttock area pointing out the 1 cm x 1 cm open area on the right buttock, turned to front and cleaned perineal area with clean wash cloths then rinsed and dried, cleaned under breasts and applied gold bond powder under her breast. CNA PPP reported that Resident #93 does take herself to the bathroom at times. Review of the Skin Integrity Care Plan dated 9/17/18, revealed ·At risk for break in skin integrity. Date Initiated: 09/17/2018; Goal ·Maintain intact skin with no skin breaks through next review. Date Initiated: 09/17/2018; Interventions/Tasks ·Clean and dry skin after each incontinent episode. Date Initiated: 09/17/2018. There was no indication that Resident #93 had an open wound on her buttock. Review of the Potential for Skin Impairment Care Plan dated 9/23/19, revealed ·The resident has potential for impairment to skin integrity related to (r/t) diabetic (DM) II, [MEDICAL CONDITIONS] (poor blood circulation), diuretic use, incontinence, chooses not to receive incontinence care at times Date Initiated: 09/23/2019; Goal ·The resident will maintain or develop clean and intact skin by the review date. Date Initiated: 09/23/2019; Interventions/Tasks Clean and dry skin after each incontinent episode. Date Initiated: 09/23/2019 ·Preventative skin care as needed Date Initiated: 09/23/2019 . There was no indication that Resident #93 had an open wound on her buttock. Resident #14 Review of a facility Admissions Record, revealed Resident #14 was a [AGE] year-old male originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of Resident #14's Wound Observation Tool, dated 7/17/19, revealed .Acquired .7/17/19 .left BKA lateral stump .pressure .Stage IV .Length (cm): 1.8 .Width (CM): 0.4 .Depth (cm): 0.4 .tunneling .undermining present .bone exposed with white sheath over .wound edges rolled under with [DIAGNOSES REDACTED] (redness) around wound bed .Infection ., e-signed by Registered Nurse YY (RN). In an interview on 10/10/19 at 1:00 PM, RN YY indicated was the wound nurse at the facility at the time Resident #14's facility acquired left BKA pressure ulcer was discovered. RN YY indicated had been treating his right BKA wound for several months and Resident #14 asked to have his left stump looked over. RN YY indicated Resident #14 had just gotten back from an outing and mentioned he had worn his left prosthetic leg for several hours and now his stump was painful. RN YY indicated there was a small circular wound on his left lateral stump. RN YY indicated washed the left stump and a whitish scab dislodged and exposed a deeper wound with his fibula bone exposed. In an interview on 10/10/19 at 11:00 AM, Physical Therapy Assistant LLL (PTA) indicated worked with Resident #14 in therapy until 5/24/19. PTA LLL indicated they worked on Resident #14 transferring himself from surface to surface and hopping while wearing the left prosthetic leg. PTA LLL indicated Resident #14 came to the facility with the prosthetic leg already fitted to his stump with a gel sleeve and a sock that goes over his stump to protect his skin (padding specially fitted inside leg). PTA LLL indicated every day that Resident #14 came to therapy would assess Resident #14's stump for pain, pressure points, and skin irritation. PTA LLL indicated Resident #14 decided to stop going to therapy and did not provide care for him again. PTA LLL indicated did not know Resident #14 had a pressure ulcer on his left stump. PTA LLL indicated the physical therapy department was not requested to make recommendations for stump monitoring or prosthetic device care. In an interview on 10/7/19 at 1:00 PM, Resident #14's Family Member MMM (FM) indicated Resident #14 probably acquired the pressure ulcer on his left stump because his prosthetic no longer fit due to weight loss. FM MMM indicated the facility also lost his gel sleeve for multiple months (protects the stump) and did not replace it. FM MMM indicated no one notified the family for a long time and once aware the family bought him another gel sleeve. FM MMM indicated the padding custom fitted into his prosthetic leg was no longer adhered to the leg and was loose and that the facility has done nothing to replace it or contact the company that originally fitted the leg. Review of Resident #14's Progress Note, dated 7/23/19, .continues on Hospice .Documented PO intake is 25-50% on average. Triggering for a significant weight loss of 10.9% over the past 90 days . Review of Resident #14's care plan focus, on 10/8/19, revealed no care plan addressing the facility acquired left BKA stump pressure ulcer or interventions that would alleviate the factors attributing to the pressure ulcer. No care plan was found addressing the care, monitoring, and education needed for Resident #14's left prosthetic leg and/or the accessories used to assure proper fit when wearing the leg. In an interview on 10/9/19 at 12:30 PM, MDS coordinator G indicated Resident #14 has not worn his prosthetic for walking in a long time due to his wound. Resident #14 would wear the prosthetic while he sat in his wheel chair sometimes. MDS coordinator G indicated there should have been interventions for monitoring of the prosthetic leg usage and the condition of his stump identified in his care plan. In an interview on 10/9/19 at 4:50 PM, Nurse Practitioner EE (NP) indicated in (MONTH) ordered a series of test for Resident #14 because he was having increased pain in his left BKA stump, where he also had an infected pressure ulcer. NP EE indicated ordered an ultrasound, and an x-ray of the left BKA stump. The ultrasound results were inconclusive and suggested further testing, and a MRI was ordered. Review of Resident #14's printed order, sent to the facility that performed his MRI, dated 8/21/19, revealed From: (facility address and phone number) Fax: N/A .Ordered By: (NP EE and office address) . Order Date: 8/21/19 .Communication: Verbal .Order Summary: MRI (LEFT KNEE) ATTN: .for Infected pressure ulcer to left stump for 1 Day .Ordered By Signature: (NP EE) . Review of Resident #14 MRI results, dated 8/26/19, revealed .Conclusion: .Open wound over the residual fibula with osteo[DIAGNOSES REDACTED] (bone infection) of the residual, fibular shaft .[MEDICAL CONDITION] (skin infection) around the open wound . Review of NP progress note dated 9/26/19, .Patient seen today per his request regarding follow-up MRI .Ordered an MRI over a month ago and did not receive any follow-up. Today nursing staff went through calendar and found out that he went to (MRI facility) on 8/26/19 for an MRI of his left BKA .report was faxed to (facility) . In an interview on 10/9/19 at 4:55 PM, NP EE indicated was surprised no one at the facility had any idea that Resident #14 had an MRI done and that the negative results (osteo[DIAGNOSES REDACTED]) went undiscovered for 4 weeks. NP EE indicated osteo[DIAGNOSES REDACTED] was a serious infection and needed to be treated as soon as possible. NP EE indicated 4 weeks later, Resident 14's best treatment option was to undergo another amputation of the left leg (to above the knee) to remove the infected bone and surrounding tissue. NP EE indicated Resident #14 refused the amputation and opted for long term antibiotics to treat the osteo[DIAGNOSES REDACTED]. NP EE indicated Resident #14's oste[DIAGNOSES REDACTED] most likely would not resolve and he would take antibiotics for the remainder of his life. NP EE indicated the nursing home was ultimately responsible for those managing his test results. Review of Resident #14's (MONTH) TAR revealed multiple changes in his dressing orders and 8 missed dressing changes out of 30 possible days in September. Review of NP EE Progress Note, dated 10/1/19, revealed .Wound on left stump was healing: last week discontinued orders for packing the wound. Today the hole appears open and deeper again. Wound nurse to follow. Changed orders to pack wound and change daily .Integumentary: Warm, open wound to left knee-worsening . In an interview and observation on 10/7/19 at 11:31 AM, Resident #14's was lying in bed, and his left stump and bandage was exposed. The bandage was signed and dated 10/3/19. Resident #14 indicated has not had his left stump dressing changed since 10/3/19 even though it was ordered to be done every day. Resident #14 indicated acquired his left stump pressure wound by either falling multiple times directly onto the stump or by wearing his ill fitted prosthetic with very little padding, likely a combination of both. In an interview on 10/8/19 at 2:20 PM, Registered Nurse [NAME] (RN) indicated worked 10/7/19 day shift and noticed Resident #14's left stump dressing had not been changed in several days. RN [NAME] indicated did not change his dressing on the day shift because spent the entire shift passing medications. RN [NAME] indicated reported to Unit Manager M (UM) that the dressing had not been done in days and needed to be done that day (10/7/19). On 10/8/19 at 9:00 AM, asked Licensed Practical Nurse FF (LPN) to observe Resident #14's left stump dressing change. On 10/8/19 at 1:30 PM, asked LPN FF again to observe Resident #14's left stump dressing change. LPN FF indicated will not get to it this shift (ends at 2:00 PM) because was too busy passing medications. LPN FF indicated would report to the oncoming nurse that Resident #14's dressing change needs to be done. During an interview and observation on 10/9/19 at 9:45 AM, Resident #14's was lying in bed, and his left stump with the bandage was exposed. The bandage was signed and dated 10/7/19. Resident #14 indicated does not remember the staff changing his dressing the day before (10/8/19). Review of Resident #14's Treatment Administration Record (TAR) for October, on 10/9/19, revealed most current dressing order dated 9/25/19, .Left stump pressure wound: Cleanse with normal saline. Gently pat dry. Apply Skin prep to surrounding peri-wound. Apply [MEDICATION NAME] to wound bed and cover with [MEDICATION NAME].every day shift for wound care . No dressing change was completed on 10/4, 10/5, 10/6, or 10/8. Resident #14's dressing orders had not been updated to reflect NP EE 10/1/19 progress note, indicating the need for packing the wound. During an observation and interview on 10/09/19 at 9:45 AM, Unit Manager M (UM) went into to Resident #14's room to inspect his left stump. UM M removed the bandage on his left stump, dated 10/7/19. UM M indicated yesterday's nurse must have written the wrong date on his bandage. UM M would change the dressing now. During an observation on 10/09/19 at 9:59 AM, Assistant Director of Nursing B and UM M entered Resident #14's room to start his dressing change. No [MEDICATION NAME] gel was applied to Resident #14's wound per order. Resident #14 grimaced and indicated pressure to the stump was very painful. UM M cleansed the wound and measured the depth of tunneling by inserting a cotton tipped swab in to the wound. Resident #14 moaned, held his breath, grimaced and indicated that was extremely painful. The wound measure measurements were length 1.0 cm, width 1.0 cm, depth 1.0 cm, and the tunneled portion was 0.5 cm. UM M and ADON B agreed the wound was larger, deeper, more painful and had more drainage than last week, indicating the wound had worsened. In an interview on 10/9/19 at 2:00 PM, NP EE indicated on 10/1/19 saw Resident #14 with ADON B and UM M. ADON B was taking over as the wound care nurse for the facility. UM M was the new promoted unit manager for Resident #14's hall. NP EE indicated verbally ordered Resident #14's wound dressing to revert to a previously used dressing order that included packing the wound and wrote it in a Progress Note as well. NP EE indicated the facility has not been dressing Resident #14's wound correctly since 10/1/19 or 9 days. Resident #45 Review of a Face Sheet revealed Resident #45 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 8/1/19 revealed a Staff Assessment for Mental Status, which indicated Resident #45 was cognitively severely impaired. Functional Status revealed, Resident #45 required extensive assistance of 2 people for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or other sleeping furniture). Review of Care Plan revealed, (Resident #45) At risk for break in skin integrity r/t (related to) sedentary lifestyle, incontinence .Date Initiated: 04/23/2018 Revision on: 05/29/2019 Maintain intact skin with no skin breaks through next review. Date Initiated: 04/23/2018 Revision on: 10/31/2018 .Inspect skin during bathing, especially over bony prominences. Date Initiated: 04/23/2018 .Observe for s/s of infection or delayed healing and report to physician PRN:redness/[DIAGNOSES REDACTED], Drainage-purulent or bloody. Date Initiated: 04/23/2018 Pressure reducing mattress. Date Initiated: 04/23/2018 Weekly skin checks. Date Initiated: 04/23/2018. During an observation on 10/07/19 at 02:13 P.M., Resident #45 in his room, lying on back in bed, bed flat. Resident #45's legs and feet laying directly on the bed, no pressure reducing positioning observed. LPN FF provided catheter care to resident. LPN FF reported that Resident #45 wasn't feeling well today and hasn't been out of bed. During an interview on 10/10/19 at 11:49 [NAME]M., UM Y reported that Resident #45 was admitted to the facility with a pressure wound on his right ankle. UM Y reported that Resident #45 does not have a care plan or orders for reducing pressure specifically to feet and ankles while in bed. UM Y reported that Resident #45 is 100% dependent on staff to provide position changes to relieve pressure. During an observation on 10/09/19 at 10:59 [NAME]M., Resident #45 was in his room, sitting in broda chair (wheeled recliner) with eyes closed. During an observation on 10/09/19 at 12:23 P.M., Resident #45 was in his room, sitting in broda chair (wheeled recliner) with his eyes closed. CNA D observed retrieving resident and pushing him to the dining room for lunch. During an observation and interview on 10/9/19 at 3:20 P.M., Resident #45 was in his room, sitting in broda chair. Noted that Resident #45 had been in his chair for approximately 4.5 hours. CNA EEE reported that Resident #45 stays up in his chair until he let's us know that he wants to go to bed, otherwise staff will transfer Resident #45 to bed after dinner, at about 7:00 P.M. Indicating that Resident #45 would be sitting in his chair from 10:59 [NAME]M.-7:00 P.M. (8 hours). During an interview on 10/10/19 at 08:40 [NAME]M., CNA T reported that Resident #45 would not be able to out of bed this morning, because staff will not have time to get him up. During an observation on 10/10/19 at 09:27 [NAME]M., Resident #45 was in his room, lying in bed on his back with head of bed at 30-40 degrees, and his breakfast meal tray at the bedside. Resident #45 reported that he wanted to get out of bed. During an observation and interview on 10/10/19 at 10:03 [NAME]M., CNA T and CNA NNN were preparing to provide Resident #45 a bed bath and transfer him into his chair. Observed incontinence brief saturated with loose stool, overflowing onto Resident #45's bed. This surveyor observed resident's left buttock having a large area of redness, 3 lines of deep redness and deep creases in the skin. CNA T reported that Resident #45 has had this red area on his left buttock since Monday (4 days). CNA NNN applied Aloe to the left buttock and it was noted that the entire area was nonblanchable [DIAGNOSES REDACTED] (skin redness that does not improve when pressure is applied with fingers) . This surveyor also observed redness and pressure indentation marks to the entire outside of Resident #45's right ankle bone. No pillows utilized or pressure relieving boots for feet and ankles were observed in Resident #45's bed. According to Fundamentals of Nursing 9th edition by Potter & Perry, Nonblanchable [DIAGNOSES REDACTED] is visible skin redness that persists with the application of pressure. It indicates structural damage to the capillary bed/ microcirculation. This is an indication for a category/ stage I pressure ulcer. Potter, [NAME] [NAME]; Perry, Anne Griffin; Stockert, [NAME]; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review the facility failed to provide adequate pain control with dressing changes for 1 of 24 residents (Resident #14) reviewed for pain, resulting in acute pain and mental anguish. Findings include: Review of a facility Admissions Record revealed Resident #14 was a [AGE] year-old male originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS), on 10/3/19, revealed Resident #39 was cognitively intact. Review of Resident #14's care plan focus revealed . (Resident #14) has potential for pain r/t (related to) Depression, surgical incision, [MEDICAL CONDITIONS] . Revision on: 08/06/2019. Interventions related to this focus include: Observe and report to Nurse any s/sx (sign/symptoms) of non-verbal pain. For example: .Body (tense, rigid, rocking, curled up, thrashing) .Pain meds as ordered .Date Initiated: 07/11/2019 . Review of Resident #14's Treatment Administration Record (TAR), revealed .Left stump pressure wound: Cleanse with normal saline. Gently pat dry. Apply Skin prep to surrounding peri-wound. Apply [MEDICATION NAME] to wound bed and cover with [MEDICATION NAME] every day shift for wound care apply [MEDICATION NAME] gel prior to packing -Order Date- 09/25/2019. Review of Resident #14's TAR, revealed .[MEDICATION NAME] Gel 2 % (used to numb the skin and for pain relief) Apply to left stump wound bed topically every day shift prior to wound treatment pain control -Order Date- 08/22/2019. Review of Resident #14's Medication Administration Record [REDACTED]. Review of medication insert, [MEDICATION NAME] TM ([MEDICATION NAME] Tablets USP, CII 5 mg .Full US prescribing infomation including box warning ., revealed when taking by mouth Roxicodoone 5 mg tabs may take 20 to 30 minutes to start noticing effects of the drug and 1 to 2 hours to feel the full pain relieving effects of the medication. SpecGxLLC (8/2017). [MEDICATION NAME] TM ([MEDICATION NAME] Tablets USP, CII 30 mg. Retreived from URL: http://www.mallinckrodt.com During an observation and interview on 10/09/19 at 9:45 AM, Unit Manager M (UM) went into to Resident #14's room to inspect his left stump for bruising. UM M removed the bandage on his left stump covering his pressure ulcer. UM M indicated since the bandage was removed should do Resident #14's dressing change. UM M left Resident #14's room and passed his nurse, Registered Nurse L (RN), and requested a pain pill to be given to Resident #14. During an observation and interview on 10/09/19 at 9:50 AM, RN L entered Resident #14's room and administered a pill. RN L indicated only removed a 5 MG [MEDICATION NAME] tablet from the medication cart; no [MEDICATION NAME] gel was requested. During an interview on 10/09/19 at 9:56 AM, UM M indicated would do Resident #14's dressing change now and did not need to delay the dressing change 20-30 minutes for any reason. During an observation on 10/09/19 at 9:59 AM, Assistant Director of Nursing B and UM M entered Resident #14's room to start his dressing change. No [MEDICATION NAME] gel was applied to Resident #14's wound. Resident #14 grimaced and indicated pressure to the stump was very painful. UM M cleansed the wound with normal saline and measured the depth of tunneling of the wound by inserting a cotton tipped swab into the wound. Resident #14 moaned, held his breath, grimaced and indicated that was extremely painful. UM M indicated the wound was deeper than last week, and it hurt a lot more than last week. The start and completion of Resident #14's dressing change occured less than 30 minutes from [MEDICATION NAME] administration and without the ordered [MEDICATION NAME] gel. During an observation and interview on 10/9/19 at 10:15 AM, Resident #14 indicated could not talk right then because he was in so much pain. Resident #14 indicated to come back in 20 to 30 minutes when the pain pill started to work. Resident #14 was holding his left leg behind the knee, with his eyes closed, and he was pursed lipped breathing, indicating pain. During an interview on 10/9/19 at 11:00 AM, Resident #14 indicated the dressing change was terribly painful. Resident #14 indicated when the staff used the [MEDICATION NAME] gel and allowed for his pain pill to work the dressing was tolerable. Resident #14 indicated his dressing changes have been frequently missed when the facility was low staffed. Resident #14 indicated when the nurses were prepared to do the dressing change, he does not stop them to ask for the [MEDICATION NAME] or to wait for the pain medication to work because he was afraid the nurse would not have time to come back later to do the dressing change.

This citation pertains to Intake #'s MI 728, MI 275 & MI 494 Based on observation, interview and record review the facility failed to provide sufficient staffing to ensure resident needs were met timely for 8 of 24 sampled residents (Resident #s 258, #51, #14, #94, #45, #42, #85, #33) reviewed for staffing, resulting in resident neglect, unmet care needs, worsening of pressure ulcers, acquisition of pressure ulcers, potential worsening of range of motion and contractures, abuse, and unmet care for all residents residing in the facility. Findings include: Review of the Facility assessment dated (MONTH) 2019 revealed, Our programs, series and facilities must be designed and operated with superior quality in order to satisfy the need of our customers .We believe our residents are our highest priority. We believe in the preservation of dignity, self-respect, and resident rights in a loving and caring environment. We believe int he resident-centered approach to care in which the total health needs of the resident are met . The Assessment indicated the facility Acuity, average monthly: Extensive services: average 1 resident or less per month; Special Care High: average 1 resident or less per month; Reduced Physical Function: average of 22 residents or less per month. The Assessment indicated General Care: Skin Integrity, Extensive wound care program that provides prevention, ongoing skin care, and wound care for wounds that are either surgical, received, and/or acquired .Provide person-centered/directed care, All requests are honored within reasonable accommodation. The physical/cognitive/spiritual care of the resident is person centered. If the resident is unable to make their own clinical decisions, legal representation and medical decision making is documented in their individual EMR. Resident #258 Review of a Face Sheet revealed Resident #258 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #258, with a reference date of 8/19/19 revealed a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #258 was cognitively impaired. Review of a facility Witness Statement Form dated 8/24/19 time of incident 8:40 AM., revealed: Resident #258's name on the top of the form. (CNA SS) reported to me (LPN P) that it appeared that the resident had not been changed at night due to her brief being saturated to the point that it completely disintegrating and look like a pile of mashed potatoes dropped on the floor. (CNA SS) also told me that the night shift CNA had told her that the resident was fine and she had believed her. I (LPN P) reported the incident to the ED (NHA A) who is also the abuse coordinator. She told me to educate my CNA about doing walking around and physically check each resident and change of shift rather than taking her word for it. This document was signed by LPN P. During an interview on 10/09/19 at 1:48 PM., LPN P reported the staff was way understaffed on the night shift (8/24/19) prior to him being notified by CNA SS that Resident #258 was left wet and soiled to the point her brief was saturated through. LPN P reported CNA SS came to him and informed him of Resident #258's brief being so wet, it was falling apart as CNA SS tried to remove it from underneath Resident #258. LPN P reported he went down to Resident #258's room to assist CNA SS with changing Resident #258. LPN P reported as they changed Resident #258 the brief was falling apart, and looked like mashed potatoes on the floor. LPN P reported after he and CNA SS finished changing Resident #258 he immediately called Nursing Home Administrator (NHA) A because not only did he (LPN P) think Resident #258 was neglected but so did CNA SS which is why she (CNA SS) initially came to him. LPN P reported when speaking with NHA A she did not think it was a neglectful situation, and NHA A instructed LPN P to educated CNA SS on walking rounds. LPN P reported NHA A had him do education for CNA SS because NHA A indicated that she (CNA SS) should have done the walking rounds between the day and night shift, she (CNA SS) trusted the word night shift, when she (night shift CNA) said that (Resident #258) was cleaned up a little while ago. LPN P stated if we did that, staff would have to glove up, and feel everyone's brief that is not realistic. LPN P reported he (LPN P) and (CNA SS) wrote up statements and he (LPN P) placed both statements in NHA As personal mailbox. LPN P reported the next time he saw (NHA A) she asked if he (LPN P) did the education for (CNA SS), and (NHA A) also asked why there were statements were in her (NHA A) box. LPN P stated I said so you can do your investigation, she passively dismissed me, and Resident #258 was not able to say what happened due to her condition. Review of a facility Witness Statement Form dated 8/24/19 time of incident 8:40 AM., revealed: Resident #258's name on the top of the form. Statement I (CNA SS) went into the room. I was telling the resident what I was in there for. So I could get her up for breakfast. I went to get her up for breakfast and saw that she was wet. I started to clean her up when I picked up the brief it was disintegrating all over the floor. It look like a pile of mush. I went to get the nurse I told the nurse what the night CNA said she was fine. So I believed her because she had clothes on. this document was signed by CNA SS. This document was a copy given to this surveyor and recieved while the survey process was ongoing by a confidential informant. During an interview on 10/09/19 02:06 PM Certified Nurse Aide (CNA) SS reported she came in at 6 am on 8/24/19 and about 8:30 AM., she checked on Resident #258. CNA SS stated that in shift report she was told that everyone (all the residents on CNA SS assignment) had been taken care of, and everything was fine. CNA SS reported she went in to get Resident # 258 up for the dining room. CNA SS reported she went to change (Resident #258) and her brief pulled out and it literally fell to the floor in pieces like mashed potatoes, it was disintegrated. CNA SS reported she remembers that the night shift (8/23/19 going into 8/24/19) only had 2 aides (CNA's) that night. CNA SS reported she immediately went to (LPN P) to report, and she (CNA SS) did use the word neglected. CNA SS reported LPN P came down and assisted with changing (Resident #258). CNA SS reported after that LPN P instructed her to write a statement up. CNA SS reported she wrote the statement, and gave it to LPN P. CNA SS reported after a while LPN P came down to her and told her (CNA SS) that (NHA A) wanted her (CNA SS) re-educated on walking rounds. CNA SS reported LPN P did education for walking rounds. CNA SS reported she (CNA SS and LPN P) both thought it was a neglectful situation. CNA SS stated if there were more than 2 aides, I doubt this would have happened. I do not think it was neglect on the night shift CNA's, I think it is a neglectful situation because of low staffing levels. CNA SS reported NHA A never followed up with her (CNA SS). CNA SS reported she did not believe an investigation was done, or any protocol followed as to retraining for neglect. Review of a Staffing Report revealed the facility had a census of 113 residents on 8/23/19. During the Night Shift hours (10pm-6am), there were 16 worked hours for Registered Nurses (2 RN's), 16 worked hours of Licensed Practical Nurses (2 LPN's), and 37.5 (approximately 4 CNA's) worked hours for Certified Nurse Aides reported. On 8/24/19 during the Morning Shift hours (6am-2pm), there were 16 worked hours for Registered Nurses, 16 worked hours of Licensed Practical Nurses, and 62 worked hours for Certified Nurse Aides reported. Review of the Facility Nursing Staffing report dated 8/23/19 revealed there were 4 CNA's scheduled to work the Night Shift hours with one additional CNA listed as a trainee and was scheduled to work with one of the 4 CNA's. During an interview on 10/09/19 at 3:19 PM., Registered Nurse (RN) L reported on 8/24/19, she (RN L), LPN P and CNA SS all worked the day shift. RN L reported the 3rd shift from 8/23/19 was extremely short staffed. RN L stated there was a staffing issue that evening before, I don't know how many staff the facility was down off the top of my head, but I know it was a really rough night for them. The staffing here is really bad. RN L reported nurses work 6 am-6pm and tend to stay over to chart because its difficult to complete everything during the shift. RN L reported CNA's are showing signs of burnout they (CNA's) are frustrated. RN L reported many residents are complaining, sometimes about meals, and getting cold food. RN L reported the biggest complaint is the call light times taking too long. RN L reported there are CNA's that are suppose to be shower aides, and restorative aides, but they (CNA's) get pulled to the floor to do cares for the residents, and some (resident) have missed showers. RN L reported one of the problems also is for over 100 residents there are only 2 showers in the facility, and there are no showers in the resident rooms. During an interview on 10/07/19 at 4:10 PM Licensed Practical Nurse (LPN) P reported staffing at the facility is very short. LPN P reported the facility recently got agency staffing. LPN P reported the problem with the agency staff is they call in, and then no one comes in. LPN P reported the unit managers at times have come in to assist until around 12:00 AM. LPN P reported the facility is so short at times for about 59 residents there might be only 1 staff for all 59 residents on that unit. LPN P stated the lowest (staff ratio) I (LPN P) have seen on night shift there were only 2 CNA's for the entered building for 3rd shift which was a month or two ago. LPN P reported residents are complaining about staffing, especially the residents that are cognitively intact. LPN P reported there has been an increase in falls during the night shift. LPN P indicated it has been brought to managements attention, to the Nursing Home Administrator (NHA) A and the Director of Nursing (DON's) attention. LPN P reported the CNA staff are scared to loose their jobs, and they are in fear to report anything. LPN P stated Of course I (LPN P) notice staff burnout, and CNA's on night shift always question if they should quit, because its just them and another aide. During an interview on 10/09/19 at 2:06 PM., Certified Nurse Aide (CNA) SS the staffing is so bad here, CNA's are burnt-out. CNA SS indicated they (CNA's) are tired., some residents are having behaviors, and the residents are frustrated because staff cannot meet their needs. CNA SS reported residents are missing their showers on a regular basis, when the units are short staffed they pull the bath aide to the floor. CNA SS stated we do have shower aides and restorative aides, but it doesn't do any good, because they are being pulled to the floor, this has been going on for couple months. During an interview on 10/10/19 at 11:06 AM., ADON B staffing at the facility has been a struggle. ADON B reported staff retention is our biggest problem. During an interview 10/10/19 at 11:27 AM., LPN FF reported staffing is short at the facility, and she hears complaints from staff and residents about the long call light times, and the shortage of qualified staff. Burnout is the condition that occurs when perceived demands outweigh perceived resources (Potter et al., 2013 a). It is a state of physical and mental exhaustion that often affects health care providers because of the nature of their work environment. Over time, giving of oneself in often intense caring environments sometimes results in emotional exhaustion, leaving a nurse feeling irritable, restless, and unable to focus and engage with patients (Potter et al., 2013b) .[MEDICATION NAME] fatigue impacts the health and wellness of nurses and the quality of care provided to patients .When a nurse experiences ongoing stressful patient relationships, he or she often disengages (Slatten et al., 2011) .It is not uncommon for nurses who are experiencing [MEDICATION NAME] fatigue to become angry or cynical and have difficulty relating with patients and co-workers ([NAME] et al., 2011). Potter, [NAME] [NAME]; Perry, Anne Griffin; Stockert, [NAME]; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations 1671-1672). Elsevier Health Sciences. Kindle Edition. Resident #51 Review of a facility Admissions Record, revealed Resident #51 was a [AGE] year-old male originally admitted to the facility on [DATE] with a pertinent [DIAGNOSES REDACTED]. Review of Resident #51's Minimum Data Set (MDS) assessment on 9/25/19, revealed The Brief Interview for Mental Status (BIMS) score was 15 or cognitively intact. In an interview on 10/7/19 at 10:40 AM, Resident #51 indicated was concerned with not receiving restorative therapy. Resident #51 indicated had been working with therapy and was released with a restorative program to follow three times a week. Resident #51 indicated the restorative aides ran this program and should have been working with him. Resident #51 indicated does not know when the last time the restorative aides helped him with his ordered exercises. Resident #51 indicated complained last week but nothing has been done. Review of Resident #14's MDS, Section O .O0500 Restorative Nursing Programs, dated 9/25/19, revealed .Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none of less than 15 minutes daily) .0 .Range of motion (active) .0 .Bed mobility . 0 . Transfer .0 . Walking . Review of Resident #51's Concern & Comment Form, dated 9/26/19 at 10:05 AM, revealed .Receptionist .Helped him fill out .Please describe your Concern .Restorative therapy told (Resident #51) they are too busy to work with him for the past month. He is very frustrated as he was up and walking with therapy for the past 3 months .Associate Receiving Concern . (Receptionist) . 9/26/19 .10:13 AM . No Facility Investigation and Response to Resident #51's concern until 10/7/19, 11 days later. In an interview on 10/10/19 at 10:31 AM, CNA D indicated was one of the two restorative aides for the facility. CNA D indicated has not been able to consistently complete a full day of restorative therapy in a long time. CNA D indicated has been pulled to the floor frequently and so has the other restorative CNA NNN. CNA D indicated was pulled today to the floor and will not be able to complete restorative tasks today. CNA D indicated pulling the restorative aide to cover staffing concerns in the facility started about 4 months ago. CNA D indicated the two restorative aides were supposed to be scheduled 7 days a week, one CNA on the floor and one CNA on restorative. On Monday's one CNA was scheduled to do residents weights and the other was to do restorative therapy. Restorative therapy hardly gets done and Monday weights are rarely done on Monday's anymore. CNA D indicated if they were not pulled to work the floor, would have to complete all the missing weights not done on Monday and restorative was pushed to another day. CNA D indicated used to complete a paper log to indicate who was seen or why they were not seen. CNA D indicated stopped using paper log because the log would say pulled to floor in almost every space (last log dated 5/19). CNA D indicated residents have complained about not doing their exercises. CNA D indicated has voiced the resident's concerns to the UM, ADON, DON, and NH[NAME] CNA D indicated Resident #51 was on the current restorative therapy list and should have been participating for the last several months. CNA D indicated has not done restorative therapy with Resident #51 in at least a month and neither has CNA NNN because has been covering the floor. In an interview on 10/10/19 at 10:00 AM, Nursing Home Administrator A (NHA) indicated CNA D and CNA NNN were the two CNA's that ran the restorative program. NHA A indicated the facility staffed restorative aides everyday but often those aides were being pulled to work on the floor instead of doing restorative therapy. NHA A indicated has requested for those aides to not be pulled and to fill the empty the CNA spots with CNA volunteers. Resident #14 Review of a facility Admissions Record revealed Resident #14 was a [AGE] year-old male originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of Resident #14's Minimum Data Set (MDS) assessment, revealed a Brief Inventory of Mental Status (BIMS) score was 15 or cognitively intact. In an interview on 10/9/19 at 4:50 PM, Nurse Practitioner EE (NP) indicated in (MONTH) ordered a series of test for Resident #14 because (Resident #14) was having increased pain in his left BKA stump, where he also had an infected pressure ulcer. NP EE indicated ordered an ultrasound, and an x-ray of the left BKA stump. The ultrasound results were inconclusive and suggested further testing, and a MRI was ordered. Review of Resident #14's printed order, sent to the facility that performed his MRI, dated 8/21/19, revealed From: (facility address and phone number) Fax: N/A .Ordered By: (NP EE and office address) . Order Date: 8/21/19 .Communication: Verbal .Order Summary: MRI (LEFT KNEE) ATTN: Stump w/ & w/o contrast one time only for Infected pressure ulcer to left stump for 1 Day .Ordered By Signature: (NP EE) . Review of Resident #14's MRI results, dated 8/26/19, revealed .Conclusion: .Open wound over the residual fibula with osteo[DIAGNOSES REDACTED] of the residual, fibular shaft .[MEDICAL CONDITION] (skin infection) around the open wound . Review of NP progress note dated 9/26/19, .Patient seen today per his request regarding follow-up MRI .Ordered an MRI over a month ago and did not receive any follow-up. Today nursing staff went through calendar and found out that he went to (MRI facility) on 8/26/19 for an MRI of his left BKA . a report was faxed to (facility) . In an interview and observation on 10/7/19 at 11:31 AM, Resident #14's was lying in bed, and his left stump with a pressure ulcer bandage was exposed. The bandage was signed and dated 10/3/19. Resident #14 indicated has not had his left stump dressing changed since 10/3/19. It was ordered to be done every day. Resident #14 indicated the nurses often tell him they are too busy to change his dressing on their shift, and pass the dressing off to the next shift, but those nurses were busy too and don't do it either. In an interview on 10/8/19 at 2:20 PM, Registered Nurse [NAME] (RN) indicated worked 10/7/19 day shift and noticed Resident #14's left stump dressing had not been changed in several days. RN [NAME] indicated did not change his dressing on the day shift because spent the entire shift passing medications. RN [NAME] indicated sometimes there was a third nurse scheduled to do skin assessments and dressing changes, but often that third nurse was pulled to a hall assignment due call ins. RN [NAME] indicated staffing has been an issue for nursing and with aides for the passed few months. On 10/8/19 at 9:00 AM, requested Licensed Practical Nurse FF (LPN) to observe Resident #14's left stump dressing change. LPN FF indicate would try to complete the dressing change on first shift. On 10/8/19 at 1:30 PM, asked LPN FF again to observe Resident #14's left stump dressing change. LPN FF indicated will not get to it this shift (ends at 2:00 PM) because was too busy passing medications and there was not a third nurse today to do dressing changes. LPN FF indicated would report to the oncoming nurse that Resident #14's dressing change needs to be done. During an interview and observation on 10/9/19 at 9:45 AM, Resident #14's was lying in bed, and his left stump with a bandage was exposed. The bandage was signed and dated 10/7/19. Resident #14 indicated does not remember the staff changing his dressing the day before (10/8/19). Review of Resident #14's Treatment Administration Record (TAR) for October, on 10/9/19, revealed most current dressing order dated 9/25/19, .Left stump pressure wound: . No dressing change was completed on 10/4, 10/5, 10/6, or 10/8. Review of Resident #14's (MONTH) TAR revealed multiple changes for his .Left stump pressure wound: . dressing orders and 8 missed dressing changes out of 30 possible days in September. Review of Resident #14's Skin Assessments' revealed no nursing skin assessments have been documented since 8/8/19. During an observation and interview on 10/09/19 at 9:50 AM, RN L entered Resident #14's room and administered a pill. RN L indicated only removed a 5 MG [MEDICATION NAME] tablet from the medication cart; no [MEDICATION NAME] gel was requested. During an interview on 10/09/19 at 9:56 AM, UM M indicated would do Resident #14's dressing change now and did not need to delay the dressing change 20-30 minutes for any reason. During an observation on 10/09/19 at 9:59 AM, Assistant Director of Nursing B and UM M entered Resident #14's room to start his dressing change. No [MEDICATION NAME] gel was applied to Resident #14's wound. Resident #14 grimaced and indicated pressure to the stump was very painful. UM M cleansed the wound with normal saline and measured the depth of tunneling of the wound by inserting a cotton tipped swab into the wound. Resident #14 moaned, held his breath, grimaced and indicated that was extremely painful. UM M indicated the wound was deeper than last week, and it hurt a lot more than last week. The start and completion of Resident #14's dressing change occured less than 30 minutes from [MEDICATION NAME] administration and without the ordered [MEDICATION NAME] gel. During an observation and interview on 10/9/19 at 10:15 AM, Resident #14 indicated could not talk right then because he was in so much pain. Resident #14 indicated to come back in 20 to 30 minutes when the pain pill started to work. Resident #14 was holding his left leg behind the knee, with his eyes closed, and he was pursed lipped breathing, indicating pain. During an interview on 10/9/19 at 11:00 AM, Resident #14 indicated his dressing change are terribly painful. Resident #14 indicated when the staff used the [MEDICATION NAME] gel and allowed for his pain pill to work the dressing was tolerable. Resident #14 indicated when the staff were busy or short they do not wait long effect for my pain medication to take effect. Resident #14 indicated since his dressing changes have been frequently missed when the facility was low staffed, he does not stop them to ask for the [MEDICATION NAME] or to wait for the pain medication to work. Resident #14 indicated was afraid the nurse would not make time to come back later to do the dressing change. Resident #14's missed dressing changes and fear of not having dressing changes done when staff actually do come to change the dressing regardless of pain medication effectiveness indicated Resident #14 has been harmed by this facility practice which contributed to his infection of osteomylitis. In an interview on 10/10/19 at 3:00 PM, Unit Manager Y (UM) indicated Resident #14's unit has been without a unit manager for approximately 5 to 6 months. UM Y indicated the wound nurse then left in September. UM Y indicated the facility had to band together and cover Resident #14's unit and later cover wound care. UM Y indicated the lack of a manager coupled with a lack of staffing lead to things being missed like weights, restorative care, and wound care. Resident #94 Review of a Face Sheet revealed Resident #94 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #94, with a reference date of 8/30/19 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #94 was cognitively intact. Review of a Care Plan revealed, Focus: (Resident #94) has an ADL self-care performance deficit r/t (related to) MS, tremors, muscle spasms. Goal: Will receive the staff assistance necessary to complete ADLs. Date Initiated: 09/24/2019. Interventions: Eating: Extensive assistance x1 Date Initiated: 09/24/2019. Toileting: Extensive assistance x1 Date Initiated: 09/24/2019 Transfers: Extensive assistance x1 Date Initiated: 03/15/2019 ·Showers twice weekly and prn (as needed) on 2nd shift Date Initiated: 08/24/2018. During an interview on 10/08/19 at 11:24 [NAME]M., Resident #94 reported that he didn't get his scheduled shower this morning, instead he received a bed bath, because of short staffing. Review of Bathing Task located in Resident #94's EHR revealed, Resident #94 preferred showers on Tuesday and Thursday. The record indicated that Resident #94 received a bed bath on 10/8/19 (Tuesday). During an interview on 10/08/19 at 11:55 [NAME]M., Certified Nursing Assistant (CNA) TTT reported that when a designated Shower Aide is not available or pulled to work on the floor, the CNA's should be providing showers to the residents as scheduled. During an interview on 10/07/19 at 09:36 [NAME]M., Resident #94 reported that the facility is short staffed, especially on evening shift. Resident #94 reported that he needed assistance to eat due to his shaking and he's had to wait 40 minutes, after his meal is delivered, for staff to arrive in the dining room. During an interview on 10/10/19 at 12:55 P.M., Resident #94 reported that he was not able to stand at all anymore and that he hasn't been able to use the toilet on his own or change his own incontinence brief for about 3 months due to his MS progressively getting worse. Resident #94 reported that he depends on facility staff to assist him with incontinence care. Resident #94 reported that he cannot propel himself in his wheelchair. During an observation and interview on 10/10/19 at 1:03 P.M., CNA T and CNA NNN entered Resident #94's room to transfer the resident into bed. CNA T reported that the resident uses a sit to stand device or a hoyer lift that requires 2 people assisting. CNA T reported that Resident #94 was not able to bear weight with transfers anymore. During an interview on 10/10/19 at 01:25 P.M., CNA T reported that if Resident #94 requested to be transferred for incontinence care during mealtimes, she would not be able to help him because he requires 2 people to transfer and there is only 1 CNA working on the hall during mealtimes, while the other CNA is feeding residents in the dining room. CNA T reported that the person working on the hall also is responsible for answering other call lights during mealtime. Review of a document provided by CNA K indicating residents that require 2 staff members for transfers on Wood Hall revealed, 24 out of 62 residents required 2 staff members during transfers for all care. Resident #45 Review of a Face Sheet revealed Resident #45 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 8/1/19 revealed a Staff Assessment for Mental Status, which indicated Resident #45 was cognitively severely impaired. Functional Status revealed, Resident #45 required extensive assistance of 2 people for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or other sleeping furniture). Review of CarePlan revealed, (Resident #45) At risk for break in skin integrity r/t sedentary lifestyle, incontinence .Date Initiated: 04/23/2018 Revision on: 05/29/2019 .The resident has an ADL self-care performance deficit .Date Initiated: 03/01/2019. Provide feeding assistance. Resident eats in assisted dining room. Date Initiated: 11/01/2018. Transfers: Dependent on mechanical lift (hoyer) x 2 staff Date Initiated: 03/01/2019. During an observation on 10/07/19 at 02:13 P.M., Resident #45 in his room, lying on back in bed, bed flat. Resident #45's legs and feet laying directly on the bed, no pressure reducing positioning observed. LPN FF provided catheter care to resident. LPN FF reported that Resident #45 wasn't feeling well today and hasn't been out of bed. During an observation on 10/07/19 at 02:13 P.M., Resident #45 in his room, lying on back in bed, bed flat. Resident #45's legs and feet laying directly on the bed, no pressure reducing positioning observed. LPN FF provided catheter care to resident. LPN FF reported that Resident #45 wasn't feeling well today and hasn't been out of bed. During an interview on 10/10/19 at 11:49 [NAME]M., UM Y reported that Resident #45 was admitted to the facility with a pressure wound on his right ankle. UM Y reported that Resident #45 does not have a care plan or orders for reducing pressure specifically to feet and ankles while in bed. UM Y reported that Resident #45 is 100% dependent on staff to provide position changes to relieve pressure. During an interview on 10/10/19 at 11:49 [NAME]M., UM Y reported that Resident #45 was admitted to the facility with a pressure wound on his right ankle. UM Y reported that Resident #45 does not have a care plan or orders for reducing pressure specifically to feet and ankles while in bed. UM Y reported that Resident #45 is 100% dependent on staff to provide position changes to relieve pressure. During an observation on 10/09/19 at 10:59 [NAME]M., Resident #45 was in his room, sitting in broda chair (wheeled recliner) with eyes closed. During an observation on 10/09/19 at 12:23 P.M., Resident #45 was in his room, sitting in broda chair (wheeled recliner) with his eyes closed. CNA D observed retrieving resident and pushing him to the dining room for lunch. During an observation and interview on 10/9/19 at 3:20 P.M., Resident #45 was in his room, sitting in broda chair. Noted that Resident #45 had been in his chair for approximately 4.5 hours. CNA EEE reported that Resident #45 stays up in his chair until he let's us know that he wants to go to bed, otherwise staff will transfer Resident #45 to bed after dinner, at about 7:00 P.M. Indicating that Resident #45 would be sitting in his chair from 10:59 [NAME]M.-7:00 P.M. (8 hours). During an interview on 10/10/19 at 08:40 [NAME]M., CNA T reported that Resident #45 would not be getting up for breakfast this morning. CNA T stated, I have to help in the dining room, so I can't do (Resident #45's) care right now .I don't have time. During an observation on 10/10/19 at 09:27 [NAME]M., Resident #45 lying on back in bed with head of bed at 30-40 degrees, and meal tray at bedside. Resident #45 reported that he wanted to get out of bed. During an observation on 10/10/19 at 10:03 [NAME]M., CNA T and CNA NNN entered Resident #45's room to provide care and get him out of bed. A bed bath, catheter care and incontinence care was performed. Observed incontinence brief saturated with loose stool, overflowing onto Resid (TRUNCATED)

Based on interview and record review the facility failed to obtain MRI result, and notify the practitioner of the results in a timely manner, for 1 of 24 residents (Resident #14), reviewed for infections, resulting in delayed treatment and worsening of a pressure ulcer. Chronic [DIAGNOSES REDACTED] is a severe, persistent, incapacitation infection of bone, which develops after two months of an injury or initial infection .The common signs and symptoms are pain and movement restriction .Treatments .include antibiotics and surgery to remove the dead tissue . (sic) Tangella, K. MD (May 17, (YEAR)). Chronic [DIAGNOSES REDACTED]. Retrieved from http://dovemed.com Findings include: Review of a facility Admissions Record revealed Resident #14 was a [AGE] year-old male originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. In an interview on 10/9/19 at 4:50 PM, Nurse Practitioner EE (NP) indicated in (MONTH) ordered a series of test for Resident #14 because (Resident #14) was having increased pain in his left BKA stump, where he also had an infected pressure ulcer. NP EE indicated ordered an ultrasound, and an x-ray of the left BKA stump. The ultrasound results were inconclusive and suggested further testing, and a MRI was ordered. Review of Resident #14's printed order, sent to the facility that performed his MRI, dated 8/21/19, revealed From: (facility address and phone number) Fax: N/A .Ordered By: (NP EE and office address) . Order Date: 8/21/19 .Communication: Verbal .Order Summary: MRI (LEFT KNEE) ATTN: Stump w/ & w/o contrast one time only for Infected pressure ulcer to left stump for 1 Day .Ordered By Signature: (NP EE) . Review of Resident #14's MRI results, dated 8/26/19, revealed .Conclusion: .Open wound over the residual fibula with osteo[DIAGNOSES REDACTED] of the residual, fibular shaft .[MEDICAL CONDITION] (skin infection) around the open wound . Review of NP progress note dated 9/26/19, .Patient seen today per his request regarding follow-up MRI .Ordered an MRI over a month ago and did not receive any follow-up. Today nursing staff went through calendar and found out that he went to (MRI facility) on 8/26/19 for an MRI of his left BKA . a report was faxed to (facility) . In an interview on 10/10/19 at 2:00 PM, MRI Medical Records staff KKK (MRI MR) indicated Resident #14's MRI was performed on 8/26/19 and mailed on 8/27/19 at 1:00 PM to the provider's address (NP EE's office). MRI MR KKK indicated did not fax the results to Resident #14's nursing home because the MRI order sent did not have the nursing homes fax number on it. The fax number was listed as N/[NAME] MRI MR KKK indicated if there was no fax number listed then we were to mail the results to the provider that ordered the test. In an interview on 10/9/19 at 4:55 PM, NP EE indicated was surprised no one at the facility had any idea that Resident #14 had an MRI done and that the negative results (osteo[DIAGNOSES REDACTED]) went undiscovered for 4 weeks. NP EE indicated osteo[DIAGNOSES REDACTED] was a serious infection and needed to be treated as soon as possible. NP EE indicated 4 weeks later Resident 14's best treatment option was to undergo another amputation of the left leg (to above the knee) to remove the infected bone and surrounding tissue. NP EE indicated Resident #14 refused another amputation and opted for long term antibiotics to treat the osteo[DIAGNOSES REDACTED]. NP EE indicated the facility should have been following up on the MRI results, especially since his previous ultrasound results suggested further testing and his pressure was already infected. NP EE stated, The MRI facility told us that they mailed the results to my office. I am rarely there and do not typically receive test results at the office. NP EE indicated the nursing home facility ultimately was responsible for those test results. In an interview on 10/10/19 at 3:00 PM, Assistant Director of Nursing B (ADON) indicated does not know how Resident #14's MRI results were missed for 4 weeks. ADON B indicated had just started the ADON position around that time. ADON B indicated the nurse receiving NP EE's order should have called the MRI place, set up the appointment, and faxed over the order. That nurse should have passed on the appointment information to the next shift and to the Unit Manager. Then the nurse sending the resident out for the test should have also report to the next shift and to the Unit Manager to expect test results. Usually, a Unit Manager would be overseeing this process, so test results did not get missed, but at that time there was not a Unit Manager for Resident #14's unit. Review of Resident #14's Progress Notes from 8/21/19 to 9/26/19, revealed no note regarding an MRI ordered for Resident #14 for 8/26/19, no note indicating Resident #14 went to the MRI on 8/26/19 and should be expecting results, and no note indicating results were received for the MRI on 9/25/19.

This citation pertains to MI 128. Based on observation, interview and record review the facility failed to follow standards of practice regarding use of restraints in 1 of 10 residents (Resident #102) reviewed for professional standards, resulting in [DIAGNOSES REDACTED] and wounds to the hands and arms of Resident #102. Findings include: Review of the textbook Fundamentals in Nursing revealed, The use of a restraint must be clinically justified and a part of the patient's prescribed medical treatment and plan of care. A physician's orders [REDACTED]. The order must be current, state the type and location of restraint, and specify the duration and circumstances under which it will be used. These orders need to be renewed within a specific time frame according to the policy of the agency .You must conduct ongoing assessment of patients who are restrained. Proper documentation, including the behaviors that necessitated the application of restraints, the procedure used in restraining, the condition of the body part restrained (e.g., circulation to hand), and the evaluation of the patient response, is essential. Restraints must be removed periodically, and the nurse assesses the patient to determine if they continue to be necessary. Taken from Potter, [NAME] [NAME]; Perry, Anne Griffin; Stockert, [NAME]; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Review of the Policy Restraint & Position change alarm use dated 11/2017 revealed a Physical restraint was attached or adjacent to the resident's body, Cannot be easily removed by the resident and Restricts the resident's freedom of movement or normal access to his/her body. The Policy further revealed a physician's orders [REDACTED].Documentation in clinical notes may include .date and time of use;type of restraint and resident tolerance. Review of the Face Sheet revealed Resident #102 was an [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 had severely impaired cognition and was an extensive assist of at least one staff member for transfer, dressing, ambulation and bathing. In an observation on 8/12/19 at 9:35 AM, Resident #102 was noted to be in her room. Observed on her right wrist was a bandage. The bandage was removed by Registered Nurse (RN) CC and a wound was observed to the right wrist of Resident #102. RN CC measured the wound as 0.4 cm (centimeter) x 0.4 cm with a depth of 0.2 cm with scant serous (clear, thin, watery plasma) drainage from the wound discovered on 6/17/19. Review of the Restraint-Physical Initial evaluation dated 6/13/19 revealed Resident #102 had agitated behavior of poking and digging at her eyes. The Initial evaluation revealed Resident #102 had 1 to 1 increased staff in direct care of her for added safety and .for safety we (facility) will use soft mittens PRN (as needed) for 24 hours (indicated restraint would terminate on 6/14/19). Review of the physician's orders [REDACTED]. In an interview on 8/14/19 at 9:32 AM and on 8/26/19 at 9:15 AM, Unit Manager (UM) X stated the physician's orders [REDACTED].#102 was for 24 hours from 6/13/19 to 6/14/19. UM X stated the order read for soft mittens and for staff to check every 30 minutes and remove the restraint every 2 hours for Resident #102. UM X stated the facility didn't have that product (soft mittens) on premises to place on Resident #102's hands and follow the physician's orders [REDACTED]. UM X stated, on 6/14/19, had students sitting with her (Resident #102) .it (sitting one to one) was very effective the students had to hold her (Resident #102) hands, she (Resident #102) wanted to keep bringing those hands to her eyes. In an interview on 8/14/19 at 10:00, Licensed Practical Nurse (LPN) T stated she worked the weekend of 6/15/19 to 6/16/19. LPN T stated Resident #102's bilateral arms and hands were wrapped with geri sleeves (a soft fabric sleeve) secured with ace wraps (an elastic band). LPN T stated, I was not the one who put them on and I didn't question it (the restraint). LPN T stated, no I did not take them (restraint) off that weekend and nobody reported finding any blisters until Monday (6/17/19). In an interview on 8/26/19 at 2:35 PM, CNA K stated, on 6/16/19, Resident #102 had net things on Resident #102 hands that looked like those ace wraps holding on the nets. CNA K stated the net things with ace wraps .looked awful tight on Resident #102's arms. In an interview on 8/26/19 at 3:30 PM, CNA LL stated, on 6/1/19, Resident #102 was at the desk trying to pull arm sleeves off (improper restraints). CNA LL stated Resident #102 couldn't leave her (Resident #102) in her room because Resident #102 was trying to get out of her restraints on her arms. In an interview on 8/14/19 at 10:00, Licensed Practical Nurse (LPN) T stated she worked the weekend of 6/15/19 to 6/16/19. LPN T stated Resident #102's bilateral arms and hands were wrapped with geri sleeves (a soft fabric sleeve) secured with ace wraps (an elastic band). LPN T stated, I was not the one who put them on and I didn't question it (the restraint). LPN T stated, no I did not take them (restraint) off that weekend and nobody reported finding any blisters until Monday (6/17/19). In an interview on 8/14/19 at 10:14 AM, Registered Nurse (RN) Y stated she took care of Resident #102 on the night on 6/16/19. RN Y stated, I didn't investigate her (Resident #102) hands (indicated did not monitor restraints). In an interview on 8/12/19 at 2:48 PM, Nurse Practitioner (NP) M stated Resident #102 was found on 6/17/19 with ace wraps with a sock or tubi grips (a soft sleeve) on her hands and arms. NP M stated Resident #102's arms and hands were wrapped tight. NP M stated she removed the constricting wraps to Resident #102's arms and saw [MEDICAL CONDITION] (swelling), blisters and her (Resident #102) right hand was swollen. NP M stated she diagnosed Resident #102 with [DIAGNOSES REDACTED] (a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells) and the damage that was done couldn't have happened in a short amount of time the damage was quite significant. NP M reviewed the order for restraint dated 6/13/19 and stated the restraint should have been discontinued on the 14th (6/14/19) but they (restraints) were on all weekend and were on Monday morning (6/17/19). In an interview on 8/13/19 at 12:03 PM, Director of Nursing (DON) B stated on 6/17/19 she observed, both hands of Resident #102 which had some blisters and portions of Resident #102's hands were dark red (indicated poor blood flow) and Resident #102 had [DIAGNOSES REDACTED]. DON B stated the restraint had pulled tight in spots causing blisters on bilateral hands and arms of Resident #102. DON B stated the restraints were .on through the weekend. DON B stated staff should not have used the restraint over the weekend after 6/14/19. Review of the Treatment Administration Record (TAR) dated 6/2019 revealed no documentation of monitoring or assessment of Resident #102's restraints for 6/15/19 and 6/16/2019. In an interview on 8/14/19 at 2:41 PM, UM X reviewed Resident #102's treatment record and stated, not seeing any documentation of monitoring or release of the restraints. Review of the Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome, to left lateral (outside) forearm with Granulation tissue (beefy red), .serious drainage and wound measurements of 0.6 cm x 1 cm. Review of the Emergency Department Documentation dated 6/19/19 revealed Resident #102 Arrives via ems (emergency medical services) from facility and Patient was restrained with soft restraints and now has skin breakdown over bilateral hands. Review of the Wound Ulcer Incision assessment dated [DATE] revealed Resident #102 wound .Present on admission to bilateral posterior (back), Palmar (related to palm) hand(s) and Friction/shear wound to bilateral wrist.

This citation pertains to MI 128, MI 258, MI 660 and MI 185. This citation contains 2 Deficiency Practice Statements A & B. Deficiency Practice Statement A Based on observation, interview and record review the facility failed to: 1.) use the correct physical restraint and 2.) follow nursing standards and physician's orders [REDACTED].#102) reviewed for restraints, resulting in an immediate jeopardy which began on 6/14/19 when facility staff did not monitor and discontinue a physical restraint and Resident #102 was found on 6/17/19 to still have physical restraints on which caused [DIAGNOSES REDACTED] to both hands, forearms and pressure wounds. This deficient practice caused Resident #102 serious harm and injury. Based on observation, interview and record review the facility failed to provide an environment free of unnecessary physical restraints in 1 of 7 residents (Residents #103) reviewed for physical restraints, resulting in an immediate jeopardy for Resident #103, that began on 7/31/19, when staff physically restrained and forced Resident #103 to receive unwanted care. This deficient practice caused the likelihood for a serious decline in mental and psychosocial well-being of Resident #103 that is not solely due to the normal disease progression. Findings include: A physical restraint is any manual method or physical or mechanical device (such as full set of side rails), material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely (TJC, (YEAR)). Potter, [NAME] [NAME]; Perry, Anne Griffin; Stockert, [NAME]; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Review of the Policy Restraint & Position change alarm use dated 11/2017 revealed Policy: The intent is for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience, prohibits the use of physical restraints to unnecessarily inhibit a resident's freedom of movement or activity, and limits physical restraint use to circumstances in which the resident has medical symptoms that may warrant the use of restraints. When a physical restraint is used, the facility must use the least restrictive restraint for the least amount of time and provide ongoing re-evaluation of the need for the physical restraint. The policy indicated a Physical restraint was attached or adjacent to the resident's body, Cannot be easily removed by the resident and Restricts the resident's freedom of movement or normal access to his/her body. The Policy further revealed a physician's orders [REDACTED].Documentation in clinical notes may include .date and time of use;type of restraint and resident tolerance. The Policy indicated, Procedure: Assessment: 3. The resident or resident representative may request the use of a physical restraint; however, if there are no medical symptoms identified that require treatment, the use of a restraint is prohibited. Review of the policy and procedure Protection of Residents: Reducing the Threat of Abuse & Neglect revised 2/2018 revealed, Each Resident has the right to be free from abuse, neglect, .no limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone. It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, .Prevention: .The facility must .Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents care needs and behavioral symptoms, if any .Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as: Verbally aggressive behavior; Physically aggressive behavior; Sexually aggressive behavior .Residents with communication disorders .Residents that require extensive nursing care and/or are totally dependent on staff for the provision of care. Resident #102: Review of the Face Sheet revealed Resident #102 was an [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 had severely impaired cognition and was an extensive assist of at least one staff member for transfer, dressing, ambulation and bathing. In an observation on 8/12/19 at 9:20 AM, Resident #102 was noted to be in her room. Observed on her right wrist was a bandage. The bandage was removed by Registered Nurse (RN) CC and a wound was observed to the right wrist of Resident #102. RN CC measured the wound as 0.4 cm (centimeter) x 0.4 cm with a depth of 0.2 cm with scant serous (clear, thin, watery plasma) drainage from the wound that was discovered on 6/17/19. This surveyor attempted to interview Resident #102, she was non-interviewable. Review of the Restraint-Physical Initial evaluation dated 6/13/19 revealed Resident #102 had agitated behavior of poking and digging at her eyes. The Initial evaluation revealed Resident #102 had 1 to 1 increased staff in direct care of her for added safety and .for safety we (facility) will use soft mittens PRN (as needed) for 24 hours (indicated restraint would terminate on 6/14/19). Review of the physician's orders [REDACTED]. In an interview on 8/14/19 at 9:32 AM and on 8/26/19 at 9:15 AM, Unit Manager (UM) X stated the physician's orders [REDACTED].#102 was for 24 hours from 6/13/19 to 6/14/19. UM X stated the order read for soft mittens and for staff to check every 30 minutes and remove the restraint every 2 hours for Resident #102. UM X stated the facility didn't have that product (soft mittens) on premises to place on Resident #102's hands and follow the physician's orders [REDACTED]. UM X stated, on 6/14/19, had students sitting with her (Resident #102) .it (sitting one to one) was very effective the students had to hold her (Resident #102) hands, she (Resident #102) wanted to keep bringing those hands to her eyes. In an interview on 8/14/19 at 10:00, Licensed Practical Nurse (LPN) T stated she worked the weekend of 6/15/19 to 6/16/19. LPN T stated Resident #102's bilateral arms and hands were wrapped with geri sleeves (a soft fabric sleeve) secured with ace wraps (an elastic band). LPN T stated, I was not the one who put them on and I didn't question it (the restraint). LPN T stated, no I did not take them (restraint) off that weekend and nobody reported finding any blisters until Monday (6/17/19). In an interview on 8/26/19 at 2:35 PM, CNA K stated, on 6/16/19, Resident #102 had net things on Resident #102 her hands that looked like those ace wraps holding on the nets. CNA K stated the net things with ace wraps .looked aweful tight on Resident #102's arms. In an interview on 8/26/19 at 3:30 PM, CNA LL stated, on 6/1/19, Resident #102 was at the desk trying to pull arm sleeves off (improper restraints). CNA LL stated Resident #102 couldn't leave her (Resident #102) in her room because Resident #102 was trying to get out of her restraints on her arms. In an interview on 8/14/19 at 10:14 AM, Registered Nurse (RN) Y stated she took care of Resident #102 on the night on 6/16/19. RN Y stated, I didn't investigate her (Resident #102) hands (indicated did not monitor restraints). In an interview on 8/12/19 at 2:48 PM, Nurse Practitioner (NP) M stated Resident #102 was found on 6/17/19 with ace wraps with a sock or tubi grips (a soft sleeve) on her hands and arms. NP M stated Resident #102's arms and hands were wrapped tight. NP M stated she removed the constricting wraps to Resident #102's arms and saw [MEDICAL CONDITION] (swelling), blisters and her (Resident #102) right hand was swollen. NP M stated she diagnosed Resident #102 with [DIAGNOSES REDACTED] (a painful condition that occurs when pressure within the muscles builds to dangerous levels caused by the tight wrapping. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells) and the damage that was done couldn't have happened in a short amount of time the damage was quite significant. NP M reviewed the order for restraint dated 6/13/19 and stated the restraint should have been discontinued on the 14th (6/14/19) but they (restraints) were on all weekend and were on Monday morning (6/17/19). In an interview on 8/13/19 at 12:03 PM, Director of Nursing (DON) B stated on 6/17/19 she observed, both hands of Resident #102 which had some blisters and portions of Resident #102's hands were dark red (indicated poor blood flow) and Resident #102 had [DIAGNOSES REDACTED]. DON B stated the restraint had pulled tight in spots causing blisters on bilateral hands and arms of Resident #102. DON B stated the restraints were .on through the weekend. DON B stated staff should not have used the restraint over the weekend. Review of the Treatment Administration Record (TAR) dated 6/2019 revealed no documentation of monitoring or assessment of Resident #102's restraints for 6/15/19 and 6/16/2019. Review of the Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome, to left lateral (outside) forearm with Granulation tissue (beefy red), .serious drainage and wound measurements of 0.6 cm x 1 cm. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome wound to right medical (inside) aspect wrist which measured 3.2 cm x 1 cm. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .2 cm x 2 cm wound to Resident #102's left upper forearm. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .2.2 cm x 2.4 cm wound to Resident #102's left inner aspect of elbow. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .4 cm x 4.2 cm wound to Resident #102's right medial aspect wrist. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .2.1 cm x 1 cm wound to Resident #102's right third digit posterior base. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .3 cm x 1/5 cm wound to Resident #102's right fourth digit medial posterior base (ring finger). The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .2.5 cm x 1 cm wound to Resident #102's right thumb. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .3 cm x 2.4 cm wound to Resident #102's right thumb palm side. Review of the Emergency Department Documentation dated 6/19/19 revealed Resident #102 Arrives via ems (emergency medical services) from facility and Patient was restrained with soft restraints and now has skin breakdown over bilateral hands. [DIAGNOSES REDACTED]. Resident #103 Review of a Face Sheet revealed Resident #103 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 5/15/19 revealed a Brief Interview for Mental Status (BIMS) by staff assessment of severe cognitive impairment. Review of the Functional Status revealed that Resident #103 required extensive assistance of 1 person for bed mobility and 2 persons for transfers between surfaces. Review of Resident #103's Care Plan revealed, Focus: The resident is/has potential to be physically and verbally aggressive (hitting, kicking, spitting, yelling, swearing) r/t Anger, Poor impulse control, Developmental Delay Date Initiated: 09/27/2018 Interventions: COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior Date Initiated: 09/27/2018 . Give the resident as many choices as possible about care and activities. Date Initiated: 09/27/2018 . When the resident becomes agitated: Intervene before agitation escalates; Provide reminders of rewards with good behavior; Notify resident of discussions with brother if behavior escalates. Resident often responds well to reminders of good vs. bad behavior rewards Date Initiated: 09/27/2018. Review of Resident #103's Care Plan revealed, Focus: The resident is resistive to care (often becomes combative with cares (hitting, kicking, spitting, pinching)) r/t (related to) developmental delay, ineffective coping, disease process (intermittent [MEDICAL CONDITION]) Date Initiated: 01/23/2019 Interventions: Allow the resident to make decisions about treatment regimen, to provide sense of control. Date Initiated: 01/23/2019 . If during care resident becomes agitated, aggressive and or combative; staff is to stop care (do not force personal care), take step back & attempt to redirect resident focus. If behavior continues, make second attempt to redirect focus to allow positive engagement (utilize positive talking points i.e. relationship with brother, remind of reward for good behavior). If second attempt to redirect proves unsuccessful, inform (Resident #103) that you are leaving room & reporting to nurse, offer alternate care staff. Third attempt with alternate care staff. Date Initiated: 07/15/2019 If possible, determine resident's preference for ADL activities and return at the agreed upon time. Date Initiated: 01/23/2019 If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. Date Initiated: 01/23/2019. During an attempt to interview Resident #103 on 8/13/19 at 2:25 P.M. Resident #103 stated, Get out of here!!! while swinging his arm towards this surveyor. This surveyor complied with Resident #103's wishes. Review of Resident #103's Intake Report dated 7/31/2019 filed with the state agency revealed, Incident Summary: Administrator (NHA A) notified by charge nurse on duty (LPN Y) at 4:45am, that an (CNA HH) on duty reported to her that she witnessed her co-worker-(CNA GG) who was also on duty in the facility at the same time do the following: (CNA HH) reported that co-worker (CNA GG) held residents arms down really hard while resident was hitting and kicking her during personal care. (CNA HH) stated to (CNA GG) that she was going to give resident bruises (none found), and (CNA GG) response was I don't give a fu**. (CNA HH) also stated that she witnessed (CNA GG) spit on resident as a retaliation for resident spitting on her. Charge nurse on duty pulled (CNA GG) off the floor immediately and interviewed her and she stated the following: that resident started getting physically aggressive during personal care and held his arms down as a safety precaution, due to resident hitting, kicking, pinching and scratching her. (CNA GG) denies spitting on resident or stating I don't give a fu**. Charge nurse did find that (CNA GG) had both forearms as well as her chest had several scratches and spots on her. (CNA GG) suspended immediately and walked out of facility pending investigation. During an interview on 8/13/19 at 1:03 P.M. CNA HH stated, on 7/31/19, (CNA GG) and I had gone into (Resident #103's) room and attempted to change him in his chair .he let me take down his pants, I found a lot of BM (feces), so we transferred him to his bed, he started to hit (CNA GG) .she held his arms down across his chest so he wouldn't hit her. I went over to the sink and I saw him spit on her and then I heard another spit and then (CNA GG) said, See do you like that? .(Resident #103) still tried to fight and (CNA GG) was holding him down and I noticed that she was putting all her body weight on his chest, I asked her to let up a bit and she said I don't give a f***! .then we transferred him back into his chair and he calmed. I reported my concerns to (LPN Y) .she called (DON B) .(CNA GG) was sent home. During an interview on 8/13/19 at 5:14 P.M. (CNA GG) stated, I went in to change (Resident #103) he was in his chair and had been up since the previous 3rd shift, because he refused to be changed. (CNA HH) and I transferred him into bed .and once in bed I held his arms down because he was punching and pinching and (CNA HH) cleaned him up. That's how I was trained to do (Resident #103), one person holds his arms and the other person changes him .He spit in my face and I said Oh my f***ing God! and then he did it again and I said (Resident #103) how would you like that? He didn't say anything, he just tensed up his face and stuck his lip out because he was mad .I shouldn't have said the F word, but I am not going to let him punch me and that's why I was holding his hands down .every day people have to do this with him. During and interview on 8/14/19 at 9:13 [NAME]M. LPN Y reported that she was the nurse on Resident #103's hall on 7/31/19. LPN Y stated, It was 4:00 [NAME]M. and I was at my med cart. (CNA HH) came to me to report witnessed abuse, she indicated that (CNA GG) went into (Resident #103's) room to provide care because he had refused cares for day shift .(CNA HH) said that (CNA GG) held (Resident #103's) hands down because it was too late into the process of cleaning him up to leave .they had to finish. (CNA HH) said that she asked (CNA GG) to let up and said Stop don't hold his arms so tight you will leave bruises .(CNA HH) said that (CNA GG) said I don't give a F***! (CNA HH) said that she saw (Resident #103) spit at (CNA GG) and then heard another spit and then heard (CNA GG) say and How do you like it when someone does it to you? LPN Y reported that when she interviewed CNA GG, CNA GG admitted to holding Resident #103 down, so that they could clean him up, but denied spitting on Resident #103. LPN Y reported that it is common practice to hold Resident #103's hands out of the way so that he doesn't hit or scratch staff. Review of the CMH plan of care dated 6/5/19 revealed: Challenging Behavior Identified in Functional Analysis: Physical Aggression - Hitting, kicking, spitting, biting, scratching, pulling another person toward him and then hitting, kicking, spitting, scratching or biting. Proactive Measures: 3. When you need to do any care with Client (Resident #103) a calm, nice and engaging approach should be used for example, Hey Client can I talk to you for a minute? or Hey Client I have a question for you. This helps Client feel as though he is in control of the conversation. Client has the capability of doing sone of his care himself when it comes to changing him. Start with asking him, Client do you want to help me change you or do I need to get help? He seems to like the idea of helping staff so rarely does he say go get help when asked this question. 8. If Client beconms physically aggressive. Step back from him so you are at a safe distance. Your reaction to him may be situational. If you have to complete a task for his health such as change him and he is physically aggressive, respond to him letting him know you have to complete the task and you will wait until he is being safe to do so. Ask him to let you know when he is ready and wait silently, without any interaction including looking at him. If Client tries to engage staff in other conversation, reply with Are you ready for me to change you? If he says yes, try again, if he says no, wait or try another staff if possible. During an interview on 8/14/19 at 12:10 P.M. NHA A regarding the incident on 7/31/19 with Resident #103, reported that Resident #103 often refuses care at first, then will agree and then explode mid-care. NHA A reported that it is not uncommon for Resident #103 to go multiple shifts between cares due to refusing. NHA A reported that (CNA GG) held his arms and leaned into him to provide protection on 7/31/19. NHA A stated, When I initially got the call, it was reported to me that (CNA HH) thinks that (CNA GG) spit on (Resident #103) in response to him spitting on her .but when I interviewed (CNA GG) she said that (Resident #103) spit on her twice. (CNA HH) said that (CNA GG) was holding (Resident #103) too hard when he was swinging and pinching .(CNA HH) said that his arms were crossed on his chest and held there by (CNA GG). NHA A reported that Resident #103 has an OBRA case manager visits from Community Mental Health (CMH) weekly or monthly, but do not currently have the reports that they write. NHA A reported she is requesting the final new plan of care ASAP. NHA A stated, We actually have the final copy (of the CMH plan of care) dated 6/5/19, but it is not signed yet, therefore it has not put into place (indicating incident on 7/31/19 may have been avoided if CMH care plan had been in place.). In an interview on 8/14/19 at 1:45 NHA A stated that Community Mental Health (CMH) worker is meeting with Resident #103's durable power of attorney (DPOA) today to sign approved behavioral plan. NHA A reported she wouldn't expect that this should have taken 2 months from preliminary to final, but that she has only been here for 6 weeks and met with CMH just last week. NHA A provided this surveyor with ongoing training provided to staff regarding Resident #103 care/behaviors Kardex. Surveyor noted that CNA K (Resident #103's currently asssigned CNA) was not included on this educational training log. NHA A reported she didn't know if the log was up to date, but that she would check. No further information was provided prior to exit to indicate if staff currently assigned to Resident #103 knew the appropriate, care planned interventions for care. During an interview on 8/14/19 at 3:00 P.M. NHA A reported that the reason CNA GG held Resident #103's arms down on 7/31/19 was to protect herself, because he was trying to hit her. NHA A reported that Resident #103 was hitting CNA GG because he did not want her to be providing incontinence care. NHA A reported that if the staff would have stopped attempting to perform incontinence care, Resident #103 would have stopped hitting CNA GG and would have been safe in bed. Review of the Progress Notes Dated 8/1/19-8/12/19 revealed Resident #103's behaviors continued to escalate after the 7/31/19 incident and staff requested and received an order for [REDACTED]. On 8/21/19 the Administrator was verbally notified and received written notification on 8/21/19 of the immediate jeopardy that began on 6/14/19 and was identified on 8/21/19 due to the facility's failure to prevent unnecessary physical restraint which placed all residents in the facility at residents at risk for serious negative health effects/outcomes. A written plan for removal for the immediate jeopardy was received on 8/27/19 and the following was verified on 8/27/2019: 1. Resident #102 was assessed by the NP and treatment nurse on 6/17/19. New treatment orders were put in place and no restraints of any kind were being utilized at that time. 2. On 6/17/19, Resident #102 no longer had a restraint and only one other resident in house had a self-releasing seat belt. 3.On 8/21/19, education was started by the Assistant Director of Nursing and Unit Manager on the facility's restraint policy and use of restraints and 100% of facility staff will be educated. 4. Beginning 8/21/19, whole house audits of resident with restraints will be conducted by the Unit Manager/ Assistant Director of nursing weekly to assure the ordered restraint is in place assessed and monitored. 5. On 8/21/19, staffing was reviewed on the days of concern. The DON is responsible to ensure appropriate staffing meets the current needs of the residents. Ancillary staff is used when available. A nurse on call rotation is in place to provide staff with off shift support to assist with staffing needs. 6. The CNA that was caring for Resident # 103 was suspended immediately pending investigation on 7/31/19. The CNA was provided corrective action and education including dealing with behaviors and appropriate means to mitigate behaviors on 8/8/19. The CNA was re-suspended on 8/21/19. 7. Resident # 103 was assessed by Charge Nurse on 7/31/19 for signs and symptoms of injury or fearfulness with none noted. There were no other residents affected. 24 Residents were interviewed on 8-7-19 starting at 10:30am with no complaints of inappropriate care or fearfulness noted. 9. On 8/21/19 education was started the Assistant Director of Nursing and the Unit Manager on Protection of Residents, reducing the threat of abuse and neglect with emphasis on residents rights to be free from physical restraints and 100% of facility staff will be educated. In addition Community Mental Health has provided education dealing with behaviors and appropriate means to mitigate behaviors according to Resident #103 care plan. Although the immediate jeopardy was removed on 8/21/19, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to not all education had been completed and sustained compliance had not yet been verified by the State Agency. Deficiency Practice Statement B Based on observation, interview and record review the facility failed to provide an environment free of unnecessary physical restraints in 1 of 7 residents (Resident #101) reviewed for physical restraint, resulting in the potential for Resident #101 to continue being restrained. Findings include: Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 5/10/19 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #101 was cognitively moderately impaired. Review of the Functional Status revealed that Resident #101 required extensive assistance of 1 person for transfers between surfaces. Review of Resident #101's Intake Report dated 6/24/2019 filed with the state agency revealed, Incident Summary: (CNA HH) contacted (Director of Nursing (DON) B) to report incident and (DON B) contacted (NHA A) at 10:13pm to report the allegation of mistreatment. (NHA A) contacted (CNA HH) via phone around 10:20pm to conduct a phone interview and the following information was reported: (CNA HH) reported that she heard (Resident #101's) alarm going off so she responded and noticed that resident was attempting to get out of bed. (CNA HH) stated that she started moving forward to assist (Resident #101) when second CENA (CNA V) came in the room and stated to the resident You cannot get up it is 10 pm . Resident still attempted to try and get up and (CNA V) stated No this is not happening, you are to go to sleep . At that time (CNA HH) reported that (CNA V) held down residents legs for about 15 seconds, however resident remained persistent to get up, so (CNA V) moved his legs and pushed them towards the floor and pulled resident to a seated position on his bed by his right hand abruptly. (CNA HH) stated that at that time resident stated that he did not want to get up anymore, she witnessed (CNA V) pick up resident's legs and abruptly put his legs back in bed. Resident stated God D*** it and stated Ouch. (CNA HH) did say that (Resident #101) often says this even if you are providing peri care or repositioning and did not show any additional signs of discomfort. (CNA HH) stated that (CNA V) was putting the fall prevention mattress on the floor next to resident's bed when she heard (CNA V) state to herself, but loud enough for her to hear Stupid A**, and walked out of the room. (CNA HH) ensured that the resident was ok and calm and did not show any signs of agitation .Investigation Summary/Actions Taken: .the facility was substantiating allegation of mistreatment and terminated (CNA V) employment. Review of Resident #101's Care Plan revealed, RISK: non complaint with fall safety interventions .at times to be non-compliant with treatment plan and safety interventions The resident, at times, chooses to transfer from bed, to knees . Date Initiated: 09/17/2018 .If, when (Resident #101) attempts to get out of bed, staff is to remind him of the time of day or night it is, if he continues to request to get up from bed then assist x 1 person with a gait belt up into w/c (wheelchair). Date Initiated: 07/03/2019. During an observation and attempt to interview Resident #101 on 8/13/19 at 2:36 P.M. Resident #101 did not respond to this surveyor's greeting, comments or questions. During an interview on 8/13/19 at 1:03 P.M. CNA HH stated, On 6/24/19 (Resident #101's) bed alarm was going off and he said he wanted to get up, so I started preparing things and (CNA V) came in and said that this wasn't happening and told him (Resident #101) that he wasn't getting up .(Resident #101) was very adamant .(CNA V) told him You are not getting up! . he was trying to get his legs on the ground, so (CNA V) held his legs down so that he couldn't move and then (CNA V) said OK! and thrusted his legs to the floor and yanked his hand so that he was in a sitting position . his hearing aide fell on the floor, he then said that he didn't want to get up anymore .(CNA V) stated, Good! and pulled his legs back up onto the bed, not gently .there was no reason that he couldn't get up. (CNA V) then said stupid a**! as she left the room . I called the (DON B), and she said that (CNA V) would have to go home. This surveyor attempted a telephone interview with CNA V on 8/13/19 and 8/14/19, with no response. During an interview on 8/14/19 at 10:37 [NAME]M. RN FF reported that on 6/24/19 CNA HH and CNA V were in Resident #101's room and Resident #101 was yelling. RN FF reported not knowing what was going on in the resident's room. RN FF reported that CNA HH came to her and stated, I didn't like what just happened in there. RN FF reported that she was in the middle of passing medications, so she had asked CNAHH to give her a few min

This citations pertains to MI 387, MI 554, MI 559 and MI 128. Based on observation, interview and record review the facility failed to provide adequate staffing to meet resident needs for 1 of 3 residents (Resident #102) reviewed for staffing, resulting in the physical restraint and subsequent skin injury to Resident #102. Findings include: Review of the Face Sheet revealed Resident #102 was an [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 had severely impaired cognition and was an extensive assist of at least one staff member for transfer, dressing, ambulation and bathing. In an interview on 8/14/19 at 3:06 PM, Human Resources Director (HRD) Z stated in 6/2019 the facility had 13 unfilled CNA positions and 4 unfilled nursing positions. HRD Z stated these openings represented more than 10 percent of the facility workforce. In an interview on 8/14/19 at 9:32 AM, UM X stated Resident #102 was digging at her eyeballs .we (facility) needed to make her (Resident #102) safe. UM X stated, If you (staff) were not there physically, she (Resident #102) would cause harm to herself. Unit Manager (UM) X stated on 6/13/19 the facility did not have enough line staff support for the 1 to 1 for Resident #102. UM X stated, on 6/14/19, there were students who sat 1 on 1 with Resident #102 to keep her safe. UM X stated she did not check to see if any additional staff were to provide additional 1 on 1 care for the weekend (6/15/19 to 6/16/19). In an interview on 8/14/19 at 10:00, Licensed Practical Nurse (LPN) T stated she worked the weekend of 6/15/19 to 6/16/19. LPN T stated Resident #102's bilateral arms and hands were wrapped with geri sleeves (a soft fabric sleeve) secured with ace wraps (an elastic band). LPN T stated, I was not the one who put them on and I didn't question it (the restraint). LPN T stated, no I did not take them (restraint) off that weekend and nobody reported finding any blisters until Monday (6/17/19). In an interview on 8/26/19 at 2:35 PM, CNA K stated, on 6/16/19, Resident #102 had net things on Resident #102's hands that looked like those ace wraps holding on the nets. CNA K stated the net things with ace wraps .looked awful tight on Resident #102's arms. In an interview on 8/26/19 at 3:30 PM, CNA LL stated, on 6/1/19, Resident #102 was at the desk trying to pull arm sleeves (geri sleeves,improper restraints) off. CNA LL stated Resident #102 couldn't leave her (Resident #102) in her room because Resident #102 was trying to get out of her restraints. CNA LL stated, I think she (Resident #102) would have benefited from a one to one on. In an interview on 8/14/19 at 9:50 AM, Scheduler R stated no extra staff were provided on the weekend of 6/15/19 to 6/16/19 for 1 to 1 care for Resident #102. Scheduler R stated, not that I have on the schedule; no staff were added for a 1 to 1 for Resident #102. In an interview on 8/14/19 at 10:00 AM, Licensed Practical Nurse (LPN) T stated, on 6/15/19 to 6/16/19, it wouldn't have been feasible to pull one (CNA for a 1 to 1) for Resident #102. In an interview on 8/14/19 at 4:01 PM LPN U stated on 6/15/19 to 6/16/19, facility didn't have enough staff to pull for a full time 1 to 1 for Resident #102. Review of the Facility Daily Staffing Sheet dated 6/15/19 revealed 1 c/o (call off) for nursing staff, 2 c/o for CNA staff (indicated 3 staff missing from the scheduled) and 1 nursing c/o for 6/16/19 (indicated 1 staff missing from the scheduled). Review of the Restraint-Physical Initial evaluation dated 6/13/19 revealed Resident #102 had agitated behavior of poking and digging at her eyes. The Initial evaluation revealed Resident #102 had 1 to 1 increased staff in direct care of her for added safety and .for safety we (facility) will use soft mittens PRN (as needed) for 24 hours (indicated restraint would terminate on 6/14/19). Review of the physician's orders [REDACTED]. In an interview on 8/14/19 at 9:32 AM, Unit Manager (UM) X stated the physician's orders [REDACTED].#102 was for 24 hours from 6/13/19 to 6/14/19. UM X stated the order read for staff to check every 30 minutes and remove the restraint every 2 hours for Resident #102. In an interview on 8/14/19 at 10:00, Licensed Practical Nurse (LPN) T stated she worked the weekend of 6/15/19 to 6/16/19. LPN T stated Resident #102's bilateral arms and hands were wrapped with geri sleeves (a soft fabric sleeve) secured with ace wraps (an elastic band). LPN T stated, I was not the one who put them on and I didn't question it (the restraint). LPN T stated, no I did not take them (restraint) off that weekend and nobody reported finding any blisters until Monday (6/17/19). In an interview on 8/14/19 at 10:14 AM, Registered Nurse (RN) Y stated she took care of Resident #102 on the night on 6/16/19. RN Y stated, I didn't investigate her (Resident #102) hands (indicated did not monitor restraints). Review of the Treatment Administration Record (TAR) dated 6/2019 revealed no documentation of monitoring, assessment or release of Resident #102's restraints for 6/15/19 and 6/16/2019. In an interview on 8/14/19 at 2:41 PM, UM X stated she was not seeing any documentation staff monitored or assessed the restraints of Resident #102 after 6/14/19. UM X stated she assumed the lack of documentation was due to a lack of time for staff to complete tasks. In an interview on 8/12/19 at 2:48 PM, Nurse Practitioner (NP) M stated Resident #102 was found on 6/17/19 with ace wraps with a sock or tubi grips (a soft sleeve) on her hands and arms. NP M stated Resident #102's arms and hands were wrapped tight. NP M stated she removed the constricting wraps to Resident #102's arms and saw [MEDICAL CONDITION] (swelling), blisters and her (Resident #102) right hand was swollen. NP M stated she diagnosed Resident #102 with [DIAGNOSES REDACTED] (a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells) and the damage that was done couldn't have happened in a short amount of time the damage was quite significant. NP M reviewed the order for restraint dated 6/13/19 and stated the restraint should have been discontinued on the 14th (6/14/19) but they (restraints) were on all weekend and were on Monday morning (6/17/19). In an interview on 8/13/19 at 12:03 PM, Director of Nursing (DON) B stated on 6/17/19 she observed, both hands of Resident #102 which had some blisters and portions of Resident #102's hands were dark red (indicated poor blood flow) and Resident #102 had [DIAGNOSES REDACTED]. DON B stated the restraint had pulled tight in spots causing blisters on bilateral hands and arms of Resident #102. DON B stated the restraints were .on through the weekend. DON B stated staff should not have used the restraint over the weekend. Review of the Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome, to left lateral (outside) forearm with Granulation tissue (beefy red), .serious drainage and wound measurements of 0.6 cm x 1 cm. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome wound to right medical (inside) aspect wrist which measured 3.2 cm x 1 cm. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .2 cm x 2 cm wound to Resident #102's left upper forearm. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .2.2 cm x 2.4 cm wound to Resident #102's left inner aspect of elbow. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .4 cm x 4.2 cm wound to Resident #102's right medial aspect wrist. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .2.1 cm x 1 cm wound to Resident #102's right third digit posterior base. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .3 cm x 1/5 cm wound to Resident #102's right fourth digit medial posterior base (ring finger). The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .2.5 cm x 1 cm wound to Resident #102's right thumb. The Wound Observation Tool dated 6/17/19 revealed Resident #102 had compartmental syndrome .3 cm x 2.4 cm wound to Resident #102's right thumb palm side. Review of the Wound Ulcer Incision assessment dated [DATE] revealed Resident #102 wound .Present on admission to bilateral posterior (back), Palmar (related to palm) hand(s) and Friction/shear wound to bilateral wrist. In an observation on 8/12/19 at 9:20 AM, Resident #102 was noted to be in her room. Observed on her right wrist was a bandage. The bandage was removed by Registered Nurse (RN) CC and a wound was observed to the right wrist of Resident #102. RN CC measured the wound as 0.4 cm (centimeter) x 0.4 cm with a depth of 0.2 cm with scant serous (clear, thin, watery plasma) drainage from the wound discovered on 6/17/19. During an interview on 8/14/19 at 9:13 [NAME]M. LPN Y stated, The building is run a lot on PRN staff and a lot of times they are short and I think it adds to a lot of problems. I think they (CNA's) can provide the care, even when they work short they are willing to work hard and do their job. The night shift aides compensate for short staffed. Sometimes the nurses don't pick up shifts and then they are short too. During an interview on 8/14/19 at 11:00 [NAME]M. CNA K stated, We are really short staffed right now today is good. But sometimes we only work with 4 .that's about 16 residents per CN[NAME] It's impossible to do proper care, then they want us to do baths too, people can't be changed, maybe we get to them once, sometimes twice. We try to get everyone, but sometimes its impossible. During an interview on 08/26/2019 at 8:56 [NAME]M. CNA P reported that staffing is less than par, today only 4 CNA's the unit for first shift, which means 16 residents per staff member. CNA P reported that this causes issues, like call lights not getting answered, people falling because they try to go to the bathroom on their own, mostly happens during mealtimes and when staff takes breaks. CNA P reported that there is a lot of staff burnout and quitting because of pay and benefits. During an interview on 8/22/19 at 8:30 [NAME]M. CNA NN reported that the facility is short staffed. Residents are complaining about call lights not being answered. CNA NN reported that residents tell her that they don't turn their call lights on because they don't want to stress out the staff.

Based on observation, interview and record review, the facility failed to prevent the development of a pressure ulcer and provide necessary interventions in the care of a pressure ulcer, in 1 of 2 residents reviewed with pressure ulcers (Resident #10), in a total sample of 22 residents, resulting in an avoidable pressure ulcer. Findings include: Review of the Face Sheet and Minimum Data Sheet dated 6/14/16, reflected Resident #10's [DIAGNOSES REDACTED]. The MDS reflected that Resident #10's ability to make daily decisions was severely impaired and she currently required the assistance of one to two staff member for transfer, bed mobility, toileting, hygiene, and bathing. Review of the facility Policy Assessing Avoidable Versus Unavoidable Pressure Ulcers (no date), reflected 1. BEFORE A PRESSURE ULCER CAN BE DETERMINED TO BE UNAVOIDABLE, THE FOLLOWING MEASURES, AND OTHERS IF NECESSARY, MUST BE CONSIDERED, IMPLEMENTED AS NEEDED, DOCUMENTED, AND ESTABLISHED AS SUFFICIENT AND REASONABLE TO PREVENT THE FORMATION OF PRESSURE ULCERS WITHOUT SUCCESS: B. IDENTIFY MEDICAL CONDITIONS THAT PREDISPOSE RESIDENTS TO PRESSURE ULCERS- Provide supporting documentation of any comorbidities including at least on significant disease or condition that impairs circulatory E. IMPLEMENT CARE PLANNED INTERVENTIONS-for all selected medical conditions and risk factors identified on admission, or on an At Risk Assessment,,,b. MINIMIZE PROLONGED PRESSURE IN BED OR CHAIR- pressure reducing mattress or chair cushions, repositioning devices, kneepads, and heel relief .H. WHEN PRESSURE ULCERS ARE IDENTIFIED- provide prompt care planning, .and implementation of interventions designed to minimize or resolve the pressure ulcers. Review of the facility Pressure Ulcer Prevention (no date), reflected 5 Measures to protect the patient against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: b) utilize postioning devices to keep bony prominences form direct contact; d) heel protections/suspension should be implemented while the patient is in bed; . Review of the Physician Orders dated August 2016, reflected Nursing Intervention-Prevalon (heel protector) boot to left foot, dated 6/17/16. Nursing intervention-Prevalon boot to be worn left foot at all times except during care or therapy, dated 6/291/6. Review of the Care Directive for (Certified Nursing Aid's (CNA)) dated 8/18/16, reflected Resident #10 was to have prevalon boot to left foot. Review of the Nursing Progress Notes, dated 6/17/16 at 2:41 a.m., reflected CNA noticed a large intact blister to left foot while doing care. Blister intact will monitor for changes and have a Prevalon boot to left foot. Review of the Risk for Pressure Ulcers Care Plan dated 6/7/16, reflected Resident #10 is at risk for developing a pressure, Relating To *Incontinence *weakness, debility, dementia, status [REDACTED]. Goals; Resident will have intact skin, free of redness, blisters or discoloration over a bony prominence through next review date. Approaches; Encourage resident to float heels when in bed. Noted on the care plan dated 6/17/16; Alteration in skin integrity related to stage II (intact blister) to left heel. Approaches; 6/16/16-Prevalon boot to left foot at all times except with care. During an observation on 8/18/16 at 9:25 a.m., Registered Nurse (RN) X completed the treatment to Resident #10's left heel, the wound appeared 1/2 inch x approximately 3/4 inch x 1/8 inch deep with side clean and the inner portion of the wound brownish red. Registered Nurse (RN) X washed her hands, put on gloves, cleansed the wound bed with normal saline, changed gloves, placed santyl (ointment that cleans wounds) in the wound bed and put an abd (padded gauze) over the heel and wrapped with a gauze wrap. During observations on 8/16/16 at 9:15 a.m. and 8/18/16 at 9:55 a.m., Resident #10 was laying in her bed in the room, safety interventions were in place, but her heels were on the bed on 8/16/16 and Resident #10 was laying on her back. On 8/18/16 Resident #10 was laying on her right side with her left heel stacked on top or the right. The prevalon boot was laying on top of the covers at the end of the bed. In an interview on 8/18/16 at 12:50 p.m., Director of Nursing (DON) B reported that she was not aware of how Resident #10 had developed the pressure ulcer to her left heel. DON B reported that when Resident #10 came to the facility with a left [MEDICAL CONDITION] she did not do much for herself. DON B reported that a CNA found the pressure ulcer on Resident #10's foot while doing care. #

Based on interview and record review, the facility failed to prevent accidents in 2 (#5, #20) of 10 residents reviewed for falls, from a total sample of 23 residents, resulting in Resident #5 sustaining bruising, abrasions, and pain and Resident #20 sustaining an open fracture of the left ankle. Findings include: Resident #5 Review of Resident #5's record revealed a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS), dated [DATE] indicated she was cognitively impaired, required extensive assistance of two persons for transfers and extensive assistance of one person for dressing and hygiene. Review of the Falls Care Plan for Resident #5 dated 9/8/12 revealed she had been identified to be at risk for physical injury from falls related to history of falls, fall screen of 18 and use of antidepressants, antianxiety and antipsychotics, with an intervention listed to include a broda chair with a lap tray when out of bed (dated 8/23/13), two person assist with transfers (typed but undated). Review of the physician's orders [REDACTED]. Review of the Certified Nurse Aide (CNA) Care Guide revealed Resident #5 was to be in a Broda chair with a lap tray when out of bed. Review of facility Incident Report dated 2/6/14 at 7:10 pm, revealed Resident #5 was being transferred to the restroom when she put her foot out and leaned forward and fell out of her wheelchair (not Broda chair). The report indicated Resident #5 was observed face down, left arm under her with left side of her head resting on lap tray. The incident report indicated Resident #5 had a bruise and an abrasion with body parts affected to include shoulder, knee and back. The report indicated Resident #5 was transferred to the hospital for evaluation. Review of the emergency room Physician report dated 2/6/14 revealed Resident #5 was being pushed in her wheelchair by staff at the facility when she put her feet down on the ground and fell forward out of the wheelchair. The note indicated Resident #5 did strike her head on the ground, was unable to recall the incident, had low back pain, and bilateral shoulder pain. In an interview on 7/17/14 at 1:45 pm, CNA "U" stated she transferred Resident #5 in her bathroom from the toilet to a wheelchair using a one person assist transfer. CNA "U" stated Resident #5's broda chair was to difficult to get into the bathroom, so she (CNA "U") transferred Resident #5 into a regular wheelchair. CNA "U" stated Resident #5 was a "two person assist" transfer at that time, but she transferred Resident #5 by herself. CNA "U" stated she did not put foot pedals on the wheelchair and started to exit the bathroom with Resident #5 in the wheelchair. CNA "U" stated just as she was pushing Resident #5 through the doorway of the bathroom, Resident #5 put her feet down on the floor, leaned forward and fell out of the wheelchair onto the floor. CNA "U" stated she called for a nurse on the "walkies" and everybody came, because Resident #5 landed on the floor by the sink in her room. CNA "U" stated an ambulance came and took Resident #5 to the hospital. CNA "U" stated she received a write up for not following the care guide, for transferring Resident #5 with one person, when she should have transferred Resident #5 with two persons, for putting Resident #5 in the wrong chair and for not putting foot pedals on Resident #5's wheelchair before transporting her out of the bathroom. Review of facility "Corrective Action Form" dated 2/10/14 revealed CNA "U" received a written warning with a description of the incident, "associate failed to follow careguide when assisting a resident. The "Consequence to the Company" listed on the form was "harm to patient". Resident #20 Review of a "Face Sheet", undated, indicated Resident #20 was an [AGE] year old woman originally admitted to the facility on [DATE]. A "Minimum Data Set" (MDS) assessment dated [DATE] indicated Resident #20 did not have problems with short or long term memory, required extensive assistance of two people for bed mobility and transfers, needed extensive assistance from one person for dressing, toileting, and personal hygiene. Review of an outside facility "Internal Medicine Progress Note" dated 4/17/14, indicated Resident #20 had [DIAGNOSES REDACTED]. A note following the documented [DIAGNOSES REDACTED].#20) reported improvement. "Per physical therapy (PT) note, patient is ok to go home with 24 hour assist or low intensity rehab. Per nursing staff (at the hospital) (Resident #20) was a two person assist. This was communicated to the patient and her daughter. Eventually both patient and daughter agreeable with Nursing Home (NH) placement." Review of a facility "Physical Therapy Care Plan" dated 4/18/14 indicated Resident #20 was to be a 1 person assist for transfers. Review of a "Witness Interview/Statement Form" dated 4/23/14 timed 6:15 a.m., written by Competency Evaluated Nurse Aide (CENA) "S", "(Resident #20) was on the toilet getting dressed. When (Resident #20) said she was ready I told her to stand up. (Resident #20) was holding onto the bar and I had her arm for a boost. (Resident #20) stood up for a second but then came down slowly on her left leg. I (CENA "S") had my hands on (Resident #20) all the way to the floor. Resident stated her leg was hurting and her left leg was underneath her. I notified the nurse. I put a gait belt on (Resident #20) and the nurse and I lifted her up and then noticed her left ankle suffered from an open fracture (a broken bone that breaks through the skin)." Review of a "Witness Interview/Statement Form" dated 4/23/14 timed 6:20 a.m., written by Registered Nurse (RN) "T" indicated, "At approximately 6:20 a.m. I (RN "T") got called down to (Resident #20's) room by (CENA "S") via walkie. I entered bathroom observed (Resident #20) on her bottom in the nude with only a brief and pajama bottoms halfway on in front of toilet. I assessed (Resident #20's) pain level. (Resident #20) denies. Asked what happened (Resident #20) resident responds that she was standing up while (CENA "S") pulled her pants up, then shortly after she began to slide down. I (RN "T") assessed bilateral upper extremity range of motion (ROM), present. Bilateral lower extremity were unable to be assessed at that moment because of positioning with left lower extremity (LLE) tucked underneath right lower extremity (RLE). Attempted x 1 (one time) to transfer with 2 people from floor to wheelchair but during lifting (Resident #20) a little off the floor, I (RN "T") and another nurse noticed minimal blood beneath (Resident #20's) bottom. We sat (Resident #20 back down to assess further. Upon lifting pajama up from LLE, (RN "T") observed left foot turned sideways and bone protruding out of the skin. (Resident #20) restless and attempting to get off the floor. (RN "T") quickly covered left ankle with gauze and Kerlix, transferred (Resident #20) from floor to wheelchair with two people assisting. A third nurse came in, holding LLE, immobilizing leg." Review of a "Witness Interview/Statement Form" dated 4/23/14 timed 6:20 a.m., documented by RN "X", "During morning report I was called to (Resident #20's room) by CENA "S". Upon entering (Resident #20's) bathroom I observed (Resident #20) sitting on floor, half dressed. (Resident #20's) right leg was out in front and left leg was bent underneath resident. 6 a.m. nurse (RN "T") did nursing assessment and then that nurse and (CENA "S") went to pick up (Resident #20) when we noticed blood droplets on the floor. (Resident #20) was sat back down and further assessment of resident was completed. Pajama pants were pulled up and left foot was turned sideways with bone and adipose tissue protruding from inner foot. The two morning nurses wrapped (Resident #20's) leg/foot while I got paperwork together for the ambulance and a fourth nurse called for paramedics. When morning nurse asked (Resident #20 what happened, (Resident #20) stated after she stood up from toilet, feet were sliding and she slid to the ground." During an interveiw on 7/18/14 at 11:15 a.m., CENA "S" admitted she did not use a gait belt for transfering Resident #20. CENA "S" said that she sometimes uses a gait belt and sometimes doesn't, explaining that it (using a gait belt) depends on the resident and how well you know the resident. During an interview on 7/18/14 at 11:00 a.m., Unit Manager/RN "C" stated, "Gait belt use was driven by therapy. A one person assist should have a gait belt. All staff have gait belts." During an interview on 7/18/14 at 2:00 p.m., the Rehab Services Manager (RSM) "R" stated that a one person assist as noted on the care plan would mean that a gait belt would need to be used. During an interview on 7/18/14 at 4:20 p.m., Staff Development Coordinator/RN "K" sated that it is expected all staff use a gait belt during all transfers. Review of "Mosby's Textbook for Long Term Care Assistants", indicated "A transfer belt is used for transferring most residents in nursing centers. The belt is used to hold onto the resident during transfer. Remember, if the resident needs assistance to transfer, a transfer belt is required. The belt is applied around the resident's waist. The belt also is called a gait belt and is used when walking with a resident. Transfer (gait) belts help prevent falls and other injuries." Sorrentino, S. A., & Gorek, B. (1999). Mosby's Textbook for Long Term Care Assistants (Third ed., p. 216). St. Louis, MO: Mosby.

This citation pertains to intake number MI 981 Based on observation, interview, and record review, the facility failed to prevent a fall with major injury in 1 of 3 (#101) sampled residents reviewed for falls, from a total of 3 sampled residents, resulting in Resident #101 sustaining a hip fracture, decreased mobility and increased pain. Findings include: According to the admission face sheet (not dated), Resident #101 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to admission minimum data set (MDS, resident assessment tool) dated 3/14/2014, Resident #101 was rarely understood and was not able to complete the Brief Interview for Mental Status. According to the most recent MDS dated [DATE], Resident #101 scored 0/15 on the Brief Interview for Mental Status which indicated total cognitive impairment. Review of the interim care plan and permanent care plan for falls for Resident #101, both dated 3/7/2014 (admitted ) revealed he was at risk of falls. The care plan indicated his score on the falls assessment was 26 (anything above 10 indicative of "risk of falls"). The interventions at that time were a tiered mattress to the side of the bed and a pummel cushion in the wheelchair. The pummel cushion was discontinued on 3/11/2014 and he was placed in a scoot chair with a tab alarm to the back of the chair. Review of the nursing notes revealed the following: 3/19/2014 "Broda chair appears to work better for resident with independent movement in hallway and resident made fewer attempts to get out of chair this shift." 3/22/2014 "Resident becoming combative with staff. Continues to attempt to get out of w/c (wheelchair) with out assistance. Able to be walked to restroom and back to w/c when able to." 3/22/2014 "While up in Broda chair earlier this shift, resident kept trying to get out of chair to walk. Resident doesn't understand that he is unable to walk at present. He continues to have very poor safety awareness. Not understanding his physical limitations." 3/24/2014 "Resident restless and attempting to climb out of bed...Resident has repeatedly attempted to stand up from the chair..." 3/24/2014 "NO (nursing order) to place in a scoot chair with his sensor alarm in place. Does still bend forward from the waist but doesn't appear to have enough strength to stand upward." Review of an "Incident/Accident Data Entry Questionnaire" revealed Resident #101 had a fall on 3/26/2014 at 9:15 am. According to the report Resident #101 was "sitting in w/c in hallway. Tab alarm sounding. CNA (certified nursing assistant) came around corner and observed resident lying on his left side. Stated 'I was trying to walk'." The form also indicated that Resident #101 had a low bed, chair alarm, tiered mattress, scoot chair and under the section, "is the resident a candidate for hip protectors", the writer entered "yes" but documented that the hip protectors were not on at the time of the fall due to "resident wishes." According to the nursing notes from 3/26/2014, and an x-ray dated 3/26/2014, Resident #101 had sustained an "acute intertrochanteric femoral fracture with mild displacement with varus angulation." According to the nurses notes 3/26/2014, "Therapy brought resident to the desk and reported that resident complaining of left hip pain during exercise." During an interview with Case Manager, Licensed Practical Nurse, (LPN) "B" on 5/21/2014 at 11:15 am, she stated that all new admissions (residents) get chair and bed alarms, floor mats and hip protectors until they are cleared by therapy to be safe without them. An interview on 5/22/14 at 3:15 p.m., Registered Nurse (RN) "G" who was on duty at the time Resident #101 fell , confirmed that he did not have any hip protectors on at the time of the fall on 3/26/2014. RN "G" also confirmed that Resident #101 had made multiple attempts to stand prior to the fall. She added that she did not notify anyone of these attempts and did not attempt to place any seat belt on him because "we are not allowed to use restraints." A review of the physician's orders [REDACTED]." During an interview on 5/22/2014 at 9:45 am, unit manager, RN "E" verified that Fall Guards on the physician order [REDACTED].#101 was to have hip protectors on at all times. She did not know why he did not have them on at the time of the fall. During an interview on 5/23/2014 at 9:45 am, Activity Director (AD) "H" confirmed that Resident #101 "attempted to stand all the time." AD "H" confirmed that she notified the unit manager multiple times of his attempt to stand. AD "H" also stated that he never had hip protectors on because she would have noticed it. She stated that he removed his clothes all the time and an activity aid was always putting them back on. She stated that if he had them on, she would have noticed it. An interview with family member (FM) "J", FM "I", FM "F" and granddaughter-in-law took place in the conference room on 5/23/2014 at 2:00 pm. Family member "I" stated first, "what's so hard is that the day before his fall, he (Resident #101) walked clear down to therapy." FM "J" stated, "but he never will again." FM "J" reported that she visits everyday and he (Resident #101) is frequently in his underwear. FM "J", "I would have noticed even one day if he had hip protectors on." FM "F" stated "they (the facility) should have put a seat belt on him before he fell , not waited until after." ( )