Every finding on record at Majestic Care of Flushing

The Citation pertains to Intake Number 3074530. Based on interview and record review, the facility failed to ensure that staff were utilized appropriately to sufficiently meet the needs of facility residents through multiple resident interviews and interviews with the confidential group of residents and low weekend staffing was triggered through payroll-based journal, resulting in resident increased call light complaints, unmet care needs, and a lack of resident assessment and monitoring. Findings include: On 06/29/2026 at 1:04 PM, a meeting was held with a confidential group of residents, who regularly meet once a month. The confidential group was asked what the average call light response time is. The consensus of the confidential group is that the minimum amount of time is about 30 minutes. One resident was in the bathroom for 45 minutes and started yelling to get help. The group stated sometimes it can be as long as two hours. The confidential group believes they facility needs to hire more staff and that the current staff call in too much. In an interview and records review on 06/29/2026 at 4:07 PM with Certified Nurse Assistant (CNA)/Staff scheduler L the state surveyor revealed that the survey team had heard from Resident complaints of short staffing from several residents with reported call light response times which are 30-45 minutes and up to 2 hours. Residents reported that staff sit in the lounge room and watch TV and do not respond to call lights or residents' needs. CNA L stated that as the scheduler she follows a per patient day (PPD-average number of nursing or clinical hours provided to each resident on a daily basis) of 2.85 hours/per resident. CNA L stated that the facility does not use acuity, Just the 2.85 hours/per resident guideline from corporate. 1:1 coverage- so since the census has dropped, it freed up some hours, and she was told not to include that in her PPD. Electronic Record reviews and interview with CNA L of random weekend staffing revealed: January 17th, 2026, Certified Nursing Assistants (CNA) on 2nd shift had a no show and call in from 2:00PM to 10:00PM and a second call-in 3:00PM to 7:00PM worked short that shift. Record review of the Saturday January 17, 2026, staffing sheet presented to the surveyor noted CNA names and call-ins of 4 total for the day. February 14th, 2026, Certified Nursing Assistants (CNA)CNAs on 2nd shift had two (2) call-ins or no show/no call on the 2:00PM -10:00PM shift and worked short. 3rd shift also short one CNA call-in 10:00PM -6:00AM. April 4th, 2026, - Certified Nursing Assistants (CNA) on 1st shift had four (4) CNA call offs on the 6:00AM to 2;00PM shift, they worked short, 2nd shift had 3 call offs on 2:00PM to 10:00PM shift and worked short. April 5th, 2026- Certified Nursing Assistants (CNA) on 1st shift had three (3) CNA call offs on the 6:00AM to 2;00PM shift, 2nd shift had two (2) CNA call offs on 2:00PM to 10:00PM shift and worked short. 3rd shift had two (2) CNA call offs on the 10:00PM to 6:00Am shift. May 23rd, 2026- 2nd shift had five (5) CNA call offs on 2:00PM to 10:00PM shift and staff worked short. May 25th, 2026- Certified Nursing Assistants (CNA) on 1st shift had six (6) CNA call offs on the 6:00AM to 2;00PM shift, and three (3) Unit managers call off on the 8:00AM to 4:30PM shift, and three (3) licensed nurses call-off on the 10:00PM to 6:00AM shift and worked short. 3rd shift had four (4) CNA call offs on the 10:00PM to 6:00Am shift. CNA L stated that the facility will stack the weekend staffing to anticipate call offs. CNA L stated that she had heard from the residents that there is only 1 CNA on the night shift, but I compare the clock-ins against the schedule and there has not been only 1 CNA on that shift. The CNAs tell the residents stuff that's not true. 3rd shift staff are in the lounge area watching TV and do not respond to the call lights. The cameras do not work and the staff know it. The PPD that is a budget of 2.85 hours per resident, and schedule accordingly. Management does not want to go over or under, so CNA L schedules right to that, as close as she can. Corporate states that she is over the PPD, and CNA L stated that she is under the PPD. CNA L did not know why the payroll-based journal (PBJ) triggered in the first quarter. An interview and record review on 06/30/2026 at 12:03 PM with Human Resource staff K revealed that she does the payroll and assumed that corporate pulls the PBJ data from the payroll. Corporate submits the PBJ. She does not submit PBJ. That's above her pay grade. Record review of CMS PBJ report for Weekend staffing data is excessively low per the PBJ report. In an interview on 06/30/2026 at 12:21 PM with the Director of Nursing (DON) weekend staffing posted public in the hallway is to be posted by the charge nurse on duty for the weekend and that facility Payroll-Based Journal (PBJ) is submitted at the corporate level. In an interview on 06/30/2026 at 12:29 PM, Registered Nurse (RN)/Regional Clinical Consultant M revealed that the Payroll-Based Journal (PBJ) data is submitted by either corporate or the Nursing Home Administrator (NHA) and the get the assisted living facility next door and the long term care facility, which share staff sometimes. The corporate office may be getting them mixed up and they are triggering the excessively low weekend staffing. An interview on 06/30/2026 at 12:42 PM with the Nursing Home Administrator (NHA) revealed that the payroll-Based Journal (PBJ) is submitted by corporate and the NHA was aware of the excessively low weekend staffing that triggered in March 2026. Resident #78: In an interview on 6/28/2026 at 11:07 AM, Resident #78, when asked about Weekend staffing, stated they are short staffed all the time. They don't respond to the lights, when they do come into the room, they shut the light off and don't do anything and don't come back. The night shift is the worst. They don't answer the call lights for 30 minutes to 3 hours. We wait a long time for staff, and nothing gets done about it. We can hear them in the hallway laughing and carrying on. but they don't come to help. In an interview on 06/29/2026 at 10:58 AM, Resident #78 stated that call lights are still too long, the aides don't do sh** and the nurses don't tell them to do anything. I complain about staff and nothing gets changed or done about it. They want my money, but don't want to do anything for me. Resident #10: In an interview on 06/29/2026 at 1:53 PM, Resident #10 stated that the call lights are not responded to it take 30 minutes or more, I could piss my pants and they don't come. Resident #44: Record review of 'Report of Concern' form for Resident #44 dated 6/30/2026 had a description of concern: Call light put on aide came in said a few people ahead of him time was documented as 3:25AM. The aide didn't come back until about 4:20AM (55-minute wait). Resident's written statement that the aide is nice, but he doesn't like to sit in poop. Record review of the Health Care Association of Michigan (HCAM) 'Rights of Residents in Michigan Nursing Facilities', dated 2024, revealed the residents are entitled to receive adequate and appropriate care, and to receive, from the appropriate individual within the health facility .,

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include: On 06/28/2026 at 9:43AM during the initial kitchen tour, an attached hose with a spray nozzle downstream of an atmospheric vacuum breaker (AVB) was observed at the utility sink near the dishwashing area. On 06/28/2026 at 9:44AM the drain line to the sanitizer side of the three compartment sink was observed partially sitting inside the drain. On 06/28/2026 at 9:54AM an attached hose with a chemical feeder was observed without an AVB and wasting tee on the utility sink. On 06/28/2026 at 9:55AM the drain line to the ice machine was observed sitting inside the drain pump in the east nutrition room. On 06/28/2026 at 9:59AM the drain line to the ice machine was observed sitting inside the drain in the north hallway nourishment room. On 06/28/2026 at 11:37AM during lunch observation, Dietary Manager H temped the pasta salad at 55 F and the marinated zucchini at 70 F. The pasta salad and zucchini were placed in the freezer to cool down. During this observation Dietary Manager H was interviewed on what temperature the food should be holding at, and she stated 41 degrees. On 06/28/2026 at 11:51AM the walk-in cooler door was observed left propped open, and the temperature reading was 55 F. On 06/28/2026 at 12:48PM the walk in cooler temperature reading was 44 F and the door was closed. On 06/28/2026 at 12:50PM during lunch service, egg salad temperature was recorded at 51 F using a thermometer probe. In addition, the egg salad was observed sitting on ice in the steam table and the ice was melting. On 06/28/2026 at 12:52PM the pasta salad temperature was recorded at 57 F using a thermometer probe. According to the State of Michigan's 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).According to the State of Michigan's 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.According to the 2022 FDA Food Code, 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.According to the FDA 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5 C (41 F) or less.According to the facility's food preparation policy, All foods will be held at appropriate temperatures, greater than 135 F (or as state regulation requires) for hot holding, and less than 41 F for cold food holding.

Based on observation, interview, and record review, the facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include:On 06/28/2026 at 1:54PM while touring the facility with Maintenance Director G, there were approximately eight dirty gloves, a plastic lid and straw, with a strong odor surrounding the dumpster area. In addition, the sliding door to the dumpster was left open. During this observation, Maintenance Director G began to pick up the debris surrounding the dumpster area and was interviewed on how often the dumpster area is cleaned and he stated it's cleaned weekly or as needed. Maintenance Director G was asked whether there are any cleaning logs for when the dumpster area is cleaned, and he said no. According to the FDA 2022 Food Code, 5-501.115 Maintaining Refuse Areas and Enclosures A storage area and enclosure for refuse, recyclables, or returnables shall be maintained free of unnecessary items.

Based on observation, interview, and record review, the facility failed to ensure appropriate backflow prevention was installed at plumbing fixtures and ensure a safe and sanitary environment for 4 residents (Resident #45, Resident #50, Resident #52 and Resident #77), resulting in the potential for contamination to the water supply. Findings include: Resident #50 (R50): On 6/28/26 at 11:06 AM, an interview was conducted with R50 who was sitting in his room in his wheelchair. The Resident answered questions and engaged in conversation. The Resident was asked to have his bathroom looked at and the resident consented. An observation was made of a toilet bowl plunger standing upright by the toilet. The plunger had visible debris around the rubber part of the plunger. The Resident was asked when the toilet had last been clogged and the Resident stated, It has not been clogged for a while, and indicated it might have been a couple months ago. The debris on the plunger was dried. An observation was made of two fracture pans (used under a resident for urine and/or bowel movement. The two pans did not have a name, room number or initials indicating who the pans belonged to. Both pans were not in bags, and one was positioned on a towel bar, and one was on a grab that was next to the toilet and in the way of use of the grab bar when using the toilet. Both pans looked used due to debris dried on the inside of the pans. Resident #45 and Resident #52: On 6/28/26 at 10:01 AM, an observation was made in Resident 45 and 52's room. The Residents were not present at the time. The bathroom was observed that was shared between two rooms, both with two beds. The bathroom had an odor. The floor had multiple white specs on the floor, the wall was nicked up at wheelchair height, dried toilet paper was on the door jam and a plunger with a lot of debris stuck over the rubber part of the plunger was laying on the floor by the toilet. Resident 52 had urinals positioned laying on the floor with one urinal filled with urine and the other urinal partially filled. In the nook across from the beds, a hole was noted in the wall with wires hanging out of the hole and you could see inside the wall. On 6/28/26 at 10:37 AM, an observation was made with the Director of Nursing (DON), Maintenance Director G and the Sanitarian Surveyor of Resident 45 and 52's room. An observation was made of the dirty toilet bowl plunger laying on the floor. The DON reported that one of the Residents will sit on the toilet for a long time and she thought it was the Resident's own plunger and that the facility plungers where not of that type. The DON indicated it should be cleaned and stored properly. On 6/28/26 at 10:42 AM, an interview was conducted with Housekeeping Staff V who was cleaning Resident 77's room across from Resident 45 and 52's room. The Housekeeping staff was asked about issues with gnats/fruit flies and reported it was an everyday thing, and indicated the Resident's keep food in the room, urinals were full of urine and housekeeping staff often have to empty out urinals. The room the housekeeping staff was cleaning had wet paper towels near the Residents bed and wet area in and around Bed A that the staff identified as urine, dried area on the floor along the floor across from the beds that was identified as a spill and reported it could have been urine. It was identified that the spill happened a while ago and the staff identified that the spills were not always cleaned up when they happen and were left for when housekeeping comes in in the morning. Resident #77: On 6/30/26 at 10:00 AM, an observation was made of Resident 77's room that had a sticky substance on the floor of the room from the Resident's bed to the bathroom. Next to the Resident's bed near the wall was a wet area with a wet paper towel. An observation was made of gnats hovering above the floor by the bed where it was visibly wet. There was a strong odor of urine in the room. Housekeeping staff W was in the room to clean and an interview was conducted. When asked about the gnats, the Housekeeping staff reported an ongoing issue with the gnats and indicated it had been reported. The Housekeeping staff reported that in this room, there is urine on the floor all the time and stated, you can see it now and indicated the dried sticky area from near the bed to the bathroom and by the resident's bed. The Housekeeping staff reported that this room and the room across the hall was always in need of being cleaned and that urine was often left on the floor and urinals were needed to be emptied. When asked about the staff responsible for cleaning up spills, the Housekeeping staff indicated that spills should be cleaned up when they happen and then Housekeeping should come through to sanitize. The bathroom was observed and was noted to be wet around the base of the toilet and over a large area of the floor. The Housekeeping Staff was asked about it and reported that the toilet leaked, and it had been reported but has not yet been fixed. There was an odor of urine in the bathroom and a couple gnats were flying around in the bathroom. On 06/28/2026 on 1:40PM an attached hose with a chemical feeder downstream of an atmospheric vacuum breaker (AVB) to the utility sink was observed in the service hallway janitor's closet. On 06/29/2026 at 9:26AM interviewed Maintenance Director G on the utility sink needing a wasting tee in the service hallway janitor's closet and he stated he was familiar with wasting [NAME], and he would contact the chemical dispenser company. On 06/29/2026 at 9:42AM an attached hose with a spray nozzle downstream of a hose bib vacuum breaker (HBVB) was observed at the outside spigot in the activity's courtyard. During this observation, Maintenance Director G removed the spray nozzle from the hose. On 06/29/2026 at 9:45AM an attached hose with a spray nozzle downstream of an HBVB was observed at the outside spigot near the front entrance. During this observation, Maintenance Director G removed the spray nozzle from the hose. On 06/29/2026 at 9:59AM an attached hose with a chemical feeder downstream of an AVB was observed at the utility sink in the janitor's closet in north hallway. According to the State of Michigan's 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve). According to the State of Michigan's 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.

This citation pertains to intake Number 3037980. Based on observation and interview the facility failed to serve food that was palatable and at an appropriate temperature and that residents were given choices of food preferences for 6 residents (R2, R3, R10, R22, R38, R78) of 10 residents reviewed for food and a confidential group of residents. Findings include:On 06/29/2026 at 12:00PM, observation of lunch meal was conducted in the Sunnyside Dining Room: This is a point of service meal for the residents that are in here, the food is served from steam wells located in the dining room. On 06/29/26 at 12:15PM, a test tray was received as requested. The meal provided is a cheeseburger on a bun and waffle fries. The waffle fries have good flavor but are a little spicy and are soggy and cold. The cheeseburger is not very warm, and no condiments were provided for the cheeseburger or fries. On 06/29/2026 at 12:26PM, an interview was conducted with R44. R44 was asked about the quality of the food at the lunch meal. R44 stated the food was ok today, but the waffle fries were a bit harsh for him (spice). Resident #38: On 06/28/2026 at 10:05AM, an interview was conducted with R38. R38 was asked about the quality of the meals. R38 stated that yesterday's lunch (6/27/26) was inedible, R38 stated she had her family grab her some fast food on the way home from work and bring it to her. R38 stated that a lot of the time the meals are cold when they get to our room. R38 stated when she received dinner yesterday (6/27/26), that she pulled the top off of it looked at it and put the top back on the plate and sent it back; R38 stated it was terrible looking. Resident #3: On 06/29/2026 at 8:54AM, R3 was interviewed about the food in the facility. R3 stated that the food is terrible. R3 was asked why they felt that the food is terrible. R3 stated, it's just not good and it seems like every meal is just thrown together. R3 stated the other day they received spaghetti noodles with no sauce on them and green beans. The meals just don't make sense; the food items don't go together. R3 stated that there are a lot of times when she will call her family and have them send her money so she can order food or have them bring me something to eat. On 6/30/26 at 12:30PM, observation revealed and empty Kentucky Fried Chicken bag in the garbage. When R3 was asked about it, she stated she had her family bring it for her so she can eat. Confidential Group of Residents: On 06/29/2026 at 1:04PM, a meeting was held with a confidential group of residents. When the group was asked about the food in the facility, the following responses were received. Three confidential residents said the hot dogs for lunch today (6/29/26) were not good. Three confidential residents stated that they regularly order food to the facility from outside restaurants. The group states you can't always get a hold of the always available menu. One confidential resident stated that to get anything off the always available menu, you need to have it ordered in a certain timeframe and that even if you order it in time, you still might not get it. Record review of the always available menu revealed the following alternative food options. -Hamburger (with lettuce and tomato) -Hot Dogs -Deli Sandwich -Grilled Cheese Lunch choices due by 9:30AM Dinner choices due by 1:00PM. Resident #78: In an interview on 6/28/2026 at 11:07AM, Resident #78, stated that cold food has been better lately, but taste is not good. I have to wait for the room trays, my roommates come and I have to wait for 10 minutes or more, and I know it's sitting in the hall getting cold. The snacks are crap. We get cheap food snacks, off-brand crackers and cheese, oatmeal cream pies, Cheez its, all junk foods. Weekend staffing- they are short staffed all the time. They don't respond to the call lights, when they do come in, they shut the light off and don't do anything and don't come back, the night shift is the worst. They don't answer the call lights for 30 minutes to 3 hours, we wait a long time for them, and nothing gets done about it. We can hear them in the hallway laughing and carrying on. but they don't come to help. Resident #10: In an interview on 06/28/2026 at 12:16 PM, Resident #10 stated the food 7 years ago at the facility was good and they sent a menu to the resident room and you filled it out and they brought what you ordered. Now there is only 1 entree, and you get what you get. After dinner, once the carts are out, they tear everything down in the kitchen and if you want to order a different alternative menu choice that is very limited. Residents can order an alternative but have to turn in the request slip by lunch. They only put the menus at the nursing station and do not give them to the residents in the rooms. Us bed bound residents cannot get to the nursing station to get a menu. Snacks are not good, there are no nutritious snacks like cottage cheese, fresh fruit, and healthy items. An observation and interview were conducted on 06/29/2026 at 1:01 PM of Resident #10, who was in bed with noon meal tray of chili dog, and waffle fries. Resident #10 stated that he was asleep and they didn't wake him up and now it's cold and soggy. Portions are small and there's no flavor. Record reviewed of the alternate choice menu in Resident #10's room. Resident #10 stated that the list of 4 choices shrunk from at least 10 choices which included salads, PBJs, soups, cottage cheese and other good foods. It's really sad for us residents that know what use to be offered and now they have cut the budget, and we are not getting the fresh vegetables and fruits, its summer and all our fruit/vegs is from a can. Resident #2: In an interview on 06/28/2026 at 12:04 PM with Resident #2 stated that most of the food s**ks, and there are very few good food items, The food taste is bad; it is salty and just is not good. Meats are dry and tough to chew. They don't bring us menus, and the alternate menu only has 4 choices, and nothing is fresh. The alternate menu residents can only order one item, you cannot order a hotdog and a hamburger or grilled cheese, just one item. Observation on 06/29/2026 at 10:40 AM at the Med-Bridge nursing station noted that menus in the culinary menu basket on the nursing station desk also had alternate choice menus. Record review of the 'Always Available Menu' (undated) noted only had 4 food choices, hotdog, hamburger, deli sandwich, grilled cheese. The form noted: Please note this is for main entree substitution only, please choose only one entree, please use separate sheets for lunch and dinner, handwritten alterations will not be accepted and please fill sheet out daily. Lunch choices were due by 9:30AM and dinner choices were due by 1:00PM. Record review of the 'Week 1' menu dated June 22-June 28th, located at the Med-Bridge nursing station for the week of survey did offer only one entree: Monday-Chili dog on a bun, waffle fries, coleslaw, cherry cobbler. Tuesday-Baked fish, rice, green beans, cornbread, lemon pie and so on . The surveyor noted that there was only one entree/choice offered per meal and only alternate menu items of hotdog, hamburger, deli sandwich or grilled cheese. In an interview on 06/29/2026 at 11:02 AM with Resident #2 stated that the food still s**ks and the other night we had a pepperoni sandwich it was nasty. They serve white macaroni with onions, it's nasty. Resident #2 stated that she usually has the aide get her a hotdog or a hamburger, we can't have both we have to choose only one, one hotdog doesn't fill you up, and sometimes you can get chips and other times they send just the hotdog and no ketchup or mustard. In an observation and interview on 06/29/2026 at 12:54 PM with Resident #2 stated that She had the chili dog. Surveyor observed the chili dog with the top scrapped off and only one to two bites. Resident #2 stated that they bring her tray in and open the milk and then they leave. Resident #2 was observed to have built-up utensils on meal tray. Resident #2 stated that she does have the fat handled utensils. The chili dog was not very good, and she took all the chili off because it did not taste good. Coleslaw does not taste good either, no, no one helps me eat, no they don't cut up my hotdog/chili dog or any of that stuff. Resident #22: In an interview on 06/28/2026 at 11:55 AM, Resident #22 stated that the food here is the same old crap, never good, the food has to get better. In an observation and interview on 06/29/2026 at 12:58 PM, Resident #22 stated that he got the chili dog with onions but it was not very good and the waffle fries are soggy, they don't bring no ketchup for the fries, it's just not good, the taste, the temperature, all of the meal was bad.

Based on observation, interview and record review, the facility failed to ensure a pest free environment of fruit flies and gnats for seven residents (#43, #45, #50, #52, #70, #77 and #86) of seven residents reviewed for pest control.Findings include:Resident 43:On 6/29/26 at 8:51 AM, an observation was made of Resident 43's room. The Resident was lying in bed and was not reliable with an interview. The room had scattered debris on the floor. There was a wet brief on the handrail in the bathroom, and two gnats were hovering in the area of the wet brief. Resident 45 and 52:On 6/28/26 at 10:01 AM, an observation was made in Residents 45 and 52's room. The Residents were not present at the time. Multiple fruit flies/gnats were observed on bed B's bedside table and overbed table. There were food bags on the bedside table and multiple gnats on the bags, there was a glass with a top on it and had some colored liquid left in the cup with multiple gnats on the top on the cup and on the side of the cup, multiple gnats were seen on the privacy curtain between the two beds, on the wall, overbed light fixture, on the Resident's bed and flying around the room. A count of fifty gnats was conducted and ceased counting at 50 in Bed B's area. An observation was made of Bed A's area with multiple fruit flies/gnats on the Resident's bed, overbed table and urinals that were positioned on the floor. On 6/28/26 at 10:37 AM, an observation was made with the Director of Nursing (DON), Maintenance Director G and the Sanitarian Surveyor of Resident 45 and 52's room. Multiple gnats/fruit flies were seen in both Bed A and B areas with multiple flies on the Resident's drinking glass and food bags. The DON stated, Will have someone clean in here. On 6/28/26 at 10:42 AM, an interview was conducted with Housekeeping staff V who was cleaning Resident 77's room across from Resident 45 and 52's room. The Housekeeping staff was asked about issues with gnats/fruit flies and reported it was an everyday thing, and indicated the Resident's kept food in the room, urinals were full of urine and housekeeping staff often have to empty out urinals. The room the housekeeping staff was cleaning had wet paper towels near the Residents bed and wet area in and around Bed A that the staff identified as urine, that was dried on the floor along the floor across from the bed to the bathroom, that was identified as a spill and reported it could have been urine. It was identified that the spill happened a while ago and the staff reported that spills were not always cleaned up when they happened and were left for when housekeeping comes in in the morning. On 6/28/26 at 12:05 PM, Resident 52 was present in their room eating lunch. An observation was made of multiple fruit flies/gnats flying in the room. It was observed that some of the Resident's items had been cleaned up or removed. There were 48 gnats counted around the Resident's area. The Resident reported he liked to keep food and the gnats were just there. During the interview, Resident 45 came into the room and was looking at the food that was on the overbed table and was covered. An observation was made of the gnats around Resident 45's area of the room as well. Resident 70:On 6/30/26 at 9:31 AM, an interview was conducted with Resident 70 who answered questions and engaged in conversation. When asked about any issues with pests in the room or facility, the Resident reported fruit flies or gnats as an issue at times in their room. The Resident stated, Yes there are gnats in there. If the tube feed (for the roommate) is left, they are attracted to it so if its not running I have them take it out. Resident 77:On 6/30/26 at 10:00 AM, an observation was made of Resident 77's room that had a sticky substance on the floor of the room from the Resident's bed to the bathroom. Next to the Resident's bed near the wall was a wet area with a wet paper towel. An observation was made of gnats hovering above the floor by the bed where it was visibly wet. There was a strong odor of urine in the room. Housekeeping staff W was in the room to clean and an interview was conducted. When asked about the gnats, the Housekeeping staff reported an ongoing issue with the gnats and indicated it had been reported. The Housekeeping staff reported that in this room, there is urine on the floor all the time and stated, you can see it now and indicated the dried sticky area from near the bed to the bathroom and by the residents bed. The Housekeeping staff reported that this room and the room across the hall was always in need of being cleaned and that urine was often left on the floor and urinals were needed to be emptied. When asked about the staff responsible for cleaning up spills, the Housekeeping staff indicated that spills should be cleaned up when they happen and then Housekeeping should come through to sanitize. The bathroom was observed and was noted to be wet around the base of the toilet and over a large area of the floor. The Housekeeping Staff was asked about it and reported that the toilet leaked and it had been reported but has not yet been fixed. There was an odor of urine in the bathroom and a couple gnats were flying around in the bathroom. Resident 86:On 6/29/26 at 8:57 AM, an interview was conducted with Resident 86, who answered questions and engaged in conversation. An observation was made of a couple fruit flies in the room. The Resident was asked if the fruit flies were an ongoing issue. The Resident responded that the flies were annoying and seen often. The Roommate was in the room and stated, When I see them, I just kill them. On 6/29/26 at 1:07 PM, an observation was made of Resident 86 eating lunch in their room. The Resident was seen swatting away a couple of gnats/fruit flies that were flying around her food items. A review of the facility policy titled, Pest Control, revised 10/13/25 revealed, .3. Definition: Effective pest control program is measures taken to eradicate and contain common household pests. D. We will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. a. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and sate and federal regulations.

This citation pertains to Intake Numbers 3074530 and 3037980. Based on observation, interview and records review, the facility failed to ensure that residents' call lights were accessible and answered in a timely manner for 10 residents (#3, #7, #10, #38, #44, #46, #50, #63, #78, #86), and a confidential group of residents, resulting in verbalizations of anger and frustration regarding not answering call lights in a timely manner. Resident 46 (R46): A review of R46's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] dementia, heart disease, diabetes and history of falling. A review of the Minimum Data Set assessment revealed the Resident had a Brief Interview of Mental Status score of 09/15 that indicated moderately impaired cognition and needed supervision or touching assistance with walking. On 6/29/26 at 9:17 AM, an interview was conducted with R46 who answered questions and engaged in conversation. The Resident had a wound to the top of his head with sutures and reported he was walking and had fallen. An observation was made of the Residents call light on the floor and the bed controller on the floor with the call light. The Resident was asked if he had any concerns of the call light system, the Resident laughed and said, No Comment and shook his head back and forth in a negative response, then reported that it takes a while before it was answered. It was observed that the bed was up in a higher position. The Resident indicated he had been looking for his light for a while because he wanted to adjust the bed and didn't know where his bed controller was at and could not find the call light. At this time the Administrator (NHA) was walking in the hall and was called into the room with the concern of the Resident's call light on the floor. The NHA put the call light back on the bed and assisted the Resident with the bed controller to adjust the way he wanted to be positioned. The NHA was unsure of the correct height of the bed and indicated she would check with the staff and have staff adjust the bed height. On 6/29/26 at 9:36 AM, an interview with Unit Manager, Nurse J regarding R46 bed controller and call light not in reach and the position of the bed. The Unit Manager reported the bed was not care planned to be low and the Resident was able to adjust the bed as he wanted, but indicated the call light should be in reach. A review of R46's care plan revealed a Focus related to risk for falls that had an intervention to Keep call light and frequently used personal items within reach. Resident 50 (R50): A review of R50's medical record revealed an admission into the facility on 9/10/25 and readmission on [DATE] with diagnoses that included heart disease, obesity, diabetes, bipolar disorder, anxiety and traumatic brain injury. A review of the Minimum Data Set assessment revealed the Resident had a Brief Interview of Mental Status score of 15/15 that indicated intact cognition. On 6/28/26 at 11:06, an interview was conducted with R50 who was sitting in his wheelchair. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about concerns he had with care received at the facility. The Resident reported long call light wait times and it was useless to use because it took too long to be answered. The Resident reported he had put it on yesterday and stated, It was on for 8 hours! An observation was made of the Resident's roommate with their call light hanging over the middle of the head of the bed with the push mechanism positioned between the wall and the head of the bed. The Resident had his head of the bed elevated and the call light was not in reach and not in sight for the Resident. Nurse Supervisor X was notified the Resident needed assistance and was unable to get to the call light. The Nurse Supervisor indicated the call light should be in reach for the resident. Resident 86 (R86): A review of R86's medical record revealed an admission into the facility on [DATE] with diagnoses that included right lower leg fracture, diabetes, heart disease, muscle weakness and difficulty in walking. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 14/15 that indicated intact cognition and the resident was dependent on a helper for toileting hygiene, bathing, personal hygiene, rolling in bed and transfers. On 6/29/26 at 8:57 AM, an interview was conducted with Resident 86 who was lying in bed. The Resident answered questions and engaged in conversation. When asked about concerns she had with the care she received at the facility, the Resident reported issues with her light not answered timely. The Resident stated, I had a bm (bowel movement), put my light on and had to wait for hours, and explained it happened last month, and stated, It takes a long time to get the light answered. An observation was made of the Resident's call not within reach for the resident. When asked about this, the Resident stated, They sometimes put the light out of reach and my roommate will get it for me. The Roommate was in the room and stated, I get her light a lot for her, it's not by her a lot of times. The Resident reported staff shutting off the light and then taking a long time to come back. On 6/29/26 at 1:05 AM, an observation was made of Resident 86 sitting up in her wheelchair. The Resident was interviewed and she explained she had gotten a shower recently and was still sitting up in her wheelchair. The Resident reported she wanted to get back to bed and stated, They (staff) have not come back to put me to bed. I had my call light on, they came in and said they would be back. I am still sitting here. My back is killing me, and reported they needed the lift to get her back into bed. The Resident had her call light in reach and was asked to put her call light on again. An observation was made from the hallway that the light was answered within a couple minutes. The staff had turned off the light and had left the room. At 1:26 PM, an observation was made of staff bringing in the lift and were going to get the Resident back to be. Resident #3: R3 admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of the endometrium, heart failure, chronic kidney disease and dependence on renal dialysis. R3 has a brief interview for mental status (BIMS) score of 15, indicating they are cognitively intact. On 06/29/2026 at 9:04AM, an interview was conducted with R3, R3 was asked if the facility staff answers the call light in a timely fashion. R3 stated that it can be 30 minutes and sometimes up to 3-4 hours to get the call light answered. R3 was asked if the response time was any worse during different shifts. R3 stated that the second shift is the worst shift for answering call lights. Resident #7: R7 was admitted to the facility on [DATE] with diagnoses that include right leg above the knee amputation, hypertensive heart disease and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R7 has a BIMS score of 15, indicating they are cognitively intact. On 06/28/2026 at 10:34AM, an interview was conducted with R7. R7 was asked how long it takes to get the call light answered. R7 stated it takes 30 minutes to get the light answered and that the 3rd shift staff is the worst. Resident #38: R38 admitted to the facility on [DATE] with diagnoses that include hypertensive heart disease, depression, glaucoma and unspecified asthma. R38 has a BIMS score of 15, indicating they are cognitively intact. On 06/28/2026 at10:10AM, an interview was conducted with R38. R38 was asked how long it takes the facility staff to respond to the call light. R38 stated that most times the call light gets answered in an hour or so. R38 stated that some of the nursing staff do a good job of telling us that they are short, that way we expect the long wait times R38 was asked if any of her needs haven't been met due to a long wait. R38 stated there have been times where she has had to go to the bathroom and staff didn't get here on time. Resident #63: On 06/28/2026 at 9:58AM, observation revealed the call light was out of reach. It was observed behind the bed and on the frame of the bed near the floor. On 06/29/2026 at 1:04PM, a meeting was conducted with a group of confidential residents. The confidential group was asked what the average call light time response was. The consensus of the group is that the minimum amount of time is about 30 minutes, one resident stated they were in the bathroom for 45 minutes and started yelling to get help. Other confidential residents stated that there are times it can be as long as two hours for a response. Resident #78: In an interview on 6/28/2026 at 11:07AM with Resident #78 when asked about cold food, the food taste is not good. and he has had to wait for the room trays, his roommate's tray comes and he has had to wait for 10 minutes or more, and he knows it's sitting in the hall getting cold. Resident #78 stated that the snacks are crap and cheap food snacks, off brand cracker and cheese, oatmeal cream pies, [NAME]-zits junk foods. Weekend staffing- they are short staffed all the time. They don't respond to the lights, when they do come into the room, they shut the light off and don't do anything and don't come back, the night shift is the worst. They don't answer the call lights for 30 minutes to 3 hours, we wait a long time for staff, and nothing gets done about it. We can hear them in the hallway laughing and carrying on. but they don't come to help. IN an interview on 06/29/2026 at 10:58 AM with Resident #78 stated that call lights are still too long, the aides don't do sh** and the nurses don't tell them to do anything. I complain about stuff and nothing gets changed or done about it. They want my money, but don't want to do anything for me. Resident #10: In an interview on 06/29/2026 at 1:53 PM with Resident #10 stated that the call lights are not responded to it take 30 minutes or more, I could piss my pants and they don't come. Resident #44: Record review of 'Report of Concern' form for Resident #44 dated 6/30/2026 had a description of concern: Call light put on aide came in said a few people a head of him time about 3:25AM the aide didn't come back until about 4:20AM. Resident stated the aide is nice but he doesn't like to sit in poop. Record review of the Health Care Association of Michigan (HCAM) 'Rights of Residents in Michigan Nursing Facilities' dated 2024, revealed the residents are entitled to receive adequate and appropriate care, and to receive, from the appropriate individual within the health facility .,

This Citation pertains to Intake Number 3074530. Based on interview and record review, the facility failed to ensure that orientation and annual competency skill assessments and annual performance evaluations were completed for 3 of 3 licensed staff and 5 of 5 unlicensed staff of 9 staff reviewed. Record review of the facility 'Education, Training, and Competency' policy, dated [DATE], revealed Training and competency evaluation programs ensure compliance with State and Federal regulations, support high-quality resident care, and ensure that all care team members possess and maintain the skills necessary to perform their roles safely and effectively . Competency evaluation is an integral component of the training program and is required for all care team members, including employees . Initial competency is evaluated during the orientation process. A care team member remains on orientation until all required competencies are verified. Ongoing and annual competency evaluations occur at frequency determined by: (2.) Evaluation of the training program, 3.) Job performance evaluations, 4.) Identified performance gaps or regulatory requirements. Competency checklists are used to document training and competency verification. Competency documentation is maintained in department files, the care team members personnel file for the current training year, and the care team members official human resource file An interview and records review on [DATE] at 11:10 AM with Human resource staff K revealed that she has only been at the facility for 1 month and the records were not kept up, were moved around and not filed in alphabetical order. Licensed Staff:Record review of Licensed Practical Nurse (LPN) N hire date of [DATE] employee file revealed the Cardio-Pulmonary Resuscitation (CPR) card expired: [DATE]. Record review of Licensed Practical Nurse (LPN) A hire date of [DATE] had a Skills assessment: Skills validation checklist dated [DATE] and there was no annual performance records to review noted in the file. Record review of Register Nurse (RN) O hire date of [DATE] and rehire date of [DATE] employee file revealed there was no Cardio-Pulmonary Resuscitation (CPR) card found. There was no orientation skills checklist from the rehire date of [DATE] found in the employee file. Unlicensed Certified Nursing Assistants:Certified Nurse Assistant P with hire date of [DATE] had no skills checklist or orientation form found in employee records. Certified Nurse Assistant Q with hire date of [DATE] had a skills assessment checklist dated [DATE] and no Annual Performance review by management on job performance. Certified Nurse Assistant R with hire date of [DATE] had a pre-employment Background check which was dated [DATE] for Assisted Living side of the building and not rechecked for Long Term Care/skilled care. A Skills validation checklist dated [DATE] was found int the CNA's file. There was no 2026 skills checklist located and no annual performance review by management on job performance. Certified Nurse Assistant S with hire date of [DATE] had no orientation skills checklist found within the employee file. Certified Nurse Assistant T with hire date of [DATE] had a skills validation checklist dated [DATE] and none for 2026. There was no Annual Performance review by management on job performance. In an interview on [DATE] at 12:03 PM, Human Resource Staff K was asked by the surveyor if there were any other documents she would like to submit to the surveyor regarding the employee files and missing documentations. Staff K stated that she would have to ask the Director of Nursing (DON) if any other documents were available. The surveyor would only accept documents until the end of the survey exit conference.

Based on observation, interview and record review, the facility failed to ensure that medication carts and treatment carts were secured, failed to clean medication carts, failed dispose of expired medications and failed to perform narcotic reconciliation counts for three of three medication carts reviewed. Findings include: On 6/28/26 at 10:37 AM, an interview was conducted with the Director of Nursing in the conference room. Upon exiting the conference room with the Director of Nursing, an observation was made of the medication cart positioned up against the Nurses' Station with the drawers facing the hallway. The medication cart was not locked, and the drawers could be opened. Resident were in the vicinity at the time. The Nurse was sitting behind the Nurses' Station and was not in a direct line of sight of the unsecured medication cart. An observation was made of the Treatment cart positioned in the hallway down from the Nurses' Station that was not secured. When asked about the medication cart and the treatment cart not being secured, the DON indicated both should be locked. The DON locked both carts and addressed the Nurse with education of securing the medication and treatment cart. On 6/29/2026, at 10:17 AM, an observation of medication cart 3 on the 100 Hall revealed an open nasal spray (Afrin) with no name nor open date noted. Nurse A discarded the spray in the trash. On 6/30/3026, at 9:00 AM, an observation of the Medication Cart 1 along with Nurse B was conducted. Resident #4's expired eye drops remained in the drawer. Nurse B was asked if they had administered the eye drops to Resident #4 that am and Nurse B stated, Yes. On 6/30/2026, at 9:09 AM, during the medication storage task with Nurse B on medication cart 1, 6 loose tablets were noted in the top drawer and middle drawers. Nurse B gathered the loose pills (2 blue, 4 white) and discarded them into the sharps container. There was an opened brimonidone eye drop for Resident #53 with an open date of 5-2-26 located in the medication drawer. On 6/30/2026, at 9:18 AM, an observation of the Medication Cart 2 with Nurse E was conducted which revealed 1 loose white tablet. Nurse E disposed of the tablet. Nurse E was asked if they reconciled the narcotic medications that morning and Nurse E stated, yes. A record review of the narcotic reconciliation document with Nurse E revealed the column incoming nurse was left blank. Nurse E was asked to provide a copy of the document. Nurse E stood in front of the surveyor and quickly signed their name. Moments later, Nurse E was noted with the open narcotic reconciliation folder although had not opened any drawer on their cart, and began to sign. Nurse E was stopped and the Director of Nursing (DON) was notified. The DON was asked to provide a narcotic reconciliation for Medication Cart 2. On 6/30/2026, at 9:30 AM, the DON and Nurse E began to reconcile narcotic medication for Medication Cart 2, Nurse E quickly stated, I'm going to be off by one for (Resident #100) for their pergamblin. I gave it to her about 9 am but didn't sign it out. Narcotic reconciliation for Residet #100 revealed 1 less narcotic in the drawer than on the signed out reconciliation form. The DON clarified with Nurse E that they did administer the pregamblin and allowed Nurse E to sign out the narcotic at that time. The DON was asked to provide the actual time the pregamblin was administered by Nurse E. On 6/30/2026, at 10:04 AM, Nurse A was alerted Nurse B administered expired eye drops to Resident #4. An observation of medication cart with Nurse A was conducted. An additional eye drop (Brimonidine) was noted for Resident #47, with an open date of 5-28. Nurse A was asked if the eye drops were expired and Nurse A reviewed the expired mediation list on the cart which revealed the eye drops were not listed. On 6/30/2026, at 10:10 AM, Nurse A called the pharmacy and spoke with Pharmacy technician D via speakerphone. Pharmacy technician D was asked what the expiration date would be for the two eye drops would be with an open date of 5-28 and pharmacy technician D stated, they are good for 28 days after the day they are opened. A review of the facility provided MEDICATION ADMINISTRATION POLICY revealed Medications are administered by license nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Keep medication cart clean, organized . perform hand hygiene prior to administering medications per facility protocol . identify expiration date and discard if necessary and replace medication . perform hand hygiene after administration per facility protocol . if medication is a controlled substance, sign narcotic book .

Based on observation, interview and record review, the facility failed to complete timely skin assessments for one resident (Resident #3), complete timely dressing changes for one resident (Resident #38), and failed to obtain a physician's order for oxygen for one resident (Resident #22) of 3 sampled residents. resulting in a lack of care coordination, documentation and assessments. Findings include: Resident #3 (R3): On 06/29/2026 at 8:58AM, an interview was conducted with R3. R3 states that she has a sore on her bottom that is new. On 06/29/2026 at 12:44PM, record review revealed that skin evaluations for R3 are not being completed at consistent intervals. On 06/29/2026 at 12:48PM, record review revealed a wound care order for the right buttocks, dated 6/15/26. On 06/29/2026 at 2:30PM, an interview was conducted with Wound Care Nurse F. Wound Nurse F was asked if R3 has any current skin concerns Wound Nurse F stated that R3 had something on her right lower buttocks. Wound Nurse F stated that it was moisture associated skin damage (MASD). Wound Nurse F stated taht R3 has treatment orders for triad. Wound Nurse F was asked how often nurses perform skin assessments on residents. Wound Nurse F stated that It depends on the unit, but they are usually done weekly. Wound Nurse F stated they do a weekly skin check and then a monthly skin sweep. Wound Nurse F was asked if R3 was a weekly skin assessment. Wound Nurse F stated, yes, staff look at her weekly and I do too. Wound Nurse F was asked where the nurses document the skin assessments. Wound Nurse F stated they are documented under skin evaluations in the evaluation tab. On 06/29/2026 at 2:45PM, record review of the Skin Evaluations under the evaluations tab revealed the following completed and documented skin assessments. -3/15/26 -4/4/26 -4/23/26 -5/8/26 -6/10/26 Review of the policy titled, Wound Care, revealed, 3. Policy a. Preventing the formation of skin conditions 1: Residents/Patients have their skin assessed at the time of admission/re-admission and evaluated routinely to ensure the skin is intact. Resident #38 (R38): R38 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include urinary tract infections, extended spectrum beat lactamase resistance, gout and heart failure. R38 has a brief interview for mental status (BIMS) score of 15, indicating they are cognitively intact. On 06/28/2026 at 10:13AM, observation revealed a medication port on the right upper chest, the dressing was dated 6/21/26. On 06/29/2026 at 10:20AM, observation revealed the date on the port dressing was 6/21/26. On 06/29/2026 at 2:25PM, record review revealed a physician's order to monitor the port and complete dressing changes. The dressing change is scheduled to be completed every 7 days on Sunday. On 06/29/2026 at 2:51PM, record review of the June 2026 treatment administration record (TAR) revealed that the dressing change was signed out as completed on 06/28/26. However, the dressing change was not completed on 6/28/26. On 06/29/2026 at 3:10PM, an interview was conducted with the Director of Nursing (DON). The DON was asked how dressing changes are completed for ports. The DON stated they are to be done weekly. The SA and the DON verified that the dressing is still dated 6/21/26 and that staff signed it out as completed on 06/28/26. Review of the policy titled, Central Venous Catheter Dressing Changes, revealed, General Guidelines: 5. Change transparent, semi-permeable membrane dressings every 5 to 7 days and PRN (as needed when wet, soiled or not intact). Record review of facility 'Change of Condition/Physician Notification' policy, dated 6/10/2026, revealed to promptly identify, respond to, and report changes in resident condition to the resident's physician and their representative. A significant change is a major decline or improvement of the residents' status. When a change in condition is discovered, the charge nurse will evaluate the resident and notify the residents physician with pertinent information to discuss care for the resident. Resident #22: In an interview on 06/28/2026 at 11:53 AM, Resident #22 stated that he went for a cardiac stress test at the hospital and stayed a few days from Saturday to Tuesday. Resident #22 stated that he has gone to the hospital a few times recently for chest pain. Resident #22 was noted to be seated up in his room in a wheelchair with oxygen via nasal canula. Record review of Resident #22's medical diagnoses list included: Chronic obstructive pulmonary disease (COPD), malignant neoplasm of bronchus or lung, anemia, heart disease, anxiety disorder, dementia, hypertension, and more diagnosis. In an observation and interview on 06/30/2026 at 9:30 AM, Resident #81 was up in wheelchair in the hallway outside of the Eagle Room corridor. He was self-propelling up the hall. The state surveyor asked Resident #22 how he was doing. It seemed that the resident appeared short of breath. Resident #22 stated that he had no Oxygen on because he had no tank holder to the back of his wheelchair. He would like some oxygen and a tank holder so that he could get out of his room more. Resident #22 stated that He gets short of breath, and the oxygen helps his chest pain. He has oxygen in his room but not when he is up and about. In an interview on 06/30/2026 at 9:41 AM, Licensed Practical Nurse/Unit Manager (LPN) J revealed that Resident #22 had been hospitalized a few times with altered mental status and chest pain on 6/20/2026. LPN J had to leave the interview to get her laptop for record review with the surveyor. An interview and records review on 06/30/2026 at 10:05 AM with Licensed Practical Nurse/Unit Manager (LPN) J revealed that Resident #22 had medical diagnoses of chronic obstructive pulmonary disease (COPD) and heart disease. On 6/20/26 Resident #22 had a change of condition and was sent to the hospital. Record review showed no physician's orders for oxygen. LPN J stated the resident does use oxygen as needed (PRN), LPN J searched through Resident #22's medical record for record review there was no batch orders or specific oxygen order found. The oxygen order was Discontinued on 6/23/26 when he went to the hospital, he was gone over 24 hours and re-admitted with no oxygen order. Record review of Resident #22's nursing progress notes revealed that there was no pain assessment for chest pain of arm radiation, jaw pain or pain scale, In the morning of 6/20/2026 there was no oxygen saturation level performed, nitroglycerin tablets x3 were given, with no blood pressure documented and no lung sounds. LPN J stated that staff are to call her when sending a resident out to hospital, but she did not call me until she sent him,

Based on interview and record review, the facility failed to provide informed consent for psychotropic medication use for two residents (Resident #1, Resident #78) of five residents reviewed for psychotropic drug use, resulting in residents being unaware of the side effects of psychotropic medication. Findings include: Resident #1: On 6/29/2026, at 1:00 PM. a record review of Resident #1's electronic medical record revealed an admission on [DATE] with diagnoses that included Schizophrenia, Bipolar disorder and Diabetes Mellitus. Resident #1 required assistance with activities of daily living and had impaired cognition. A record review of the care plan (the resident) receives psychotropic medication (or psychotropic like medication) and is at risk for adverse side effects r/t (related to) antidepressant. Antipsychotic Date Initiated: 03/02/2026 . Interventions . Discuss with MD (doctor), family re ongoing need for use of medication, Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Date Initiated: 03/02/2026 . A review of the physician orders revealed risperidone Tablet 0.25 MG (milligrams) Give 1 tablet via PEG (stomach tube) . Active Start Date 1/26/2026,,, Mirtazapine Oral Tablet 15 MG . Give 1 tablet . Start Date 2/9/2026 End Date 4/3/2026 . Mirtazapine Oral Tablet 15 MG . Give 1.5 tablet . Start Date 4/3/2026 . A review of the electronic medical record revealed no informed consent for Risperidone (antipsychotic drug) and Mirtazapine (antidepressant). On 6/29/2026, at 2:32 PM, during an interview, Social Worker (SW) C was asked to provide documentation of informed consent for Resident #1's psychotropic medications. On 6/30/2026, at 10:46 AM, the facility failed to provide documentation for informed consent for Resident #1's psychotropic medications prior to exiting the survey Resident #78: Record review on 06/29/2026 at 2:52 PM of Resident #78's June Medication Administration Record (MAR) revealed medications of Buspirone 7.5mg oral twice daily for anxiety, start date 3/26/2026, Zoloft 25mg oral every day for depression, start date 2/26/2026. Zoloft 100mg oral every day for depression, start date 11/17/2025 and Namenda 10mg oral twice daily for Dementia start date 3/6/2024. The resident did receive the medications throughout the month of June 2026. Record review on 06/29/2026 at 2:54 PM of Resident #78's consent task in the miscellaneous medical record folder revealed: Zoloft 2024 no milligrams no consent, Zoloft 75mg no consent, Namenda no consent found and Buspirone no consent found. In an interview on 06/29/2026 at 3:12 PM, Social Worker C reviewed Resident #78's electronic medical record with the state surveyor and the consents. Buspirone (anti-anxiety) 7.5mg po BID for anxiety had no consent. Zoloft (antidepressant) consent was dated 2/2/2024 with no dose/milligrams on the consent and was for the diagnosis of dementia. There was a Zoloft 50 milligram consent dated 5/13/2024. The current Zoloft dose was 75mg which had no consent. Medication Namenda (central nervous system agent) 10mg by mouth twice daily and a start date 3/6/2024 had no consent found. Record review of the facility 'Psychotropic Medication Use' policy, dated 7/2/2025, revealed that psychotropic medications are drugs that affect mood, perception, behavior, or cognition including but not limited to antipsychotics, antidepressants, anxiolytics, mood stabilizers, and stimulants .Informed consent is a process ensuring the individual or legal representative understands the purpose, benefits, risks, and alternatives to the medication . Informed consent must be obtained and documented prior to initiation or an increase in dosage of psychotropic medication, including a discussion of risks, benefits and alternatives.

Based on interview and record review, the facility failed to have a current, correct Advance Directive for one resident (Resident #2) of three residents reviewed for Advance Directives. Resident #2: Record review on [DATE] at 9:53 AM of Resident #2's physician's order noted the order for full cardiac arrest/CPR code. Record review on [DATE] at 12:32 PM of Resident #2's care plans and record review of advanced directive care plan, dated [DATE], revealed Resident #2 wished to be a DNR- Do Not Resuscitate. Record review on [DATE] at 12:35 PM of Resident #2's advance directive paperwork for DNR- Do not resuscitate was dated [DATE]. An interview was conducted on [DATE] at 3:31 PM with Social Worker C on Resident #2's advance directive. A record review of the policy shows that a DNR needs a physician's order for a DNR-Do not resuscitate. Record reviewed with the state surveyor of Resident #2's physician's orders noted the resident's code status as a Full Code. The social worker stated that nobody wrote the order for DNR-Do not resuscitate, and that is a problem and we are addressing the issue. The admission coordinator was doing advanced directives, and nursing was to write the order. The resident went out to the hospital, and we need to re-do the advance directive. It is dated 2023. Record review of the facility 'Advance Directive' policy dated [DATE] revealed to ensure that each Resident's right to make decisions regarding their health care is respected and honored through the identification, documentation, review, and implementation of Advanced Directives in accordance with federal regulations, state laws and ethical standards of care. Do Not Resuscitate (DNR) is a valid medical order, issued by an authorized practitioner, directing that cardiopulmonary resuscitation shall not be initiated in the event of cardiac or respiratory arrest Advanced Directive orders shall be reviewed with a significant change in condition, upon transfer or readmission, during periodic care plan reviews

Based on observation, interview and record review, the facility failed to ensure professional standards of care were followed with accurate documentation in the medical record in regard to meal acceptance, fluid intake, and nighttime snacks when Resident #93 was NPO (nothing by mouth) and a physician's order for monitoring a Foley catheter urinary output was documented, for one resident (Resident #93) of one resident reviewed for activities of daily living.Findings include:Resident #93 (R93): On 6/29/26 at 9:29 AM, an observation was made of Resident 93 (R93) lying in bed. The head of the bed was elevated, and an observation was made of tube feeding infused by tube feeding pump. The Resident did not respond to her name, did not answer questions and did not engage in conversation. When asked to open her hands, the Resident did not respond by opening her hand. The Resident did not have a Foley catheter but there was an unopened Foley catheter in the bathroom inside a basin. A review of R93's medical record revealed an admission into the facility on 1/24/26 with diagnoses that included dementia, Alzheimer's disease, gastrostomy status, malnutrition, and delirium. Further review of the medical record revealed the Resident was NPO (nothing by mouth) and received a PEG (percutaneous Endoscopic Gastrostomy) tube (a tube placed in the stomach to administer nutrition and medications). A review of R93's tasks for documenting amounts eaten revealed a look back of 30 days of the task that had documentation of 16 meals consumed, multiple HS (nighttime) snacks given and amounts of fluids given revealed that the task was documented that the Resident was receiving oral fluids as well as snacks and meals. The task for bladder elimination revealed the task was to select the one category that best describes the resident with the choice of continent, incontinent, did not void, continence not related due to indwelling catheter. The Resident had an indwelling catheter until 6/23/26 when the Resident had a fall and the Foley catheter was pulled out and was not replaced. There were 33 documentations that the resident was continent or incontinent of urine and the continence not rated due to indwelling catheter was documented 34 times until 6/23/26 after the catheter was out.Further review of R93's medical record revealed an order with a start date on 5/28/26 Foley catheter care every shift, every shift document mL (milliliters) output in POC. There was a lack of documentation of the amount of urine emptied from the foley catheter on the Medication Administration record, Treatment Administration Record or in the Tasks. On 6/30/36 at 11:41 AM, an interview was conducted with Unit Manager, Nurse (UM) J regarding R93's care regarding documentation of the Resident eating, drinking, getting a HS snack and the lack of documentation of urinary output. The documentation in the Tasks for meals, snacks and fluids was reviewed with the UM. The UM reported R93 does not get pleasure trays or meals or anything by mouth. After reviewing the documentation, the UM indicated the documentation does not give a good representation of the resident's care. CNA Y came for an interview regarding documentation that the Resident had taken in oral intake. The CNA reported the resident does not drink or eat food and with review of the documentation, the CNA reported the documentation was not a good representation of the Resident and stated, It looks like she eats. The CNA indicated her documentation was marked in error, that was a mistake. Further review with the UM revealed the foley catheter output should have been documented, but the UM was unable to find documentation of the output from the Foley catheter when the Resident had the catheter in. On 6/30/26 at 12:30 PM, an interview was conducted with the Director of Nursing (DON) regarding R93 lack of accurate documentation of food and fluid acceptance, nighttime snacks and the lack of documentation of the Foley catheter urinary output. The DON reviewed the documentation and was unable to find documentation of the urinary output. The Task documentation was reviewed with the DON. The DON stated, She does not eat. This shows that they are just marking it, inaccurate documentation.

Based on observation, interview and record review, the facility failed to provide unexpired eye drops to one resident (Resident #4) of five residents reviewed during medication administration. Findings include:Resident #4: On [DATE], at 9:43 AM, During medication administration, Nurse B prepared medications for Resident #4. Nurse B administered the Brinzolamide-Brimonidine Ophthalmic Suspension eye drop to each one of Resident #4's eyes. Upon return to the medication cart, Nurse B placed the eye drop into the container. The container was noted to have an open date of 5-28 hand-written on the outside of the container. Nurse B was asked if the eye drops were expired and Nurse B stated, no. A record review of the facility expired medication list located on the medication cart revealed the eye drop above was not listed. On [DATE], at 10:04 AM, Nurse A was alerted Nurse B administered expired eye drops to Resident #4. Nurse A was asked if the eye drops were expired and Nurse A reviewed the expired medication list on the cart which revealed the eye drops were not listed. On [DATE]l, at 10:10 AM, Nurse A called the pharmacy and spoke with Pharmacy technician D via speakerphone. Pharmacy technician D was asked what the expiration date would be for the Brimonidine eye drops and pharmacy technician D stated, they are good for 28 days after the day they are opened. A review of the facility provided MEDICATION ADMINISTRATION POLICY revealed Medications are administered by license nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . identify expiration date and discard if necessary and replace medication .

Based on observation, interview and record review, the facility failed to provide clean and sanitary medication passes for two residents (Resident #44, Resident #91) of five residents reviewed for medication pass and failed to maintain an indwelling catheter in a sanitary fashion for one resident (Resident #9). Findings include. Resident #9 (R9): R9 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include obstructive uropathy, adjustment disorder with anxiety, chronic respiratory failure and emphysema. On 06/28/2026 at 10:37AM, observation revealed the urine collection bag for the indwelling catheter is hanging on the garbage can and touching the floor. R9 was asked why the urine collection bag was placed there. R9 stated that the staff put it there sometimes. On 06/29/2026 at 10:48AM, observation revealed the urine collection bag is hanging on the garbage can and touching the floor. Observation revealed R9's oxygen tubing is underneath the urine collection bag as well. On 06/29/2026 at 10:49AM, an interview was conducted with Certified Nursing Assistant (CNA) Z. CNA Z was asked if the urine collection bag should be hanging from the garbage can and touching the floor. CNA Z stated I don't know, I usually hang it on the bottom bed rail when I hang it. CNA Z exited the room and did not move the catheter bag off the garbage can. Review of the policy titled, Indwelling Catheter, revealed: Procedure: 4. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: d. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. Resident #91: On 6/29/2026, at 9:09 AM, Nurse B prepared the items needed for a blood glucose meter test for Resident #91. Once the test was completed, Nurse B walked to their medication cart, opened the top drawer, pulled out an alcohol swab and wiped the glucose meter with the alcohol swab. Nurse B placed the glucometer in the top drawer of the medication cart. On 6/29/2026, at 9:50 AM, During medication administration task with Nurse A, was observed locking their medication drawer leaving the area to locate a medication in the back up. Once Nurse A returned to the medication cart, they opened it and continued to gather medications, entered room [ROOM NUMBER] and administered medications to the resident without performing hand hygiene. Resident #44: On 6/29/2026, at 10:24 AM, Nurse A returned to the medication cart and began to prepare medications for Resident #44. Nurse A was noted to punch out the medications form the cartridges in a quick manner. Nurse A was asked how they were able to punch out the pills from the cartridges so quickly and Nurse A stated, I pierce them with my nail. Nurse A administered Resident #44 medications, returned to their medication cart and grabbed a plastic medication cup on the inside. Nurse A opened a multi-use bottle of medications, and stuck their thumb nail inside the bottle to pull out a tablet. On 6/30/2026, at 11:24 AM, During infection control task, Infection Control (IC) Nurse F was alerted of observations during medication administration task. IC Nurse F provided, we use bleach wipes for the glucometers and the nurses need to wash hands before and after medication pass. IC Nurse F was alerted of how Nurse A explained that they use their nail to punch out the medication and IC Nurse F planned to education. A review of the facility provided MEDICATION ADMINISTRATION POLICY revealed Medications are administered by license nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . perform hand hygiene prior to administering medications per facility protocol . perform hand hygiene after administration per facility protocol .

Based on observation, interview and record review, the facility failed to post the actual hours worked for the licensed and unlicensed nursing staff including Registered Nurses, Licensed Nurses and nursing assistants. In an observation on 06/28/2026 at 9:30AM upon survey entrance, surveyors observed the public posting of direct care daily staff numbers located in the main entrance hallway posted on the wall in a clear plastic display. The form was dated 6/26/2026. In an interview and record review on 06/30/2026 at 12:09 PM, Human Resource staff K stated that the charge nurse is to post the daily direct care staffing hours for weekends. Record review of the beginning survey daily Staff posting was date 6/26/2026 upon survey entrance date of 6/28/2026. In an interview and record review on 06/30/2026 at 12:21 PM, the Director of Nursing (DON) stated that the daily weekend staffing posted public in the hallway is to be posted by the charge nurse on duty for the weekend and that the Facility Payroll Based journal (PBJ) is submitted at the corporate level. Record review of the facility 'Posting Direct Care Daily Staffing Numbers' policy, dated 7/2016, revealed the facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on interview and record review, the facility failed to ensure that ophthalmic eye drops, Latanoprost, was ordered and administered following the Doctor of Optometry's order for the eye drops after the Resident's eye exam in January 2026, for one resident (Resident #70) of one resident reviewed for vision care. Findings include:Resident #70: On 6/30/26 at about 11:55 AM, Resident 70 stopped the surveyor in the hallway. The Resident was visibly upset and reported she had her vision appointment. The Resident reported that she was supposed to be getting an eyedrop prescription that had been ordered after her last vision appointment in January. The Resident indicated it was not for artificial tears but they were to help with her glaucoma. I didn't know I was supposed to be getting them. They should have ordered them back in January. It could help my eyesight, help with the glaucoma, and indicated she was fearful of losing her vision. On 6/30/26 at 12:05 PM, an interview was conducted with Doctor of Optometry, Dr. U regarding the procedure of ordering medications for Residents after being seen by the vision care. The Doctor explained that if the Resident was seen prior and the Residents were to have a prescription for eye drops, they would ask the Resident if they were receiving them, if not then the Resident could ask for them and the facility would get the another prescription for the eye drops. The Doctor reported that the orders go in electronically and then they send them to the Nurse Manager or Director of Nursing. The Doctor was asked about the prescription medicated eye drops Latanoprost. The Doctor reported that the eye drops were used to decrease the pressure in the eye that would help prevent vision loss. On 6/30/26 at 12:40 PM, an interview was held with the Director of Nursing (DON) and a review of the Resident's order in the medical record dated 1/20/26, for Resident 70, revealed, Medication Prescribed Today, Medication latanoprost 0.005% eye drops, instill 1 drop by ophthalmic route every bedtime into both eyes in the evening for glaucoma, with a start date 01/20/2026, with a signature of Dr. U . The DON reported she did not know why it was not ordered that it could be it was not continued when she came back from the hospital. The Resident's orders and discontinued orders were reviewed, and the Medication Administration Records were reviewed. The DON stated, No order was ever placed, and reported she would look in to see why it was not ordered. If it was not ordered, the DON was asked if there was a risk versus benefit documentation, but it was not found in the resident's medical record.

Based on observation, interview and records review, the facility failed to maintain supervision of one resident (Resident #81) who was vaping in the facility, which is a non-smoking facility, of 3 residents reviewed for potential accidents. Resident #81: In an observation on 06/30/2026 at 8:02 AM, Resident #81 was observed vaping in the small lounge room. The state surveyor observed smoke in the room, with no staff present. Resident #81 was up in wheelchair at a table with a breakfast meal. The surveyor observed smoke in the air and entered the room to see Resident #81 vaping in the room. The state surveyor requested Certified Nurse Assistant (CNA) I seated at nursing station into lounge with the surveyor. She said that she smelled strong vape odors and smoke and stated so. In an interview on 06/30/2026 at 8:04 AM, Certified Nurse Assistant (CNA) I stated that they/residents are not supposed to vape in the building. Certified Nurse Assistant (CNA) I stated that she told Licensed Practical Nurse (LPN) E, who isthe resident's nurse. In an interview on 06/30/2026 at 8:05 AM with Licensed Practical Nurse (LPN) E while at the medication cart in the Med=Bridge hallway, the state surveyor walked with LPN E into the lounge to get the vape pen from Resident #81. The state surveyor observed that it is a blue vape pen, blueberry and banana flavored. An interview on 06/30/2026 at 8:35 AM with the Director of Nursing (DON) revealed that Resident 81's sister brings the vape pens into him and that the facility has caught the resident with a vape pen before this incident. The DON stated that she gave it to the wife the last time. The DON stated that We are non-smoking facility and there is a no smoking/vape policy. In an interview on 06/30/2026 at 10:52 AM, Licensed Practical Nurse (LPN) J stated she was told the state caught Resident #81 vaping in the small lounge, and that the staff was notifirf and Licensed Practical Nurse (LPN) E went and confiscated the vape pen. LPN J called the wife. The social worker went into educate the resident. Record review of the facility's 'Non-Smoking Facility' survey entrance notification statement noted that the facility is a no-smoking facility. Record review of Resident #81's nursing progress note, dated 6/30/2026 at 8:13AM, stated that the resident was observed utilizing what appeared to be a vape pen. Nursing staff were notified immediately. The assigned nurse approached the resident, requested the device and reminded the resident that the facility is a no-smoking environment Record review of the facility 'Safe & Homelike Environment' policy, dated 11/7/2025, revealed the purpose was to provide a safe, clean, comfortable and homelike environment that supports resident independence, enables the use of personal belongings, and ensures the delivery of care and services in a manner that minimizes safety risks and promotes well-being.

This Citation pertains to Intake Number 2997914.Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place to provide a safe and monitored environment to prevent falls with injuries for 3 residents (Resident #1, Resident #4, Resident #5) of 3 resident reviewed for falls, resulting in Residents #1, #4 and #5 repeatedly falling, hitting their heads and sustaining injuries. Findings Include: FallsResident #1:A record review of the Face sheet and Minimum Data Set/MDS indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: History of Traumatic Brain Injury, history of falls, dementia, diabetes, depression, and heart failure. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 1/15 and the resident needed assistance with all care.Further review of the MDS assessment revealed Section J: Health Conditions said Resident #1 had 2 or more falls since admission to the facility.On 5/20/2026 at 2:00 PM, the Director of Nursing was asked about Resident #1's history of falls and she said he had a few falls. The Incident and Accident reports for Resident #1 were requested.During a review of the Incident and Accident reports for Resident #1 it indicated that the resident had fallen 16 times since January 2026: 1/21/2926, 2/9/2026, 2/10/2026, 2/14/2026, 2/17/2026, 2/19/2026, 2/21/2026, 2/28/2026, 3/6/2026, 3/8/2026, 3/14/2026, 3/27/2026, 4/3/2026, 4/22/2026, 5/2/2026, 5/2/2026, 5/12/2026.Of the 16 falls Resident #1 sustained, he hit his head 6 times. On 2/17/2026 at 9:50 AM the resident fell in the hallway and per a progress note . hit head hard on floor with instant large hematoma with bleeding. (ambulance) contacted, arrived and left with pt (patient) around 1020.).A progress note dated 2/17/2026 at 5:08 PM provided, Pt returned back to facility by (ambulance) around 1545 (3:45 PM) . Pt received 3 staples to back of head (at hospital) .A physician progress note dated 3/3/2026 at 7:05 AM, revealed . Resident noted to have frequent falls per staff report. Recently evaluated in emergency department following fall from standing with scalp laceration requiring three staples. Staff monitoring closely due to fall risk and cognitive impairment.Three days later, Resident #1 was transferred to the hospital on 3/6/2026 after falling and hitting his head. A progress note dated 3/6/2026 at 10:32 PM provided, Resident was found on the floor holding side of head. Resident stated he was trying to go to the bathroom and lost balance and fell.3/6/2026 at 10:57 PM, a SBAR Summary note . resident was holding side of head by right ear and holding right hip. New Testing Orders: X-ray, CT scan.3/7/2026 at 2:24 PM, a progress note, Pt arrived back from hospital around 0730, CT and x-ray were clear.3/7/2026 at 4:05 PM, Focused charting, Post fall. Pt requires supervision and redirection, consistently attempt to stand or walk from his w/c (wheelchair), pt is unstable and high fall risk.3/8/2026 at 1:31 PM Focused charting, Post fall. Resident requires supervision as he constantly tires to get up from his w/c and is a high fall risk.4/22/2026 at 7:00 PM, a progress note Patient noted lying on the floor in front of nurses station. Patient alert and not giving reason why is on the floor but stating yes did hit his head. small abrasion on left elbow.5/4/2026 at 9:41 AM, an IDT (Interdisciplinary Team) note, IDT met to review resident sliding out of wheelchair. Resident is very unpredictable and continues to attempt to self-transfer.5/13/2026 3:53 PM, IDT note, IDT met to review resident recent fall. Resident was sitting at the nurse's station and talking with staff. Nurse was charting at desk and was alerted by noise, and resident was observed on floor.A review of the Neurological assessments/Neuros that were completed by the nurse if it was suspected a resident may have hit their head or hit their head, identified 6 sets of Neuro checks to correspond with some of the falls Resident #1 had sustained: 2/14/2026, 2/21/2026, 3/8/2026, 4/3/2026, 4/22/2026 and 5/3/2026. Five of the Neurological assessments were incomplete. Some were missing vital signs. Some were missing the neurological testing, and some were missing all of it for several days. There was no consistent assessment and monitoring to identify a neurological change in condition for Resident #1.On 5/20/2026 at 2:26 PM, Resident #1 was observed sitting in a wheelchair near the nurses desk on the Central unit. He began to lean forward and his head was bobbing, as if he was falling asleep. Nurse D was asked if the resident layed down in the afternoon and she said he would try to get out of bed if he layed down and that was why he was sitting at the nurses station. Nurse D asked the resident if he was tired and he wanted to lay down and he said Yes. The nurse was assisted by a nurse aide to transfer the resident to his bed. He was weak and had difficulty standing and following directions to sit down on the bed. On 5/20/2026 at 3:15 PM, Nurse D said Resident #1 had his brief changed and was provided with a nutritional supplement then he went to sleep. Per a progress note dated 5/20/2026 at 6:10 PM, Resident was at the nurses station half the day, had to be redirected to sit a few times. About 1500 (3:00 PM) resident was fed, changed and helped to bed. Resident sleep until dinner.On 5/21/2026 at 10:27 AM, Confidential Person K was interviewed about Resident #1 and said Resident #1 had fallen and had a huge knot on the back of his head on the left corner. During the interview, Confidential Person K stated, There would be 15-16 residents to 1 Aide on the afternoon shift. It was too much.On 5/21/2026 at 1:23 PM, Confidential Person L was interviewed and said Resident #1 had multiple falls. The Confidential Person L said there was no clear Care Plan and the resident had declined further, They said they would keep an eye on him, but he kept falling. The Confidential Person L said the resident couldn't feed himself and was barely eating his food, I think he just got weaker and doesn't have the strength to get up.A review of the Care Plans for Resident #1 identified the following: (Resident #1) is at risk for falls or fall related injury r/t (related to) incontinence, cardiac, psychotropic, antidepressant, and anticonvulsant medication use, history of falls, date initiated 11/20/2026 and revised 4/28/2026 with Interventions including: q (every) 15 min (minute) checks, date initiated 3/9/2026 and q 15 minute checks for 24 hours, dated initiated 4/23/2026 and revised 4/23/2026. There were no additional interventions related to monitoring/supervising the resident to prevent falls.A review of the 15 minute checks documentation for Resident #1 identified three documents titled 15 Minute Check and Chart and none were dated: One document indicated the resident was at the Nurses Station/NS from 6:30 AM until 11:30 AM. There was no documentation that the resident ate between 6:00 AM- 6:00 PM. There was one entry, Anxious: brief change. There were no additional entries that the resident was provided with assistance with toileting.Another document indicated that the resident was in the hallway from 6:45 AM until 9:15 AM and then was in bed from 9:15 AM until 6:00 PM. There was no indication the resident ate during that timeframe. There was documentation that the resident's brief was changed twice from 6:45 AM until 6:00 PM.The last document was from 6:00 AM until 10:15 AM and indicated the resident was at the nurse's station from 6:15 AM until 10:15 AM and was assisted with toileting at 8:15 AM. The remainder of the document was blank.Resident #4:A record review of the Face sheet and MDS assessment indicated Resident #4 was readmitted to the facility on [DATE] and on 1/6/2026 with diagnoses: Alzheimer's Dementia, depression, anxiety, psychosis, heart failure, epilepsy, COPD, and Pulmonary fibrosis. The MDS assessment dated [DATE] revealed the resident had cognitive decline, needed assistance with care and had experienced two or more falls with injury since admission. The resident was discharge to the hospital on 4/24/2026 with a change of condition.A record review of the Incident and Accident reports for Resident #4 identified the resident had fallen 6 times from January 2026 through April 25, 2026: 1/2/2026, 1/3/2026, 1/4/2026, 1/12/2026, 1/22/2026, and 2/28/2026.On 1/2/2026 the Incident Report for Resident #4 revealed that she was sedated and had attempted to get up multiple times during the night. The resident was confused, and her left hand was slightly reddened.On 1/3/2026 the resident's roommate alerted the staff that Resident #4 had fallen. She sustained an abrasion to her right cheek and a golf ball sized hematoma on her right forehead.On 1/4/2026 Resident #4 was tried to stand in the hallway and fell. She obtained a hematoma on the left side of her forehead.On 1/12/2026 the resident's roommate used the call light to let the staff know Resident #4 was in the bathroom by herself. She was found on the floor and she said she hit her head.On 1/22/2026, Resident #4 was found on the floor beside her bed. 15 minute checks were implemented.On 2/28/2026 Resident #4 was found on the floor by her bed.Resident #4 was transferred to the hospital from the facility on 1/5/2026 after falling on 1/4/2026 at the facility. She was treated for a head injury and contusion/bruise to the left knee per the Hospital discharge instructions. A history of X-rays in the hospital notes indicated on 12/25/2025 the resident had sustained a right wrist fracture.Resident #4 hit her head during a fall 3 times: 1/3/2026, 1/4/2026 and 1/12/2026. A review of the Neuro checks for the resident indicated Neuro assessments for 1/12/2026 and 1/22/2026. Both sets of Neuro assessments were incomplete.A 15 Minute Check and Chart document for Resident #4 was undated. It was timed 12:30 PM until 6:00 PM. The document indicated she was in her room in bed sleeping for part of the time and at the nurses desk awake for the rest of the time. No further information. There were no additional 15 minute check documents.A review of the Care Plans for Resident #4 identified the following: (Resident #4) is at risk for falls or fall related injury r/t (related to) impaired balance, impaired cognition, poor safety awareness, vision problems, epilepsy, anxiety, psychotropic medication use, incontinence, history of falls including recent fall which resulted in right wrist fracture, date initiated 12/3/2025 and revised 1/7/2026 with Interventions including: Room move for increased supervision for safety, date initiated 1/13/2026. The resident had already fallen 4 times and sustained 2 head injuries. There were no additional interventions for monitoring and supervision. Her Care Plans were not reviewed after she fell on 1/2/2026 and 1/3/2026. After she fell on 1/4/2026 the Care Plans were reviewed and updated with a perimeter mattress. Resident #5:A record review of the Face sheet and MDS assessment indicated Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's Dementia, history of a stroke, heart disease, depression, anxiety, epilepsy, and arthritis. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a BIMS score of 6/15, needed assistance with care and had at least 2 falls since admission, including a fall with injury.A review of the Incident and Accident Reports for Resident #5 indicated the resident had 3 falls from January 2026 through April 2026: 1/25/2026, 2/3/2026 and 4/24/2026.On 1/25/2026 the resident was found on the floor in her room.On 2/3/2026 the resident was found in the bathroom trying to sit back into her wheelchair. She said she fell and hit her face on the sink. There was redness and a skin tear to the right side of her face. Neuro checks and 15 minute checks were initiated.On 4/24/2026 the resident fell while trying to sit in her wheelchair.A review of the Neuro checks identified a document for 4/24/2026 with incomplete assessment.An X-ray of the sacrum and coccyx was completed for Resident #5 on 4/25/2026 due to complaints of pain after falling.A review of the Care Plans for Resident #5 revealed the following: (Resident #5) is at risk for falls or fall related injury r/t decreased mobility/weakness, impaired cognition, unsteady gait, incontinence, psychotropic & opioid medication use, epilepsy, poor safety awareness. She has a history of falls including a fall that resulted in a clavicle fracture, date initiated 9/12/2025 and revised 10/22/2025 with Interventions including: Increase frequency of rounding, date initiated 11/21/2025.On 5/21/2026 at 9:30 AM, the Director of Nursing/DON was interviewed about the falls with injury that Residents' #1, #4 and #5 sustained. She said the staff were performing 15 minute checks at times, because each resident had repeated falls. Reviewed that Resident #1 had 16 falls with multiple instances of hitting his head and sustaining injuries while at the facility, as well as Residents #4 and #5. Reviewed with the DON that 15 minute checks were not consistently implemented and Neuro checks were incomplete. The DON said she thought everything had been tried to prevent the residents falls. The DON was asked about closer monitoring, staffing or 1:1 monitoring and she said sometimes a Respite care outside person would come in and spend time with the residents, but it was not on a regular basis. Reviewed staffing on the Central hall where Residents #1, #4 and #5 resided and the DON said there were usually 3 or 4 nurse aides on the hall. On 5/20/2026 the first day of survey there were 3 nurse aides and on 5/21/2026 the 2nd day of survey there were 4 nurse aides; she said there were usually 2 nurses on the hall also. The DON was asked if the residents were more closely monitored when there were 4 nurse aides, as some staff indicated one staff member could more closely monitor and work with the residents who were prone to falls when there were 4 nurse aides. The DON said they did sometimes do that.A review of the facility policy titled, Fall Prevention dated approved 12/12/2023 provided, Each Person will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. Increased frequency of rounds. Sitter, if indicated. Interventions will be monitored for effectiveness.

This Citation pertains to Intake Number 2997914. Based on observation, interview and record review the facility failed to ensure that interventions were enacted to promote nutrition and prevent weight loss for one resident (Resident #1) of 1 resident reviewed for food or nutrition, resulting in Resident #1 experiencing significant weight loss without identification and access to favored foods. Findings Include: Resident #1:A record review of the Face sheet and Minimum Data Set/MDS indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: History of Traumatic Brain Injury, history of falls, dementia, diabetes, depression, and heart failure. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status (BIMS) score of 1/15 and the resident needed assistance with all care.On 5/20/2026 at 2:26 PM, Resident #1 was observed sitting in a wheelchair near the nurses' desk on the Central Unit. He began to lean forward and his head was bobbing, as if he was falling asleep. Nurse D was asked if the resident layed down in the afternoon and she said he would try to get out of bed if he layed down and that was why he was sitting at the nurses' station. Nurse D asked the resident if he was tired and if he wanted to lay down and he said Yes. The nurse was assisted by a nurse aide to transfer the resident to his bed. He was weak and had difficulty standing and following directions to sit down on the bed. The resident appeared very thin.On 5/20/2026 at 3:15 PM, Nurse D said Resident #1 had his brief changed and was provided with a nutritional supplement then he went to sleep. Per a progress note dated 5/20/2026 at 6:10 PM, Resident was at the nurses' station half the day, had to be redirected to sit a few times. About 1500 (3:00 PM) resident was fed, changed and helped to bed. Resident (slept) until dinner.A review of the Weight Summary for Resident #1 from January 15, 2026, to May 19, 2026 revealed Resident #1 had lost 14.2 lbs. He weighed 108.6 lbs. on January 15, 2026, and 94.4 lbs. on May 19, 2026. For 3 months from February 24, 2026, to May 19, 2026, the resident lost 13.1 lbs. 12.2% weight. For 30 days from April 15, 2026, to May 19, 2026, the resident lost 6.6 lbs./6.5%.A review of the documentation in the electronic medical record (EMR) Task: Nutrition- Amount Eaten from April 22, 2026, to May 20, 2026, identified the following:6 meals the resident ate 26-50%.3 meals the resident ate 0-25%.35 meals were 51-75%41 meals were 76-100%More recently since May 2026 the resident began eating less. On 5/21/2026 at 1:23 PM, during an interview, Confidential Person L stated that they said the resident couldn't feed himself and was barely eating his food, I think he just got weaker and doesn't have the strength to get up. The Confidential Person L said he used to bring the resident food and he really liked it. The Confidential Person said the resident ate the food, but a staff member told the Confidential Person the outside food wasn't good for the resident, and they no longer brought him in food. He said they would bring food the resident liked, such as burritos, because he wasn't eating the food at the facility as well. The Confidential Person said the resident had lost more weight. He said the resident lost his dentures at the facility and they had not been replaced. He was not sure what the facilities plan for replacing the dentures was.A review of the Resident Care Team Review, dated 5/6/2026, identified Weight Loss: Weight Change: a. Significant. There was no mention that the resident's dentures were missing.On 5/21/2026 at 2:00 PM, during an interview Registered Dietitian/RD M stated that she had been monitoring Resident #1 for weight loss. She said he had diabetes and sometimes his blood sugars were high, but he needed to eat more so she had added extra protein to his meals, in addition to other interventions. She said he ate better with finger foods. Reviewed with the RD M that the resident no longer had food that he enjoyed brought in from outside the facility, because someone told the family not to bring it in. The RD said she was not aware of that and asked how long it had been since he had the extra food; reviewed with her it had been greater than a month. The RD said she would check with the family to see what else the resident preferred and what he could have brought in that he would like to eat.A review of the Care Plans for Resident #1 identified the following: (Resident #1) presents with potential for nutritional risk related to recent bilateral subdural hematomas/brain bleed. (Diagnoses: diabetes, hypertension, high cholesterol, Traumatic brain injury). Therapeutic diet liberalized r/t weight loss. Supplements ordered for weight increase. Appetite stimulant. Good oral intake/appetite now but continued weight loss, date initiated 11/26/2026 and revised 4/29/2026 with Interventions including: Honor food/fluid preferences as possible, date initiated 11/26/2025. The Care Plan did not mention that the resident ate better with finger foods.A review of the facility policy titled, Nutrition Assessment, date effective 8/1/2025, stated, Purpose: To identify and accommodate the individual dietary needs and preferences of each resident/patient.

This citation pertains to Intake Number 2574995.Based on observation, interview, and record review, the facility failed to provide the appropriate skin care interventions to prevent the development of pressure ulcers and promote healing consistent with professional standards for one resident (R103) of four sampled residents reviewed for pressure ulcers, resulting in a delay in treatment and healing, worsening of newly developed wounds, infection and further complications. Findings Include:Resident #103 (R103) A review of R103 Electronic Medical Record (EMR) was conducted on August 22, 2025, at 3:30 PM. According to the clinical record, R103 was [AGE] years old, admitted to the facility on [DATE], with the diagnosis of laceration of the scalp, Cerebral Palsy, Obstructive Hydrocephalus, and Epilepsy in addition to other diagnoses. R103's Brief Interview for Mental Status (BIMS) Score, assessed on June 27, 2025, was left as zero or 99, indicating that the patient was unable to complete the interview for the assessment. Minimum Data Set (MDS) section GG dated July 1.2025, indicated that R103 is dependent on staff with all Activities of Daily Living (ADLs), including but not limited to eating, toileting, showers, and personal hygiene. R103 relied on one to two staff members for transferring to and from the chair and bed, as well as rolling in bed from side to side, and using the toilet.General Progress Notes dated 8/8/25, at 9:26 AM, was reviewed, Noted text: Resident's wound has foul odor, and had a temp of 99.1 last evening. Dr K (Last name mentioned) informed and new order received to start Bactrim DS BID (Twice a day) for 7 days. Orders Noted.A review of R103's Care Plan indicated:ADLs Care plan initiated on 6/24/25, revealing the need for assistance with incontinence care, mobility, showers, personal hygiene, toilet use, and transfers. R103 also required one-on-one assistance with feeding. R103 was assessed as a two-person assist using a Hoyer lift.A care plan for Risk of skin breakdown r/t (related to) impaired mobility, contractures, and incontinence indicated that R103 had scarring from previous pressure ulcers to the coccyx and left outer ankle. There was no active open skin breakdown noted upon admission skin assessment on 6/24/25.R103 has impaired skin integrity: Pressure ulcer to coccyx, and wounds to ischium and left heel related to mobility, contractures to lower extremity, incontinence of bowel and bladder. Initiated on 6/24/25, revision date: 8/8/25.Goal: 1.) Tissue injury will improve and be free from complications with a revised date of 8/8/2025.Note: A wound treatment intervention was initiated in R103's care plan on July 16, 2025.The following were R103's recorded Skin Assessment and Condition from admission to discharge (June 23, 2025, to discharge date on August 8, 2025: According to the Skin assessment dated [DATE], upon admission). Staff assessed by: UnknownStaples on top of R103's head from a previous history of scalp lacerationLeft trochanter hip (closed wound)Left outer ankle (closed wound)Coccyx-Scar tissue with surrounding dark soft tissue DTI (Deep Tissue Injury)Treatment applied: No. A review of the admission Skin Evaluation revealed that it was dated on 6/23/25, but was locked and signed until July 6, 2025. It was unknown who the nurse who did the assessments on June 23rd and who the staff member who locked the assessment in July 6th. The Director of Nursing and the wound Nurse was asked subsequently but no staff member could verify the accuracy of the findings during the surveyor's review on August 22, 2025, at 4:30 PM. The Weekly Skin Evaluation Forms were reviewed on 8/22/2025 at 4:30 PM. It indicated:06/30/25 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO07/07/25 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO07/14/25 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO07/21/25 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO07/28/2025 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO08/04/2025 A. Skin Evaluation: 1. After completing a head-to-toe skin assessment, are there any new skin areas? NO A review of R103's Skin assessment dated [DATE], (noted: this is R103 discharged date from the facility) revealed:Coccyx (UTD)- UTD means unstageable or unknown depth.Measurement size: 7.5 X 7.0 X depth UTD with eschar 1 00 % wound filled, heavy exudate, purulent drainage. Noted erythema described as intense bright red, dark red, or purple. 2. Left Heel-(acquired in house on 7/16/25)Measurement size: 3.5 X3.5 X depth (UTD) unstageable or unknown depth100% wound filled slough with a light amount of exudate described as purulent discharge 3. Left Ischium (acquired at the facility, first observed on 7/31/25, described as shearing and UTD (Unstageable Full Thickness or Tissue Loss)Measurement size: 3.0 cm (centimeters) X 3.2 cm x depth UTD, Slough 100% wound filled slough with a light amount of purulent drainage. A review of R103's skin record and treatment orders revealed:Physician's orders: From 6/23/25 (admission date) through 8/8/25 (discharge date ):Coccyx: Order Start Date: 7/6/26: Cleanse with cleanser, pat dry, apply calcium alginate to the wound bed, and cover with a wound dressing as needed, daily. Order Discontinued Date: 8/8/25Left Heel: Left heel wound was first discovered on 7/15/25. Physician's Order Start Date 7/29/25: Cleanse with wound cleanser, pat dry, apply calcium Alginate to wound bed, cover with foam dressing daily and as needed (PRN). Order Discontinued Date: 08/08/2025Left Ischium: Order Start Date: 8/8/25: Cleanse left Ischium with NS, cover with comfort foam, change qd and PRN every day shift for wound A review of R103's Treatment orders revealed:Date ordered: 6/23/25, Started on 6/24/25: Apply House Barrier cream to (B) Buttocks, coccyx, and peri-area every shift with incontinent episodes. Frequency: every shift and PRN (as needed)Date ordered: 8/8/25. Start Date: 8/8/25. Cleanse coccyx with NS (Normal Saline). Apply moistened gauze with Dakins Solution 1/4 strength pack to the wound. Cover with sacral dressing, changing BID and PRN (as needed) twice a day for wound care.Order Date: 8/8/25, and Start Date: 8/8/25: Cleanse Left Heel with NS, apply Medihoney topically, and cover with comfort foam, changing qd (daily) and PRN (as needed).Order Date 8/8/25 and started 8/8/25: Cleanse Left Ischium with NS, apply medihoney, cover with comfort foam, change qd and PRN. Every day shift for the wound. No treatment to the Left Ischium was ordered, despite being observed and assessed on 7/31/25, with an open area 2.8 cm (length) X 2.6 cm (width) X 0 depth with a light serous drainage.Order started on 7/22/25, Enhance Barrier Precautions when engaging in high-contact resident care activities for chronic wounds every shift.Order started on 8/8/25 - Bactrim DS oral Tablet 800-160 mg (Sulfamethoxazole-Trimethoprim). Give one (1) tablet by mouth two times a day for wound infection until 8/14/25 Treatment Administration Record (TAR) for R103 was reviewed, and it was found that missed treatments and assessments were as follows: Missed Treatment in July 2025 was noted below:- Weekly Skin Assessment (every Tuesday)= missing on 7/15/25- House Barrier cream to (B) Buttocks, coccyx, and Peri-Area every shift with an incontinence episode. There were no record of 7/13/25 (Days), 7/20/25 (Days), and 7/21/25 (Days)- Left Heel= 7/18/25 & 7/28/25 Coded 2 (Refused)-Coccyx= 7/13/25, 7/15/25, 7/20/25, and 7/21/25 did not indicate that the treatment was done. 7/18/25 and 7/28/25 were coded as 2 (Refuse)- No treatment to the Left Ischium was ordered despite the 7/31/25 assessment with an open area 2.8 cm (length) X 2.6 cm (width) X 0 depth with a light serous drainage Missed Treatment in August 2025, were noted below: Sunday, August 3, 2025: No treatment was administered to the Coccyx, Left Heel, and House barrier cream was not applied as ordered.An interview with the previous wound care Nurse, H, was conducted on August 21, 2025, at 1:15 PM. Nurse H admitted that she was the Wound nurse during 6/19/25 through 7/31/25. She was assigned the evening shift as a Unit Manager (Nights). She recalled that R103 did not have any open area when she was admitted . R103 had some noticeable scars from a previous injury at the coccyx area that had healed. She explained that, We noticed the same area developed discoloration and later opened up as described on the 7/10/25 assessment as a deep tissue injury (DTI). Stage 3 pressure sore on the coccyx measurement: 6.2 cm (Length) X 7.9 cm (Width) X zero (Depth). It had moderate serosanguineous drainage. Nurse H was an LPN and was a certified wound nurse. She stated that she was unaware of a newly developed open area on the left heel, which was first noted on July 15, 2025. The Director of Nursing conducted the initial assessment, but no one had informed me about the newly opened area. I was unaware of the left heel, so during the 7/17/25 evaluation, I was unable to reassess the wound on the left heel. So, on the 7/17/25 assessment I did, it did not include the left heel, because I did not get a report from a nurse aid or nurses. When asked about the Left Ischium open area, she confirmed she assessed a newly developed open area located at the left ischium described as another site that measured 2.8 cm (Length), 2.6 cm (width) X zero depth, denuded (loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate, or friction. Not sure what happened, but we were putting treatment on the wound, but it was not recorded. We applied the same treatment as the coccyx, considering the wound as extending from the coccyx; however, this was not documented in the doctor's order or recorded. There was no treatment order from the doctor obtained for the Left ischium. Nurses don't do wound rounds with the doctors. No one was assigned to rounds with the doctor. Doctors do their own assessment and evaluation.An interview with the current Wound Nurse M was conducted on 8/20/25 at 4:20 PM. Nurse M indicated she started working as a wound nurse at the facility on 8/4/25. Nurse M revealed that she is an LPN with wound certification. She admitted that she vaguely remembers R103. But reviewing the assessment done on 8/8/25, before R103's discharge, Nurse M mentioned that the wound in the coccyx was infected with a purulent heavy drainage and foul odor. The physician was called, and oral antibiotics were ordered immediately. An interview with the Director of Nursing (DON) was conducted on August 20, 2025, at 4:30 PM. She revealed that R103 was discharged on 8/8/25 to a new foster care home. He stayed with us from 6/23/25 to 8/8/25 for short-term rehab and for new home placement. There was a question about previous foster care, and because of physical violence, he needed a new placement. R103 had mental incapacity- he was struck on the head. On 7/15/25, during therapy, they stated they found shearing on the Left outer heel. The Therapist (PTA) found it during the therapy session. The DON admitted that the left heel wound developed and was acquired at the facility. She further stated: The hospital records did not mention any open area or DTI in R103's hospital Discharge summary dated [DATE]. On August 8, the physician prescribed oral antibiotics because his wounds were infected. On the same day, R103 was discharged because a bed opened up, and was immediately discharged to the community. He started with only one dose. An interview with the PTA staff B was conducted on 8/21/25 at 10:30 AM. PTA staff B stated, R103 was at the rehab gym on his [NAME] chair, doing R103's stretches when I noticed the sock was damp. I immediately removed the sock on his left foot. I found an open area that looked like the skin had come off. It appeared that a blister had ruptured, and the fluid had been absorbed into the sock. I did not see blood. The sock was damp where the wound (Left Heel) was wet to the touch. It was rounded in shape, a bit bigger, and superficial. The wound was located on the inner side of the heel of the left foot. I immediately notified my Rehab Department Director and got the Director of Nursing. I don't remember what day it was, as it was not found in the notes. I don't know how the wound developed. I have no idea, to be honest! R103 doesn't move very much. I did not observe any repetitive or jerky movements in his feet during the therapy session. He did not express any discomfort or pain.An interview with Dr. K was conducted by phone on 8/27/25 at 4:45 PM. She indicated that she does rounds to see residents and see them, but did not remember rounding with the wound nurse on a weekly or monthly basis. She further specified: We see patients individually. Dr. K reviewed R103's medical record during the interview and stated that she saw the resident a few days after admission. On 6/25/25, Dr. K noted during examination that R103 was non-verbal with no open wound ongoing during her assessment. Although R103 was bedbound, Dr. K recalled examining his back in bed, and there were no other skin impairments noted on the legs, ankles, and feet during the examination on June 25, 2025. The subsequent encounter I had with R103 was pointed out in the Progress Notes dated August 7, 1925, which stated that at 5:15 PM, I received a text regarding a necrotic coccyx with foul drainage. I ordered an antibiotic of Bactrim to give immediately after a wound culture. Dr. K was not sure what happened, but the following day on 8/8/25, R103 started on Clindamycin and not the Bactrim she had ordered. The resident was discharged on August 8, 2025, so she did not follow up.Late Entries progress notes entered Dr. L was unavailable for interview due to a scheduled vacation internationally, but according to both Dr. J and Dr. K, the dictated notes should not take more than 48 hours. The two physicians were unaware of the delay of all seven (7) Late Entries of progress notes in the EMR for R103.POLICIESOn August 22, 2025, at 3:30 PM, the Wound Management Policy was reviewed.Wound Management Policy (Original date-1/2/2024) Policy: To promote wound healing of various types of wounds. It is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Procedure:Wound treatments will be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change.In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse .

This Citation Pertains to Intake Numbers MI00152877 and MI00152910. Based on observation, interview and record review, the facility failed to ensure wounds were assessed, monitored, and that appropriate interventions were in place for 3 Residents (#1, #2, #3) of 3 residents reviewed for wounds, including Resident #1 who had a above the right knee amputation after a lack of assessment and monitoring, infection and a dehisced/opened right below the knee amputation surgical site. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: recent right below the knee amputation, diabetes, COPD, heart disease, atrial fibrillation, peripheral vascular disease, history of a stroke, depression and arthritis. The MDS assessment dated [DATE] revealed the resident needed assistance with care. The resident was transferred to the hospital on 5/1/2025 for additional surgery. Further review of the MDS assessment dated [DATE] for Resident #1 identified in Section M that the resident had a surgical wound and there was no treatment. A review of the admission Skin assessment for Resident #1 titled, Skin Evaluation, dated 3/31/2025 did not mention Resident #1 was admitted with a surgical wound related to a recent right below the knee amputation. On 4/3/2025 a Skin Condition Evaluation, revealed the resident had a RBKA (right below the knee amputation) surgical incision with no measurements. It did not identify if staples or sutures were present. It indicated a non-removable pressure dressing intact. There was no assessment of the surrounding skin (peri-wound). The assessment also provided, unable to see with this assessment due to dressing that stays in place until next appt. (appointment). On 4/10/2025 a Skin condition Evaluation, identified a RBKA, surgical incision, with no measurements. There was no mention of sutures or staples or what the peri-wound looked like. A review of the Hospital discharge instructions dated 3/31/2025 for Resident #1 identified the following: Leg Amputation, Care After . Check your residual limb, especially your incision, every day. Check for: Blisters, Scrapes, Signs of infection, such as: More redness, swelling, or pain. More fluid or blood; warmth, Pus or a bad smell. Follow instructions from your health care provider about how to take care of your incision . Change your dressing as told by your health care provider . Leave stitches (sutures), staples, skin glue, or adhesive strip in place. These skin closures may need to stay in place for 2 weeks or longer . A review of the progress notes for Resident #1 identified there was no mention of the resident's surgical incision, assessment or monitoring from 3/31/2025 the day of admission through 4/14/2025. A review of the March and April 2025 Medication Administration Records/MAR and Treatment Administration Records/TAR for Resident #1 identified there was no mention of assessment or monitoring of the Right below the knee amputation surgical site from the day of admission 3/31/2025 through 4/14/2025. A review of the Interdisciplinary Team document titled, IDT Care Plan Conference Summary, dated 4/3/2025 and locked 4/10/2025 revealed there was no mention of Resident #1's right below the knee amputation surgical site. The Nursing Goals and Summary section of the document was blank. A review of the physician orders indicated there was no mention of assessment or monitoring of the resident's RBKA surgical site until 4/15/2025: two weeks after the resident was admitted with the RBKA surgical site. A review of the Care Plans for Resident #1 revealed the following: (Resident #1) has impaired skin integrity: admitted with a R BKA surgical incision, date initiated 3/31/2025 and revised 4/18/2025 with interventions including: Assess and document skin condition, notify MD of signs of infection (redness, drainage, pain, fever), date initiated 3/31/2025; Wound treatment as ordered, date initiated 3/31/2025. Further review of the progress notes identified a Late Entry note dated 4/15/2025 at 12:30 PM, The resident returned from his appoint (ment) with a dehisced (surgical incision opened on its own) wound, to the R. BKA. Cleanse with wound cleanser, pat dry, apply iodoform packing into wound bed, apply skin prep to peri wound and allow to dry, cover with bordered dressing. Change daily and prn (as needed). The physician orders the resident to be on 1 tablet by mouth two times a day for skin infection to surgical wound until 4/25/2025. A Vascular Surgical consult note dated 4/15/2025 revealed, S/P (status post) right BKA 3/26/25 Surgical wound with dehiscence @ mid-incision. Staple removed here and there is tunneling about 1 ½ inch deep. Bloody/purulent drainage. This will need to be packed daily with packing strips. Rec. (recommend) Bactrim DS 800 mg/160 mg po BID (twice a day) x 10 days; Schedule surgical washout and debridement . Further review of the April 2025 MAR/TAR's for Resident #1 revealed a new entry dated 4/16/2025, RBKA surgical wound. Cleanse with wound cleanser, pat dry, apply iodoform packing into wound bed, apply skin prep to peri wound and allow to dry, cover with bordered dressing. Change daily and prn (as needed, every day shift for surgical wound care. A progress note dated 4/24/2025 at 1:28 PM revealed, Patient had pressure dressing to RBKA from admission until follow up with ortho. At that follow up appointment, incision was noted with open wound and infection. RBKA surgical incision with wound is currently treated with antibiotic therapy. Around the incision is not healing with the intention of surgeon's treatment order. Wound has slough (dead stringy tissue), copious serosanguinous drainage. Redness, swelling and warmth remains to suture line . A review of a Vascular Surgical consult dated 4/25/2025 for Resident #1 provided, Wound check of Right Below Knee amputation stump- non- healing . Debridement in hospital- please hold Apaxiban appropriately . On 5/13/2025 at 1:49 PM , Confidential Person E was interviewed about Resident #1's RBKA and said the resident was admitted to the facility on [DATE] from the hospital after having surgery: a right below the knee amputation/RBKA. She said the resident had a history of circulation issues, poor blood flow and prior wounds to his right lower leg. She said that is why he had an RBKA and needed to be monitored closely. She said the hospital discharge instructions said the surgical wound was to be inspected daily. Confidential Person E said the resident had a follow-up appointment with the Vascular Surgeon on 4/15/2025 and at that appointment the surgical wound opened up because it was infected and was not being monitored. She said the wound needed to be surgically cleaned (debrided, with removal of the dead tissue). At the resident's next appointment with the Vascular Surgeon on 4/25/2025 he was scheduled to have the debridement, but could not have it because the facility did not appropriately hold the resident's blood thinners prior to the procedure, so it could not be done. She said she was told if the wound did not heal, the resident would need another surgery: a right above the knee amputation. She said the resident went back to the hospital on 5/1/2025 to have the right above the knee amputation. During an interview with Wound Care Nurse A on 5/14/2025 at 8:50 AM, she was asked about Resident #1's RBKA and whether the surgical wound was being monitored. She said she was told by one of the medical providers that some surgeons do not want the surgical dressing to be removed prior to the scheduled post-surgical follow-up appointment, so the facility did not remove it. Nurse A was asked if the Surgeon's office was contacted to obtain information on how to care for the surgical site and she said the office was not contacted until after the first appointment on 4/15/2025. She was asked if there was documentation that the nurses were routinely assessing and monitoring the wound and she said there was a weekly skin assessment. Reviewed with Nurse A that the assessments did not describe the condition of the wound, how many staples, sutures or the surrounding skin. Nurse A was asked if it had been reviewed with the resident's physician at the facility, as there was no order not to monitor the surgical site or how to care for the wound. She said after the 4/15/2025 appointment, the nurses performed wound care daily, as the wound was infected and had opened. There was no routine documentation of assessment or monitoring to aid in identifying a change in the condition of the wound. Resident #2: A record review of the Face sheet and MDS assessment indicated Resident #2 was admitted to the facility on [DATE] with diagnoses: recent right above the knee amputation 5/2/2025, diabetes, chronic kidney disease, heart disease, and anxiety. On 5/14/2025 at 9:00 AM, Resident #2 was observed awake, alert, and sitting up in bed. Wound Nurse A was present and rolled up the resident's right pant leg to visualize his surgical site. Nurse A said there were 20 staples and 10 sutures; all were intact without redness or drainage. The resident said he had a dressing on the wound, but it was new, and he took it off because it was bulky. He said the nurses checked the incision every other day. A record review of the admission Skin assessment for Resident #2 titled, Skin Evaluation, dated 5/9/2025 and locked 5/10/2025 revealed the resident had a wound on the Right lower leg (rear) and Treatment was applied. There was no mention of the right above the knee amputation site. A review of a progress note dated 5/12/2025 at 6:19 PM revealed, Resident's right AKA (above the knee amputation) surgical site was assessed this a.m. Incision line is well approximated with staple intact. No redness. Swelling, or drainage noted. Orders to leave incision open to air for healing. Will continue to monitor . The resident had been in the facility for 3 days and this was the first note describing his right AKA surgical site. A record review of the physician orders for Resident #2 identified the following: Wound care: monitor right AKA site and sutures every shift. Notify Dr. If changes or signs and symptoms of infection (drainage, redness, swelling) may cover with dry dressing if needed, dated ordered 5/12/2025. This was the first order to monitor the resident's right AKA surgical wound. The assessment started 4 days after admission. A review of the May 2025 MAR/TAR's for Resident #2 revealed, Monitor right aka for signs/symptoms of infection q (every) shift, start date 5/12/2025 and Wound care: monitor right AKA site and sutures every shift. Notify Dr. If changes or signs and symptoms of infection (drainage, redness, swelling) may cover with dry dressing if needed, every day and night shift for wound care, start date 5/13/2025. A review of the Interdisciplinary Team (IDT) note titled, IDT Care Plan Conference Summary, dated 5/12/2025 and locked 5/13/2025 had a section titled Nursing goals and summary; this was blank. A review of the Hospital discharge instructions dated 5/9/2025 for Resident #2 included, Instructions: Wound care for right AKA: Ace wrap and elevate the R AKA to compress the stump and reduce edema until 5/9; Start wearing stump shrinker on 5/9; Sutures and staples to remain in place for 3 weeks, will be removed at outpatient follow up with (surgeon); You may shower but do not soak the wound in water or scrub at the incision line. Further review of the physician orders for Resident #2 identified an order written on 5/13/2025, Apply stump shrinker, one time a day for wound care, start date 5/14/2025. This was 5 days after admission. A review of the Care Plans for Resident #2 identified the following: (Resident #2) has impaired skin integrity: Right AKA surgical site, date initiated 5/10/2025 and revised 5/12/2025 with Interventions including: Wound treatment as ordered, dated 5/10/2025. There was no mention of the Hospital discharge recommendations including an assessment of the staples/sutures, how to shower or that the resident was to wear a stump shrinker beginning on the day of admission. Resident #3: A record review of the Face sheet and MDS assessment indicated Resident #3 was admitted to the facility on [DATE] with diagnoses: acquired absence of left great toe, heart failure, diabetes, peripheral vascular disease, visual loss both eyes, anxiety, depression and history of falls. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status score of 13/15 and the resident needed assistance with some care. On 5/14/2025 at 9:15 AM, Resident #3 was observed sitting in a chair in her room. She had two wound dressings: one on her right mid- shin and one on her left great toe amputation site. Both dressings were dated 5/13/2025. Wound Nurse A was also present and said she changed the dressings on 5/13/2025. Resident #3 said she worries about her left great toe site because the toe was already amputated and she is worried if it doesn't heal, she will lose more of her foot. She said the nurses were not always changing the dressing. Wound Nurse A removed the dressing on the left great toe area to observe the wound. The area was open approximately 1.2 cm x 1.2 cm in circumference with yellow stringy slough. The Wound Nurse said she was using Therahoney and calcium alginate over the area. The surrounding area was very red and inflamed. A review of the Nursing admission Skin Assessment titled, Skin Condition Evaluation, dated 4/28/2025 and completed 4/30/2025 (4 days after admission), identified two wounds present on admission: Right lower leg (front); laceration; length 4 cm, width 0.5 cm Left toe; surgical incision There was no measurement. Scabbed over; 100% wound covered over, surface intact Calloused-Fibrotic or Hyper-keratotic; Fragile: Skin that is at risk for breakdown; Intact: Unbroken skin No swelling or edema. A Skin Condition Evaluation, dated 5/1/2025 and locked on 5/5/2025 identified the following: Left toe; surgical incision; 1.8 cm length, 1.2 cm width and 0.1 cm depth; No closure measure present; Granulation, Slough (dead stringy tissue); 90% of wound bed filled Amount of exudate (drainage): moderate; Type of exudate: serosanguinous (fluid with blood); Peri-wound edges: Non-Attached: Edge appears as a cliff; Fragile skin that is at risk for breakdown; No swelling or edema. A Skin Condition Evaluation, dated and locked 5/8/2025 identified the following: Left toe; surgical incision; 1 cm length, 1.1 cm width, 0.1 cm depth; No closure method; Slough; 100% of wound filled; Amount of exudate: Moderate; Type of Exudate: serosanguinous; Periwound edges: Attached: Edge appears flush with wound bed or as a sloping edge; Periwound surrounding tissue: Intact: Unbroken skin; Normal in color; No swelling or edema. A review of the physician orders for Resident #3, on 5/14/2025 at 9:30 AM, identified the following: There was no order for a wound dressing/treatment for Resident #3's left great toe open wound. A review of the April and May 2025 Medication Administration Record/Treatment Administration Record (MAR/TAR) for Resident #3 revealed there was no documented treatment to the resident's left great toe open area. A review of an Infection screening Evaluation, dated 4/30/2025 and locked 5/6/2025 provided, Infection Analysis: . Suspected skin and soft tissue infection; McGeer's Criteria Met: Cellulitis, Soft tissue or wound infection. There was no identification of the infection location. On 5/14/2025 at 9:30 AM, Wound Nurse A was interviewed about the lack of a wound order for Resident #3's left great toe amputation site. She said she thought it was included in the order for the resident's right lower leg treatment. A review of the order revealed the left great toe was not mentioned. A review of the progress notes, MAR/TAR and nursing assessments did not identify routine assessment and monitoring of Resident #3's left great toe except for a weekly measurement by the Wound Nurse A. The wound had developed yellow stringy slough, and the peri-wound was reddened and inflamed. There was no order for the wound dressing that was observed on the left great toe area on 5/14/2025. Resident #3 had verbalized that the nurses were not consistently providing wound care to the left great toe area, but wound care was not ordered. A review of the Care Plans for Resident #3 identified the following: (Resident #3) has Skin Trauma upon admission due to post amputation to Left toe and Laceration to right lower extremity- tibial with history of Skin Infection to left toe amputation, date initiated 4/30/2025 and revised 5/7/2025 with Interventions including: Assess and document skin condition weekly and as needed, date initiated 4/30/2025; Document abnormal findings and notify MD, dated 4/30/2025; Observe for symptoms of infections (redness, drainage, warmth, increased pain), date initiated 4/30/2025; Treatment as ordered, 4/30/2025. On 5/14/2025 at 11:00 AM, Nurse C was interviewed about surgical wounds and she said assessment started on admission of the resident. She said the nurse assigned to the resident would complete the assessment and look for skin redness, breakdown, wounds, and if there were dressings. She said the nurse would document in the chart. Unit Manager B was interviewed on 5/14/2025 at 11:10 AM and asked about wound assessment of Surgical wounds. She said the wound should be assessed at least daily and documented and if there were any questions about the surgical wound, the surgeon should be called. The Director of Nursing/DON and Wound Nurse A were interviewed on 5/15/2025 at 9:30 AM, they were asked about assessment and monitoring of surgical wounds and specifically surgical amputations, as Resident's #1, #2 and #3 were not routinely monitored. Resident #1's RBKA was not monitored for 14 days after admission. There was no assessment documentation or routine monitoring to aid in identifying the wound was infected and not healing. Resident #2 did not receive a wound assessment until 3 days after admission and on the 4th day wound monitoring was initiated. Resident #3 did not have an order for treatment to her left great toe amputation site, although a treatment was being applied. The DON said the facility was reviewing their processes to ensure the resident's wounds were appropriately cared for. Physician F was interviewed on 5/15/2025 at 9:46 AM about Residents #1, #2 and #3, as each had a surgical wound from an amputation and were lacking assessment, monitoring and a written order for wound care for Resident #3. He said the residents' skin should be looked at starting on admission and should be assessed and documented at least daily. He said he wasn't sure why the nurses were not assessing or documenting that this was done. Physician F was also asked about holding a blood thinner when a resident was to have a surgical procedure, and he said sometimes the surgeon would specify how long in advance to hold it. He said it would depend on what blood thinners the resident was taking and what the procedure was. Physician F said if the surgeon did not specify how long to hold the blood thinner, then the provider at the facility would do that. If any questions, the surgeon would be contacted. A review of the facility policy titled, Wound Management Policy, dated effective 5/30/2024 provided, It is the policy of this facility to ensure residents who do not have skin integrity impairments do not develop a new condition affecting the skin. It is also the policy of this facility that those resident with impaired skin integrity are recognized by our care team, treated timely, and interventions to heal are not exhausted until the skin is healed . Resident of this facility have their skin assessed at the time of admission/re-admission and evaluated routinely . A review of the facility policy titled, Anticoagulants, dated original 1/2/2024 did not mention management of the anticoagulant medication/blood thinner prior to a surgical procedure.

This Citation pertains to Intake Number MI00145161 Based on interview and record review the facility failed to maintain the safety of one resident (Resident #701) of one resident reviewed for mental health procedures, resulting in Resident #701 attempting twice to commit suicide via strangulation at the facility without appropriate facility interventions. The facility is being cited at Past-Non-Compliance with a Compliance Date of 06/15/2024. Findings Include: Redsident #701: On 8/13/2024 at approximately 3:30 PM, a review was conducted of Resident #701's record and it revealed he admitted to the facility on [DATE] with diagnoses that included Alcoholic Cirrhosis of Liver, Paranoid Personality Disorder and Alcohol induced persisting Dementia. Further review of Resident #701's record revealed the following: Care Plan: .resident attempting to wrap call light chord around neck .1:1 sitter . (Resident #701) has two blanching red areas on neck . initiated on 6/13/2024. Physician Orders: -Resident to have 1:1 sitter upon return from hospital for personal safety - inputted on 6/12/2024. Hospital Records: Pt (patient) from (long term care unit), pt was found with a phone cord wrapped around his neck. Pt arrives with bruising and bleeding around his neck. Pt gasping. Was found unresponsive for EMS .presented as Class I trauma after being found with phone cord around neck. This is a presumed suicide attempt .problems addressed: strangulation or suffocation . On 8/14/2024 at approximately 12:45 PM, Scheduler M was asked why there was no specified 1:1 for Resident #701 on 2nd and 3rd shift on 6/14/2024. The scheduler explained CNA N was supposed to stay over on 2nd shift but was directed by CNA A to go home. On 8/14/2024 at 1:15 PM, an interview was conducted with CNA A regarding Resident #701's 1:1. The CNA explained their scheduler will denote on their assignment sheet if there is a 1:1. CNA M was Resident #701's sitter on 1st shift from 6:00 AM - 2:00 PM and they did not know who CNA M's relief was. CNA A directed the aide to speak to their scheduler regarding her relief and never directed her to go home. On 8/14/2024 at 4:00 PM, Nurse D shared the morning after Resident #701's first suicide attempt she and housekeeping completed a sweep of his room for any items he could utilize to harm himself. Nurse D reported they found multiple pill bottles in his house shoes and the sleeves of his shirts. The bottles found in the sleeves were rubber banned so they would not fall out. Nurse D stated they also found scissors and some other miscellaneous items but she did not see the cell phone charging cord or tape in the room during the sweep. On 8/14/2024 at 4:25 PM, an interview was conducted with CNA B regarding Resident #701 2nd suicide attempt at the facility on 6/14/2024. The CNA explained she and Nurse O took turns completing 10-20 minutes checks on Resident #701 during 3rd shift, as there was no staff designated for 1:1. CNA B stated Resident #701 was intelligent so they staggered the checks so he would not know exactly when they were coming. CNA B was unsure who was completing the checks on him prior to her arrival at 10:00 PM. During her visual checks of the resident, she did not observe a phone cord or tape in his room. Around 3:05 AM, Nurse O checked on him before going on break and he was fine. CNA B went to check on him at 3:20 AM and found him supine in the bed with the sheet covering his body, she noticed what looked like a dressing by his neck and that is what prompted her to pull the flat sheet back. CNA B Resident #701 had wrapped a phone charger around his neck, then wrapped toilet paper or Kleenex around the charger and secured it with tape. Resident #701 was breathing but would not respond verbally to CNA B. CNA B yelled for help and another aide responded and they had to cut the items around his neck in three or four places to release it. Further review was completed of Resident #701's record's and yielded the following: Progress Notes: 6/12/2024 at 01:00: .He was referred to (contracted psychiatric group) for cognitive assessment and mania.6/12/24: Resident was seen in his room around lunchtime with a sitter 1:1. No acute distress noted today. He elaborated on how he was feeling by stating all of the medical issues he has including his paracentesis. He seemed to be highly manic, going from one subject to another without any flow. He started with his medical issues, and then went on how he is very particular about his medications, which according to staff, he has not been taking. He also seemed to be aloof and tangeltial with a mixed of flight of ideas, which sometimes alluded to SI/HI, but made vague comments on any particular plan. His flight of ideas included his hx of being a real estate agent, which how he met his ex-girlfriend, then how his real estate partner [NAME] had made millions by having the real estate gain 64% of the profit and the duo gained the reset of the profit in AZ. He was then asked about not taking his medication and he endorsed I just want to know what they are, but I am not refusing, just catious. Staff has indicated that he does not take his meds every day. He is not sutable to be outpatient services right now, since he has had a hx of SI, recently, and him going over with vague plans needed to be either stay on 1:1 or recommended to be petitioned . 6/12/2024 at 01:44: .Neurological Status Evaluation:I answered his call light and found him with 2 strings tied very tightly around his neck and knotted. There were paper towels between the knotted strings and his neck. I cut the strings off .He appears of his usual cognition and is alert. He refuses to discuss why or how this happened, stating that his room mate put the call light on, not him. He has a very small reddened area in the front of his neck where strings were knotted . 6/12/2024 at 02:49: I answered the call light for (Resident #701) room around 12:45 am. When I entered I noted his roommate was sleeping, so I pulled (Resident #701's) curtain open to see if I could assist him and I found him with 2 strings tied very tightly in knots around his neck. His bed gown tie as well as what appeared to be an overhead light pull string. There were paper towels between the strings and his neck skin. I couldn't get the strings untied so I cut them off. His eyes were moving left to right. He was not speaking, he was breathing rapidly but not gasping. He was not discolored, his facial skin and lips were of normal color. When I attempted to speak with him, his eyes moved from left to right, non-rythmically and he did not answer. I immediately took his vitals .I shook him stating, I know you are ok, why would you do this? and his eyes flinched and he opened his eyes, his breathing was normal. He refused to answer when I asked him if he is ok and began moving his eyes from left right not rythmically, but everytime I said something his movement would stop as if to listen to me then his eye movement would begin again as would his increase of respirations. When I asked him if he put the call light on he said, no, it must've been my roommate. His eyes then moved from left to right in such a way that appeared to be focused effort to do so. His roommate was sleeping. I asked him if his visitors previously in the day had anything to do with this and he said, no, I don't want to live. I asked him if I can do anything to help him and he said, no.Staff passed water and assisted this room a few minutes after 11:30pm and both residents in this room appeared to be of their usual . 6/12/2024 at 03:43: : I received a call from (the hospital). (Resident #701) has been evaluated and appears to be of normal status, they expect to send him back to us soon. ADON and Administrator notified; orders given to assign him a 1:1 sitter upon arrival . 6/12/2024 at 15:53: Resident room was cleaned today during the cleaning approximately 5 pill bottles were found in his room inside of his house shoes. Inside of his shirts pills not in bottles were found in his shirt sleeve with a rubber band keeping them from falling out along with 2 pairs of scissors and a tile scrapper. Resident also two heated blankets on his bed. All items was turned into the administer. 6/12/2024 at 22:56: .Patient was assessed in his room, resting in bed. He had a sitter at bedside, as he attempted suicide last night with a string and paper towel around his neck. He was sent to the ER for evaluation and sent back. He requires 24/7 staff at this time . 6/14/2024 at 06:35: Resident observed in bed with a charger cord that that was reinforced with toilet paper and tape around his neck. He was unresponsive but breathing. Cord was so tight is was unable to be untangled so it had to be cut with scissors. Vitals immediately taken; all appropriate persons notified. Order to send patient out given. Spoke with Social Worker at (Hospital) and she stated she will initiate a Petition. Thorough report given. On 8/14/2024 at approximately 2:00 PM, an interview was conducted with the Administrator and DON (Director of Nursing) regarding Resident #701's two suicide attempts at the facility via strangulation. They explained after his first attempt they thought he would have been admitted to an inpatient psychiatric unit, but he was at the hospital for a short amount of time and returned back to the facility. Upon his return he was placed on 1:1 for continued safety and monitoring. They had a nurse complete a sweep of his room and found many items such as pill bottles and scissors that were removed to maintain his safety. The Administrator and DON were asked if he was petitioned by facility staff after his first or second attempt and they stated he was not. After further discussion it was found there were no other interventions implemented to maintain Resident #701 safety, no facility policy to address suicidality and subsequent procedures. Additionally, the facility discovered there was no specified 1:1 on the assignment sheet for 2nd and 3rd shift on 6/14/2024. The Administrator and DON reported the facility took steps after the incident to correct self-found deficiencies. They presented this writer with Past Non-Compliance. Facility Investigation of Suicide Attempts: Staff was in the room on 6/12/24 passing water and had checked on (Resident #701) and he was in bed. The nurse went down to residents' room at approximately 12:45 am on 6/12/24 to answer call light and observed resident with 2 strings tied around his neck. Nurse unable to loosen ties so cut with scissors . (Resident #701) told the nurse that he did not want to live so one on one was placed and nurse called the physician and received orders to send to ER for psychiatric evaluation . (Resident #701) returned from (emergency room ) on 6/12/24 at approximately 3:40 am with no new orders and that he was fine it was just Anxiety. One to one provided to resident upon return as an immediate intervention for all day on 12th . On 6/14/24 at approximately 3 am staff completed room check and observed (Resident #701) with phone cord around his neck, the cord was cut off with scissors he was alert .The physician was called at 3:30 am and received orders to send to (emergency room ) for inpatient. Social worker at hospital completed petition, and physician completed cert for involuntary placement. Facility tracked progress of resident during psychiatric placement, because of residents' acuity he was not placed at a psychiatric facility .From facility investigation we revealed that facility failed to appropriately denote 1 to 1 of staffing and maintaining safety of resident with recent active suicidal attempt as well as suicide precautions. Facility implemented suicide policy, as well as how to complete room sweeps, and how to petition residents out for active suicidal ideations . On 8/15/2024 at 1:25 PM, an interview was conducted with Nurse C regarding Resident #701's first suicide attempt. Nurse C explained there was never any indication that he was suicidal. She recalled charting at the nurses' station and the call light sounding, Resident #701's roommate was blind and a fall risk so Nurse C immediately responded to the alarm and saw Resident #701's roommate was sleeping. She then pulled back the privacy curtain to check on Resident #701 and found the pull sting from the light above his bed and string for his gown tied tightly around his neck and knotted. Nurse C stated this was toilet paper in between the two stings. The Nurse was able to cut the strings from around his neck. Resident #701 was breathing, was not gasping for air, no skin discoloration and his vitals were stable. Past Non-Compliance (PNC): During the onsite survey, Past Non-Compliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1.Systemic Changes to Prevent Recurrence: - DON/designees started education on 6/14/24, with Licensed Nurses on the process when the schedule does not appear to be correct who to call. Suicide precautions with emphasis on making sure we sweep and remove all items including trash liners, sheets, belts phone cords, call lights, shoestrings, belts anything that resident may use to harm themselves. Education completed with scheduler on making sure sitters are identified on schedule and it is accurate. Staff members are not permitted to work a shift until education has been completed -The administrator/Designee will interview 4 staff members weekly times 4 weeks, then monthly times 1 to verify understanding of who to call when they have concerns with the schedule or schedule is not accurate with a summary of findings to QAPI for review and recommendations. -Identified residents at risk for suicidal ideations or harmful behavior will be reviewed in Behavior Management weekly time four weeks then bi-weekly times 2 weeks, and then monthly times one, with findings submitted to QAPI for review and recommendations. -The DNS/Designee will review new admissions for suicidal ideations risk and assure interventions are put in place, three times a week for 4 weeks, and then weekly times 2 weeks, and then monthly with findings submitted to QAPI for review and recommendations. The facility was able to demonstrate monitoring of the corrective actions and maintained compliance. Compliance Date: 06/15/2024.

This Citation pertains to Intake Number MI00143579. Based on observation, interview, and record review the facility failed to provide pressure ulcer care per health care provider order and prevent the deterioration of Resident #74's unstageable coccyx wound and Resident #290 and #292's wound dressings not being completed per standards of clinical practice, resulting in Resident #74's wound care treatment not being completed as ordered, wound worsening, infection, and sepsis and Resident #290's and #292's foot wounds not being dated and labeled per nursing standards of practice. Findings Include: Resident #74: During initial tour on 5/20/2024, Resident #74 was observed resting in bed and did not appear to be in any distress. On 5/21/2024 at approximately 2:00 PM, a review was conducted of Resident #74's medical record and it revealed the resident initially admitted to the facility on [DATE] with diagnoses that included, Sepsis, Chronic Kidney Disease, Anemia, Myocardial Infarction and Hypertension. Resident #74 was dependent on facility staff to meet all her care needs. Further review of the resident record yielded the following: Discharge Hospital Records: .Pressure Ulcer 2/12/24 Coccyx (buttocks) .cleanse/irrigate with NS (normal saline). Apply skin prep periwound. Apply Mepilex silicone border dressing to wound bed. Date, initial, and designate T for treatment or P for prevention on Mepilex. Roll back edges every shift to assess and cleanse wound bed. Re-secure with skin prep. Change Mepilex Q3 days & prn . Treatment Administration Record (TAR): - Allevyn Sacrum External Pad- Apply to sacrum topically every day shift every 3 day(s) for wound cleanse with ns, pat dry and cover. Ordered on 2/22/24 and discontinued on 2/29/2024. - Wound Treatment- Coccyx- Cleanse site with saline or wound wash. Gently pat dry. Apply dime size amount of triad cream and spread thin layer. May leave in place and reapply in thin layers for 3 days. Remove with A&D ointment on day 4 and reapply triad as per previous instructions. Ordered on 2/23/2024. Review was completed of the TAR and indicated Resident #74's Allevyn treatment was not completed on 2/22/24, 2/25/24 and 2/28/24. The TAR had numerical indicators for the three dates listed that coded for other/see progress note. The progress notes for each date the dressing was due to be completed stated: 2/22/2024: No subsequent progress note related to the treatment. 2/25/2024: No Allevyn dressing. 2/28/2024: There was no explanation listed in the progress note as to why this treatment was not completed. It is unclear as to why Resident #74 had two different wound care treatment orders from 2/22/2024 to 2/29/2024 (when Allevyn was discontinued) when the wound care practitioner ordered Triad on 2/22/2024. On 5/21/2024 at 10:56 AM, an interview was conducted with the complainant regarding wounds at the facility. It was shared community acquired wounds at the facility were worsening as wound care was not being completed as ordered. They reported Resident #74's wound was supposed to be packed and it was only being completed when the Wound Nurse Practitioner rounded. They stated Resident #74's wound worsened and became infected due to facility neglect. Further review was completed of Resident #74's wound progressing from admission to transfer to the emergency roiagnom on [DATE]. Nursing Admission Assessment 2/20/2024: The assessment indicated Resident #74 admitted to the facility with the following skin conditions .Sacrum- Full thickness wound 4.5cm x 6.3cm. moist . She has wounds 3. Sacrum-unusual shaped full thickness wound across coccyx 4.5cm x 5.3cm. Regions cleaned with NS (normal saline) pat dry and cover with foam gentle Allevyn as were found upon admission . She is also totally dependent for all ADL as she is totally paralyzed . Care Plan: (Resident #74) was admitted with pressure ulcer to sacrococcygeal area and L (left) heel closed .Assess and document skin condition, notify MD of signs and infection (redness, drainage, pain, fever) .Notify MD of worsening or not improvement in wound .wound treatment as ordered . Nursing Progress Notes: 2/22/2024 at 11:56: Coccyx - unstageable. 2.5 x 1.6 x 0 (measurements)First Observation, no reference. Serous (Drainage). Small. (Drainage Amount). No (Odor). fragile with deep purple discoloration. Attached. triad as per order in TAR. pressure reducing mattress low air loss mattress. NP first rounding observation . 2/29/25024 at 11:03: Coccyx - unstageable 4.0x1.4x 0 (measurements) .Unstageable. Worsening. Serosanguineous (Drainage). Small (Drainage Amount). Yes (Odor)strong malodorous . 3/7/2024 at 13:53: Coccyx - St (stage) 4.4. x 5.01.1. admitted . Stage 4. Worsening. Serosanguineous (Drainage). Moderate (Drainage Amount). Yes (Odor)slight malodorous smell. Fragile. Macerated .deterioration . 3/14/2024 at 12:40: Coccyx - unstageable 4.7 x 5.5 x 0 (measurements) .Unstageable .Worsening .Moderate (Drainage Amount) .Yes .(Odor)slight malodorous smell .fragile .not attached .poor . 3/14/2024 at 13:18: Resident with probable sepsis VS (vital signs): bp:94/60 HR 111 WBC over 20 HGB 7.8, okay to sent out per DON (Director of Nursing ) ADON on call notified of transfer . 3/15/2024 at 00:00: WBC 20, on abx for wound infection. Pressure Ulcer Weekly Observation Assessment: 2/22/2024: Unstageable coccyx wound with 100% yellow adherent slough and small serous drainage. The peri wound tissue was fragile wit deep purple discoloration and wound edges attached. Current treatment was Traid This was the first observation of the wound completed by the wound NP. 2/29/2024: Worsening unstageable coccyx wound with 100% yellow adherent slough and small serosanguineous drainage. The wound had eschar forming and a strong malodorous odor. The peri-wound tissue was fragile with wound edges attached. Continue treatment of triad. 3/7/2024: Worsening stage 4 pressure ulcer with slough and neurotic tissue present. Moderate amount of pale yellow seropurulent drainage with slight malodorous smell with macerated wound edges. Treatment orders were changed. 3/14/2024: Worsening unstageable coccyx wound with 20% slough and 80% necrotic tissue. Moderate seropurulent drainage with slight malodorous smell. 12-12 undermining 2.4 cm at 11 and depth was unknown. The wound edges were attached, and infections was suspected. Wound progress was evaluated at poor. Nurse Practitioner Wound Care notes: 2/22/2024 at 00:00: .Will initiate a treatment plan to coccyx to be that of triad cream to promote autolytic debridement and to protect area from further moisture related breakdown . Coccyx, unstageable- This wound measures 2.5 x 1.6 centimeters with unknown depth. This wound is an assumed full thickness. There is a light amount of serous drainage from this area. Wound bed consists of 100% pale yellow adherent slough. Edges are attached and there is no eschar, tunneling, undermining, or odor. The surrounding tissue is fragile with a deep purple discoloration but without redness, warmth, swelling, pain, induration, or sign of infection. Treatment: Cleanse site with saline or wound wash. Gently pat dry. Apply dime size amount of triad cream and spread in thin layer. May leave in place and reapply in thin layers for 3 days. Remove with A & D ointment on day 4 and reapply triad as per previous instructions . 2/29/2024 at 00:00: .Will continue treatment plan for sacral unstageable to be that of triad cream to promote autolytic debridement and to protect area from further moisture related breakdown . Sacrum, unstageable- This wound measures 4.0 x 1.4 centimeters with unknown depth. This wound is an assumed full thickness. There is a light amount of serous drainage from this area. Wound bed consists of 100% pale yellow adherent slough with eschar formation. Slight malodorous smell. Edges are attached and there is no eschar, tunneling, or undermining. The surrounding tissue is fragile with a deep purple discoloration but without redness, warmth, swelling, pain, induration, or sign of infection. Treatment: Cleanse site with saline or wound wash. Gently pat dry. Apply dime size amount of triad cream and spread in thin layer. May leave in place and reapply in thin layers for 3 days. Remove with A & D ointment on day 4 and reapply triad as per previous instructions . 3/7/2024 at 00:00: Sacral site now stageable as there is noted granulation tissue. Bone is palpable with noted facia making this a stage IV. Will adjust treatment plan for sacral to be that hydrogel impregnated gauze to promote autolytic debridement . declining sacral wound . Sacrum, stage 4- This wound measures 4.5 x 5.0 centimeters with a depth of 1.1 centimeters. This wound is full thickness. There is a moderate amount of serosanguanious and yellow seropurlent drainage from this area. Wound bed consists of 40% pale yellow adherent slough, 30% necrotic tissue, and 30% intermittent granulation tissue. Slight malodorous smell. Edges are not attached as there is noted undermining from 9 to 11 o'clock with max depth of 1.1 centimeters and again from 12 to 2 o'clock with a max depth of 0.6 centimeters .surrounding tissue is fragile with a deep purple discoloration but without redness, warmth, swelling, pain, induration, or sign of infection. Treatment: Cleanse site with normal saline or wound wash. Pat dry. Apply hydrogel impregnated gauze (autolytic debridement) to site and gently pack with undermining areas. Apply barrier cream to periwound. Cover with gently bordered gauze. Perform daily and as needed if soiled or dislodged . 3/14/2024 at 00:00: .Sacral site unstageable as there is noted 80% necrotic tissue with a malodorous smell. Will adjust treatment plan for sacrum to be that of 1/2 percent dakins soaked gauze (wet-to-dry) dressing. This is to be performed BID and as needed if soiled or dislodged x 7 days. Will start patient on antibiotics, keflex 500 mg BID x 7 days for wound infection . declining sacral wound .Sacrum, stage 4- This wound measures 4.7 x 5.5 centimeters with an unknown depth. This wound is full thickness. There is a moderate amount of light brown seropurlent drainage from this area. Wound bed consists of 20% yellow-brown adherent slough, and 80% necrotic tissue. Noted malodorous smell. Edges are not attached as there is noted 360% undermining with a max depth at 11 o?clock of 2.4 cm. The surrounding tissue is fragile with a deep purple discoloration but without redness, warmth, swelling, pain, induration, or sign of infection . IDT (interdisciplinary Team) Risk Review Notes: IDT met .Wound note 3/7 reviewed. Wound care orders reviewed . The IDT reviewed Resident #74's wound care notes and orders from 3/7/2024 and overlooked the change in the wound care treatment order. It can be noted that after Resident #74 was assessed by the practitioner on 3/7/2024 the wound care treatment order was not changed from Triad to hydrogel impregnated gauze until 3/14/2024 at 6:00 AM. Resident #74 did not receive the appropriate wound care treatment for seven days. On 3/14/2024, Resident #74 was assessed by the practitioner and found with 80% necrotic tissue, malodorous smell, and signs of infections. Resident #74 was sent to the emergency room for probable sepsis. The hospital admission record stated the following, XXX[AGE] year old female with history of CVA and left sided hemiparesis who is bed-bound and PEG tube dependent for feeding with chronic kidney disease and hypertension .patient with infected sacral decubitus ulcer as well as foul smelling urine .CBC with WBC of 22.9, hgb 8.4 .placed on IV antibiotics .Principal problem: Sepsis Leukocytosis/Sepsis/ Infected Sacral Decubitus . Resident #74 admitted with a wound but during her course of stay at the facility it worsened and became infected. The facility did not implement the wound treatment timely nor were there any physician notes that indicated the wound worsening was unavoidable. On 5/22/2024 at 10:00 AM, a discussion was held with DON (Director of Nursing), ADON (Assistant Director of Nursing) and Corporate Consultant P, regarding the deterioration and infection of Resident #74's coccyx wound. They reported the wound began to worsen when she completed her course of antibiotics that she was admitted on . They explained they were packing her wound with hydrogel as the wound was deep and full of slough. This writer, Consultant P and DON reviewed Resident #74's wound treatment orders against the wound practitioner notes and found on 3/7/24 the practitioner changed the wound care order from Triad to Hydrogel Impregnated gauze, but this order was never inputted into the resident's chart. Resident #74 was not receiving the appropriate wound care treatment for seven days; her wound worsened and became infected. The DON and Consultant P were not able to provide rationale as to why the appropriate treatment intervention was not implemented timely. Resident #290: During initial tour on 5/20/2024, Resident #290 was observed resting in bed and was in good spirits. The resident was observed to have a dressing on her right foot that was not dated nor initialed. On 5/21/2024 at approximately 8:45 AM, Resident #290's right foot was dressing was observed to still not dated nor initialed. The ADON (Assistant Director of Nursing) was shown the dressing and reported it should be dated and initialed by the nurses who completed wound care. On 5/21/2024 at 9:39 AM, Resident #290's right foot wound dressing change was completed by the ADON. The dressing was not dated nor initialed. The dressing was dried onto the wound and wound wash had to be utilized to remove the stuck-on dressing. On 5/21/2024 at approximately 10:30 AM, a review was completed of Resident #290's medical records and it indicated the resident admitted to facility on 5/10/2024 with diagnoses that included, Sepsis, Bacteremia, Urinary Tract Infection, Anxiety, Depression, Paroxysmal Atrial Fibrillation and Heart Disease. Resident #292: During initial tour on 5/20/2024, Resident #292 was resting in bed watching television. She was in good spirits and spoke about her reasoning for entering the facility. Resident #292 had bilateral dressings to her feet that were not dated or initialed. The residents' feet were not floated nor were heel protector boots on. On 5/21/2024 at approximately 9:00 AM, this writer and the ADON observed Resident #292's bilateral dressings to her feet and they again were not dated nor initialed. The dressings were observed to have drainage seeping through that was yellow in color. The ADON was asked regarding the blank dressing and stated upon dressing changes being completed nurses should initial and date the dressings. On 5/21/2024 at approximately 10:45 AM, a review was completed of Resident #292's medical record and it indicated the resident admitted to the facility on [DATE] with diagnosis that included, Chronic Osteomyelitis with draining, Methicillin Resistant Staphylococcus Aureus (MRSA), Diabetes, Peripheral Vascular Disease (PVD) and Chronic Kidney Disease. Further review of Resident #292's medical records revealed the following: Physician Orders: - Resident to wear heel protectant boots while in bed every shift. Care Plan: (Resident #292) was admitted with right heel ischemia area d/t (due to) PVD . (Resident #292) was admitted with left heel ischemia area d/t (due to) PVD .elevate heels when in bed as allows .wound treatment as ordered . While the care plan indicated to elevate heels the resident had an order for heel protectant boots that did not carry over to care plan and Kardex. On 5/21/2024 at approximately 4:20 PM, this writer and Nurse B observed Resident #292 lying in bed and did not have on her heel protectant boots. Nurse B searched for the boots and were not able to locate them in the resident's room. We reviewed the orders and saw the resident was ordered to wear heel protectant boots while in bed. Review was completed of the facility policy entitled, Pressure Injury Prevention and Management. The policy stated, This facility is committed to .provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .Any changed to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner . The policy was not dated with a reviewed or revised by date.

This Citation pertains Intake Number MI00143956 Based on observation, interview and record review, the facility failed to provide supervision to prevent injuries for 2 residents (Resident #17, Resident #84) of 4 residents reviewed, resulting in Resident #17 sustaining a fracture of the 3rd and 4th metacarpal on the right hand, and no complete comprehensive post fall assessments for Resident #84, who sustained a fall with head injury, laceration, and required emergency medical treatment. Findings include: Record review of facility 'Fall management' policy dated 6/2023 revealed the purpose to prevent injuries related to falls. Post-Fall: (1.) Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided. A neurological assessment will be initiated on all residents with a suspected head injury based upon the fall; every 15 minutes for 1 hour then every 30 minutes for 1 hour then every 1 hour for four hours, then every 4 hours for 24 hours, then every 8 hours until 72 hours. (4.) The family will be notified immediately by the charge nurse of falls with injury. Record review of facility 'Documentation in Medical Record' policy undated with reference date of February 2023 Appendix PP guidance material, revealed each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. (4.) Principles of Documentation: (b.) Documentation shall be accurate, relevant, and complete, containing sufficient details about the residents' care and/or responses to care. Resident #84: Record review of Resident #84's electronic medical record revealed an admitted [DATE]. Record review of Resident #84's progress notes dated 4/12/2024 at 6:15 PM noted resident arrival to facility via EMS from hospital. Resident noted as alert and oriented to self only. Head to toe assessment completed. Record review of Resident #84's fall/accident report, dated 4/14/2024, revealed the resident was trying to leave the building unauthorized and when he pushed through the door a staff was standing there and startled him and he tripped and fell and hit his head on the floor. Resident #84 was noted to be unable to give a description of what he was doing. The nurse helped the resident back to his room and gave first aid, called another nurse to help facilitate the paperwork to send resident to the emergency room for the big knot that formed on the right side of his forehead and the bleeding from the abrasion on the side of the face. Resident's mental status was noted to be oriented to self and there were alarms sounding at the time. Resident #84 was noted to be an active exit seeker. Resident #84 was resistive with redirection. Record review of resident #84's progress note, dated 4/14/2024 at 00:12 AM, revealed the resident was trying to leave the building unauthorized and when he pushed through the door a staff (member) was standing there and startled resident and he tripped and fell and hit his head on the door. Record review of progress note dated 4/14/2024 at 00:13 AM noted resident sent to the emergency room for further evaluation. Record review of the Resident #84's progress note, dated 4/14/2024 3:12 AM, the resident returned from the hospital at 3:30 AM. Resident received 2 stitches on forehead and basic first aid treatments to other abrasions. EMT reported that he fell at hospital and was in restraints upon pick up. Cannot assess pain at time due to resident not being able to verbalize. Record review of the Resident #84's progress note, dated 4/14/2024 4:18 AM, revealed follow up and care instructions are on the discharge papers. Resident needs to be seen to get stitches out in 5 days. Record review of Resident #84's progress notes, dated 4/13/2024 through 4/15/2024, revealed there was no neurological evaluations documented post-fall with head injury that required emergency room treatment and sutures to the head. An interview on 05/20/24 at 11:20 AM with Resident #84, while he was lying in bed, revealed that he did try to go home, and that he got hit in the face with the door. Resident #84 stated he was going. When asked where Resident #84 was going to, the resident did not respond to the question. An interview and record review was conducted on 05/21/24 at 12:19 PM with the Director of Nursing (DON) regarding Resident #84's falls, dated: 4/14/2024, 5/15/2024, and 5/19/24. The state surveyor had the DON review the electronic medical record of Resident #84 who sustained a fall with head injury, went to the emergency room for evaluation and stitches to the head and the surveyor was requesting 'Neurological Evaluation Flow Sheet' dated 4/14/2024 once the Resident #84 returned to the facility. The DON stated that the North Hall Unit manager would have the fall packet. The DON reviewed the yellow folder post fall packets note to a shelf on the bookcase in his office. No post fall packet was found for Resident #84 in the DON's office. The DON stated that on April 14, 2024, the facility placed Resident #84 on 1 to 1 supervision while awake. An interview and observation was conducted on 05/21/24 at 12:29 PM with Licensed Practical Nurse (LPN) North Hall Unit Manager E regarding Resident #84's fall packets and a check off list that is part of the post-fall investigation. LPN E stated that the post-fall packet has everything that needs to be done post fall. Observation of a blank post fall packet revealed a 'Neurological Evaluation Flow Sheet', Incident/Fall Checklist, Incident & Accident Investigation Form, Resident #84 has had three falls since being admitted . LPN E stated that she did not do or have any post-fall packets for Resident #84. Record review of Resident #84's fall report, dated 4/14/2024, noted resident received a head injury. LPN E stated that the fall packets are filled out by the nurse at the time incident, then it goes to the Director of Nursing (DON), with the previous DON, the fall packet and neurological checks were to be scanned into electronic medical record system. LPN E stated that she had not seen or received a post-fall packet for the falls of Resident #84. LPN E stated that the facility had process that was working, and the facility got new management and the process stopped, if The DON does not have them then the there is none. 34568 Resident #17 (R17): Review of R17's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including dementia with other behavioral disturbances. According to the 3/1/24 Quarterly Minimum Data Set (MDS) assessment, R17 received a 4/15 on the Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. Review of R17's Progress Notes read, in part, 5/5/24 Resident was assisted to Central unit by another nurse who said resident was visiting another resident and fell . Resident was sitting in his wheelchair with his right hand wrapped in ice. Resident tip of right finger was ben upward .resident to be transferred to ER (emergency room ) .5/6/24 patient transferred back to facility via w/c (wheelchair) .X-ray results to right hand indicating has fractures to the third and fourth metacarpals. Cast noted to right hand up to arm is intact . On 5/20/24 at 11:52 a.m. R17 was observed in the hallway with his right arm noted to be in a cast wrapped with an ACE bandage. An interview with the Director of Nursing (DON on 5/21/24 at approximately 4:30 p.m. confirmed R17's injury of unknown source did not include witness statements from staff. The DON stated that R17 and the other resident involved were able to tell you what happened despite being cognitively impaired, and that staff were able to see R17 exit the room. The DON stated that R17 was asked to visit this specific resident in more public areas instead of her private room, and that was not followed and the time of the incident. During this interview with the DON, R17 was observed to be wheeling by the office. R17 was asked if he could recall the incident that took place on 5/5/24. R17 stated, Fall down, go boom! and pointed to the sidewalk outside. The DON stated that R17 knows that he should not have been visiting the female resident (later identified as R66) and is changing his story. On 5/22/24 at 9:05 a.m. an interview was attempted with R66. R66 recalled that R17 was in her room. When asked what happened, R66 stated, Well he (R66) likes to cuddle on the bed and likes to hum-hum with his hands. R66 could not recall when or how R17 fractured his hand and continued to attempt to fold towels on her bed. On 5/22/24 at 9:19 a.m. a follow up interview was conducted with the DON. When told what R66 had stated earlier, the DON confirmed that R66's cognition changes from day to day. The DON stated that they saw R17 come out of R66's room and did not suspect abuse. Review of R17's care plan read, in part, (R17) is at risk for falls or fall related injury r/t (related to), poor safety awareness, confusion, incontinence, gait/balance problems .he has a hx (history) of falls including recent fall with metacarpal fractures . It was noted that the interventions listed for R17 did not include increase in supervision or to attempt to keep R17 out of other resident rooms.

This citation pertains to intake MI00138477. Based on interview and record review, the facility failed to prevent an injury during activities of daily living (ADL) care for one (Resident #7) of three reviewed for accidents, resulting in Resident #7 sustaining a fractured hip during a shower. Findings include: Review of the medical record reflected Resident #7 (R7) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included unspecified intracapsular fracture of right femur, aftercare following joint replacement surgery and presence of right artificial hip joint. The significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/14/23, reflected R7 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required total assistance (a decline from extensive assistance on the 7/1/23 quarterly MDS) of two or more people for bed mobility and transfers. A discharge return anticipated MDS, with an ARD of 7/24/23, reflected R7 was coded for one fall with major injury since admission or the prior assessment, whichever was more recent. R7 discharged from the facility on 9/11/23. An SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers Progress Note for 7/24/23 at 9:02 PM reflected, .Functional Status Evaluation: Fall .Resident has moderate severe pain in R [right] hip. Recommendation stat exray [sic] and pain medication or transfer to hospital . The Primary Care Provider Feedback reflected a recommendation for an x-ray. A Progress Note for 7/24/23 at 9:25 PM reflected, .Resident and [significant other] want to have resident taken to the ER .Resident is claiming he fell out of shower bed today [sic] shower aid states this did not happen. Resident complains of r [right] hip pain and r [right] toe pain. Resident given stat pain medicine and a stat r hip exray [sic] ordered. Resident still wants to go to hospital . A facility investigation included a typed interview with former Director of Nursing (DON) S for 8/1/23, which revealed that the first shift nurse notified her around 4:30 PM that R7 reported falling in the shower. The facility investigation included a typed statement from Certified Nurse Aide (CNA) L for 7/25/23, which revealed that while bathing R7, he was rolled with his left side going towards the wall. The bed rail gave, and R7 rolled further, with his left leg going off the rail and hitting the wall. R7's hip and body went towards the wall. She did not remember R7's body hitting the wall but stated it could have. CNA L reached to grab R7 and to keep him from falling off the shower bed. From her strength, she was able to pull him back up on the shower bed. R7 was bleeding from his arm and toe. She rinsed off the blood and took R7 back to his room for care. In the room, R7 was complaining of pain. The nurse dressed the wound on R7's buttocks and his arm. CNA L covered R7's toe with a towel and blanket. CNA L put on R7's T-shirt, finished care and left the room. Additionally, the facility's investigation reflected the shower bed had since been removed from the facility until it could be repaired or replaced. The investigation did not include why the shower bed needed to be repaired or replaced. An attempt was made to contact CNA L via phone on 2/21/24 at 1:13 PM. A voicemail was left, but a return call was not received prior to the survey exit on 2/22/24. CNA L was no longer employed by the facility at the time of the survey. Review of CNA L's personnel file included a Care Team Member Corrective Action Form, dated 7/25/23, which reflected CNA L was suspended pending investigation, at 11:06 PM, once the investigation revealed the care team member may have been involved. The document reflected the incident was not discovered until 7/25/23 at 8:00 PM. The description of the violation reflected Abuse/neglect allegation. A Care Team Member Corrective Action Form, dated 7/28/23, reflected the refusal to cooperate in investigation of an allegation and that CNA L was not truthful or forthcoming with information during the investigation. The corrective action reflected CNA L's employment was terminated. During a phone interview on 2/22/24 at 9:11 AM, LPN K reported recalling that R7 claimed he had fallen in the bathroom, while being showered. She reported to her boss, former DON S. LPN K stated she assisted the CNA to transfer R7 from the shower bed to bed. R7 said his right leg hurt, and she asked if he wanted something for pain. LPN K reported administering medication for pain. She noticed an abrasion on R7's elbow. LPN K asked the CNA about it, who reported R7 got scraped when she turned the shower bed around. When going back to reassess pain, R7 said he thought his hip hurt and that he broke his hip. When LPN K asked how he would have broken his hip, R7 said he fell . The facility's investigation included a typed statement from RN M for 8/1/23, which revealed she received in report that R7 was claiming he fell out of the shower bed and wanted to go to the hospital. When answering R7's call light after report, R7 complained of right hip pain. R7 told RN M that he had fallen and that was why his hip was hurting. A few minutes after R7 was given pain medication and notified of a STAT x-ray order, R7's significant other informed RN M that R7's right big toe was bleeding. According to RN M's statement, R7's toenail was almost completely ripped off and it was bleeding rather heavily. There was gauze inside R7's sock to absorb the blood and prevent bleeding through the sock. R7 stated he wanted to go to the hospital. An attempt was made to contact RN M via phone on 2/22/24 at 10:29 AM. A voicemail was left, but a return call was not received prior to the survey exit on 2/22/24. RN M was not longer employed by the facility at the time of the survey. R7's July 2023 Medication Administration Record (MAR) reflected 650 milligrams (mg) of Tylenol was administered for level four out of ten pain at 4:00 PM on 7/24/23 and was noted to be ineffective. R7 received 50 mg of tramadol for level four out of ten pain at 4:27 PM on 7/24/23, which was documented to be effective. R7 received 50 mg of tramadol for level five out of ten pain at 7:46 PM on 7/24/23, which was documented to be ineffective. A hospital Orthopedic History and Physical for 7/25/23 at 3:23 AM reflected, .Chief Complaint: pt [patient] states he fell from bed, per ECF [extended care facility] he did not fall. Pt c/o [complains of] right hip pain .presents today with right hip fracture status a [sic] fall while being carried out of the shower .Patient was at the extended care facility where he was taking shower when he was dropped while getting out of the shower .Right lower extremity is externally rotated and slightly shortened in comparison to contralateral left .Tenderness to palpation was elicited with direct palpation about the level of the lateral aspect of the thigh .Unable to examine range of motion due to pain referred from the hip .X-ray of the pelvis, right hip does reveal a subcapital femoral neck fracture .Given the patient's right subcapital femoral neck fracture, recommendation is for operative intervention in the form of right hemiarthroplasty . A Surgical Documentation Operative Report for 7/27/23 at 5:41 PM reflected R7 underwent surgery for a right displaced femoral neck fracture. During an interview on 2/22/24 at 1:36 PM, DON B stated he was not employed by the facility at the time of R7's fracture.

Based on observation, interview and record review, the facility failed to implement and operationalize processes and procedures to ensure monitoring, accountability, and pharmacological oversight of controlled medications in the Med-bridge and North Hall of the facility per professional standards of practice. This deficient practice resulting in lack of appropriate storage, securement, reconciliation, administration, and disposal and/or return of controlled medications including lack of accurate comprehensive documentation and reconciliation of Methadone (prescription opioid medication frequently used to treat individuals with opioid dependence) brought into the facility, and the likelihood for inappropriate medication use and administration, accidental exposure, and diversion which has the potential to effect all 92 residents residing in the facility. Findings include: A tour of the North Hall Medication Cart with Licensed Practical Nurse (LPN) MM on 4/26/23 at 8:33 AM. Within the medication cart, an unlabeled medication cup filled with pills was observed in the locked narcotic drawer. When queried what the medications in the cup were, LPN MM replied that the medications were for Resident #247. When asked why the medications were in the drawer, LPN MM revealed they had pulled the meds to administer to the Resident but they were not in their room, so they put them in the drawer. When queried what medications were in the cup, LPN MM indicated the medication cup contained the Resident's morning medications. When asked if there were any narcotic/controlled medications, LPN MM revealed the medication up contained a Norco (controlled, narcotic medication for pain) and Gabapentin (controlled medication used to treat nerve pain). When queried if they had documented the medications as administered on Resident #247's Medication Administration Record (MAR), LPN MM indicated they had. Resident #247's Controlled Medication Administration Count Documentation Record was reviewed and reconciled with LPN MM at this time. The paper Controlled Medication Count Documentation Record form for Resident #247's for Norco 7.5/325 milligram (mg) and Gabapentin 300 mg did not match the number of pills in the Resident's bubble pill package. For both medications, there was one less pill in the blister pack than on the Controlled Medication Administration Count Documentation Record. When queried why the number of pills did not match (reconcile) with the number on the Controlled Medication form, LPN MM revealed they had not documented the medication on the Controlled Medication form. All Resident's narcotic medications within the cart were counted and reconciled with LPN MM at this time. The following discrepancies were identified: - Norco 5/325 mg blister pack for Resident #250. Controlled Medication Administration Count Documentation Record specified there should be 22 pills in the Resident's medication blister pack. The medication blister pack only contained 21 pills. - Norco 7.5/325 mg blister pack for Resident #251. Controlled Medication Administration Count Documentation Record specified there should be 3 pills in the Resident's medication blister pack. The medication blister pack only contained 2 pills. - Norco 5/325 mg blister pack for Resident #245. Controlled Medication Administration Count Documentation Record specified there should be 22 pills in the Resident's medication blister pack. The medication blister pack only contained 21 pills. - Clonazepam (controlled medication used treat/prevent seizures and anxiety) Disintegrating Tablets 0.25 mg for Resident #248. Documentation Record specified the Resident should have 30 tablets. There were 29 individually wrapped tablets in the medication cart. - Norco 7.5/325 mg blister pack for Resident #248. Controlled Medication Administration Count Documentation Record specified there should be 52 pills in the Resident's medication blister pack. The medication blister pack only contained 51 pills. - Norco 5/325 mg blister pack for Resident #246. Controlled Medication Administration Count Documentation Record specified there should be 3 pills in the Resident's medication blister pack. The medication blister pack only contained 2 pills. When queried regarding the discrepancies on the Controlled Substance Shift Inventory forms and the narcotic/controlled medications present in the medication cart, LPN MM stated, Gave the meds but didn't sign them out (on form). When asked why they did not sign out the medications, LPN MM revealed they were going to sign the medications out later. When queried regarding the facility policy/procedure pertaining to administration of controlled substances and documentation, LPN MM revealed they were supposed to sign out the medications on the form. When queried how another nurse would know the medication had been administered when it was not signed out, an explanation was not provided. A review and reconciliation of the North Hall Controlled Substance Shift Inventory form for April 2023 was completed with LPN MM at this time. When asked about the form, LPN MM revealed the form is utilized to count the total number of controlled medication blister packs in the cart. The form included documentation sections for Date, Time, Total # of RX (prescription) at start of shift . (+) Received from Pharmacy, (-) Emptied by Nurse, Total at End of Shift, Initial Signed: Means no discrepancies on blister packs, Outgoing Nurse, Incoming Nurse, # Turned into DNS (Director of Nursing Services). The following inaccuracies and discrepancies were identified upon review of the Controlled Substance Shift Inventory form for April 2023: - 4/6/23 at 6:00 PM: Total # of RX (prescription) at start of shift = 34; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 3; Total at End of Shift: 34 . The date was initialed as having no discrepancies. - 4/7/23 at 6:00 AM: Total # . at start of shift = 35; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 1; Total at End of Shift: 34 . The date was initialed as having no discrepancies. - 4/8/23 at 6:00 PM: Total # . at start of shift = 36; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 5; Total at End of Shift: 36 . The date was initialed as having no discrepancies. - 4/8/23 at 10:00 PM: Total # . at start of shift = 36; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 0; Total at End of Shift: 31 . The date was initialed as having no discrepancies. - 4/9/23 at 6:00 AM: Total # . at start of shift = 31; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 0; Total at End of Shift: 30 . The date was initialed as having no discrepancies. - 4/11/23 at 6:00 PM: Total # . at start of shift = 35; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 0; Total at End of Shift: 32 . The date was initialed as having no discrepancies. - 4/12/23 at 6:00 AM: Total # . at start of shift = 31; Received from Pharmacy = (+) 0; Emptied by Nurse: (-) 14; Total at End of Shift: 18 . - 4/12/23 at 6:00 PM: Total # . at start of shift = Blank; Received from Pharmacy = Blank; Emptied by Nurse: Blank; Total at End of Shift: Blank . The date was initialed as having no discrepancies. - 4/16/23 at 6:00 AM: Total # . at start of shift = 21; Received from Pharmacy = (+) 2; Emptied by Nurse: (-) Blank; Total at End of Shift: 22 . The date was initialed as having no discrepancies. - 4/21/23 at 6:00 PM: Total # . at start of shift = 38; Received from Pharmacy = (+) 6; Emptied by Nurse: (-) 1; Total at End of Shift: 27 . The date was initialed as having no discrepancies. The following incomplete/missing documentation was noted on the Controlled Substance Shift Inventory Form: - No documentation of Total # of RX (prescription) at start of shift on: 4/10/23 at 6:00 PM and 4/12/23 at 6:00 PM. - No documentation under section of form titled: Initial Signed: Means no discrepancies on blister packs on: 4/6/23 at 6:00 AM, 4/9/23 at 6:00 PM, 4/11/23 at 6:00 AM, 4/1/23 at 6:00 AM, 4/13/23 at 10:00 PM, 4/14/23 at 6:00 AM, 4/14/23 at 6:00 PM, 4/25/23 at 6:00 AM, 4/15/23 at 6:00 PM, and 4/26/23 at 6:00 AM. - No documentation of Total at end of shift on 4/12/23 at 6:00 PM and 4/13/23 at 6:00 PM. - No signature and/or initials of Outgoing Nurse and/or Incoming Nurse on 4/24/23 at 10:00 PM. - No signature and/or initials of Incoming Nurse on 4/26/23 at 6:00 AM. An interview and review of the North Hall Controlled Substance Shift Inventory form for April 2023 was completed with the Director of Nursing (DON) at 9:30 AM on 4/26/23. When queried regarding the facility policy/procedure related to controlled/narcotic medication administration and documentation, the DON stated, Should be signed out on the form. The DON revealed they were aware LPN MM had not documented administration of controlled medications. When queried regarding the medication cup filled with pills, including narcotic/controlled medications, in the cart drawer, the DON stated, They (meds) should have been wasted. The Controlled Substance Shift Inventory form was reviewed with the DON including identified inaccuracies. The DON verified the inaccuracies and incomplete documentation. When asked who is responsible for monitoring the form and ensuring periodic reconciliation of controlled medication inventory, the DON replied, My unit managers are supposed to be doing it. With further inquiry, the DON revealed the current process was not working and would need to be changed. When asked how they were able to identify and prevent loss and/or diversion of medications with the current documentation, the DON was unable to provide an explanation. A tour of the North Hall Medication room was conducted with Unit Manager LPN TT on 4/28/23 at 9:09 AM. During the tour, a black box was observed towards the back left side in a cabinet above the sink. The box was sitting on an open plastic bag with the front of the box facing the cabinet door. There was no identification present on the top of the bag/open box. Upon removal of the box from the cabinet, it was noted to be an opened and unlocked black metal lockbox. The lockbox appeared worn and had a key lock. The locking mechanism on lockbox was engaged causing the box to be opened with the key lock remaining in the locked position. The locking mechanism had visible wear and appeared damaged. The box contained two packages of very old appearing Tic Tacs, a Bridge benefit card for Witness AAA, and 15 bottles. LPN TT was asked what the bottles were and indicated they did not know. Upon touching the bottles to identify the contents, the bottles were noted to be sticky, and the contents were identified as liquid methadone. There were eight empty bottles and seven bottles of liquid methadone (prescription opioid drug) labeled for administration to Resident #253 in the lockbox. The label on each bottle specified, (Resident #253) . Methadone . Dosage: 200 mgs (milligrams) . Detailed inspection of the medication bottles revealed each of the seven bottles of liquid methadone specified the same dosage was in the container; however, there was a different amount of liquid in each bottle. LPN TT was queried regarding Resident #253, and they revealed the Resident no longer resided in the facility but was unsure of their discharge date . There was no documentation and/or reconciliation of how much methadone was originally brought into facility. LPN TT was asked when and how much medication was brought into the facility. LPN TT revealed they did not know. LPN TT was asked to have the DON come to the medication room. When queried who audits and monitors the medication storage room, LPN TT did not provide a response. LPN MM entered the medication room at this time and were asked if they knew anything about the Methadone. LPN MM did not respond. Resident #253's face sheet including their admission/discharge date s was requested. A paper was noted on the bottom of the outside of the open bag which had been positioned under the lock box. Review of the paper detailed, Security Bag . Instructions . 4 . Remove adhesive backing and fold at line indicated to create tamper evident seal . Other: Lockbox with methadone. Box is locked. No Key . The form was undated and contained illegible signatures of staff members. When asked whose signatures were on the form, LPN TT revealed they did not know. After arriving at the medication room, the DON was queried regarding the Methadone including the reason the medication was in the medication room. The DON examined the unlocked black metal lock box and was unable to provide an explanation. When queried regarding the facility policy/procedure for securement of controlled substances, the DON revealed narcotic/controlled medications are supposed to be accessible only to licensed nurses. When asked if narcotic/controlled substances should be double locked, the DON replied, Yes. When asked if all controlled medications which enter the facility should be accounted for, the DON responded that they should be. The DON was then asked why the Security Bag . Instructions . form indicated bag was sealed and the box was locked with no key when the bag was not sealed, and the box was clearly unlocked. The DON was unable to provide an explanation. A review of Resident #253's face sheet was completed at the time. Per the face sheet, Resident #253 was admitted to the facility on [DATE] and discharged on [DATE]. When queried if the lockbox had been in the facility since 9/14/22 when the Resident was admitted , LPN TT indicated they believed it came with the Resident when they were admitted . When asked why it was not sent home with the Resident when they were discharged , neither the DON nor LPN TT were able to provide an explanation. When queried how they knew the total amount of Methadone that was present in the box when the Resident was admitted , the DON stated, I don't know and indicated they would look for documentation. When asked what should have happened with the Methadone when it was brought into the facility, the DON revealed the medication should have been counted and documented by two nurses and returned to the Resident upon discharge and/or sent home with family if available/appropriate. No explanation was provided when asked why that did not occur. When queried why each bottle with liquid Methadone had a different amount of liquid but the label indicated it contained the same dosage, the DON was unable to provide an explanation. Review of Resident #253's medical record revealed the Resident was originally admitted to the facility on [DATE] with diagnoses which included depression, alcohol use, abdominal hernia, hepatitis C, and drug abuse surveillance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all Activities of Daily Living (ADL's) with the exception of eating. Review of Resident #253's Michigan Admission Agreement . EXHIBIT G . Inventory of Resident's Belongings . Date: 9/30/22 . Name of Facility Staff Performing Inventory: (Admission Staff YY) . List of Resident's Personal Belongings . In patients' chart . A list of Resident #253's personal belongings was not noted in their medical record. A Controlled Medication Administration Count Documentation Record for Methadone 200 mg was also not present in the medical record. Review of documentation in Resident #253's medical record revealed the following: - 9/14/22 at 11:31 PM: General Progress Note .Writer was given report from (Hospital). Resident was brought in alone about 17:15 via ambulance. Ambulance gave writer residents property lock box that had medications and other property such as Tic Tacs, which was witnessed by second nurse being locked in med room . (Authored by LPN BBB) - 11/3/22 at 2:05 PM: General Progress Note . Resident was discharge . leave with two EMT driver. Resident took all belong with (them) . (Authored by LPN MM) Review of staff list provided by the facility revealed LPN BBB was not listed as an employee. On 4/28/23 at 2:30 PM, Resident #253 was attempted to be contacted at the phone number listed on the facility provided face sheet. The phone number did not belong to Resident #253. A detailed review of Resident #253's face sheet revealed Witness AAA was listed as an emergency contact. Witness AAA was contacted on 4/28/23 at 2:40 PM. When queried if they had Resident #253's current contact information, Witness AAA revealed they were with the Resident and gave them the phone. An interview was completed at this time. When queried if they recalled their stay at the facility, Resident #253 verbalized they did. When asked if they had taken their home methadone with them when they were admitted to the facility, Resident #253's voice raised and began speaking in an upset tone. The Resident stated, They stole it at (Hospital). I never got it back. It was in my lock box. Resident #253 continued, I filed a complaint with the hospital. I can get in trouble at the Meth clinic. When asked what they meant regarding the Meth Clinic, Resident #253 revealed they were going to a Methadone clinic as part of their recovery from intravenous (IV) drug use and that the Methadone had very specific rules and regulations related to Methadone. Resident #253 then stated, Have to keep it (Methadone) in a lock box. I had to buy a new one (lock box). Resident #253 was asked if they were aware the Methadone and lockbox were at facility and stated, No. I thought they stole it at the hospital. Resident #253 questioned, You mean it's at the facility? When queried if they recalled what was in the lockbox when they went to the facility, Resident #253 stated, Been a long time but six or seven bottles (of Methadone). Resident #253 then stated, They (Methadone bottles) are 200 milligrams (each). I take 100 mg in the morning and 100 mg at night. When queried if all the bottles have the same amount of liquid in them when they receive them from the Methadone clinic and replied, Yes, why. Resident #253 was then asked if there was a reason all the bottles with Methadone in them had different amounts of liquid in the bottles and stated, They all have the same amount in them when I get them. They must have taken some out off the top. With further inquiry, Resident #253 stated, My nurse there goes to the Methadone Clinic with me. Resident #253 was asked if they were saying a nurse who worked at the facility and cared for them went to Methadone clinic with them, Resident #253 replied, I don't want to get them in trouble. When queried if the box was locked when they last had it, Resident #253 stated, Yes. I still have the key. I want it back. Resident #253 reiterated they can get in trouble at the Methadone clinic. Resident #253 stated, I have to keep track of it all. I didn't know they had it (at the facility). I want it back. When asked if there were any empty bottles in lock box, Resident #253 replied, Yes, I have to take the empty bottles back to the (Methadone) clinic. With further inquiry, Resident #253 revealed they are supposed to keep the empty bottles locked up in the lock box and take the entire lock box with them when they go to Methadone Clinic. Resident #253 verbalized they were upset their lockbox was at the facility, they did not know, and had filled a complaint against the hospital. The Resident expressed how difficult it was for them to stop doing drugs, how the Methadone Clinic had helped them, and the difficulties they experienced when they did not have their lockbox and Methadone to return to the clinic. When queried why they thought the hospital had taken their lockbox and Methadone, Resident #253 revealed they asked a nurse at the facility about it and were told it was not there. When asked the name of the nurse who had told them that, Resident #253 provided a physical description but was unable to recall the nurse's name. Resident #253 verbalized they were very upset that the facility did not return their property to them. On 5/1/23 at 10:34 AM and 5/4/23 at 2:10 PM, the Methadone Clinic listed on Resident #253's prescription bottles were contacted and a message with return number was left for Supervisor CCC. A return phone call was not received. LPN BBB's contact information was requested from Human Resources Staff DD on 5/3/23 at 12:22 PM but not received by the conclusion of the survey. No further documentation related to reconciliation of Resident #253's Methadone was provided prior to the conclusion of survey. Review of facility provided policy/procedure entitled, Medication Administration (Revised 3/23) revealed, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 18. If medication is a controlled substance, sign narcotic book . Review of facility provided policy/procedure entitled, Controlled Substance Administration & Accountability (No Date) detailed, Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure . 1. General Protocols: a. Controlled substances are stored in a separate compartment of an automated dispensing system or other locked storage unit with access limited to approved personnel . All controlled substances (Schedule II, III, IV, V) are accounted for in one of the following ways . ii. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. iii. All specially compounded or non-stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the Controlled Drug Record supplied with the medication or other designated form as per facility policy . h. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. i. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy . j. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify . i. Controlled substances that are destroyed are appropriately documented; and ii. Medications removed from either the automated dispensing system or medication cart/cabinet have a documented physician order . 2. Storage and Security . b. Areas without automated dispensing systems utilize a substantially constructed storage unit with two locks and a paper system for 24-hour recording of controlled substance use . Obtaining/Removing/Destroying Medications . d. Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Drug Disposition Record, Controlled Drug Record, or via the automated dispensing system . 9. Inventory Verification . b. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift . e. Any discrepancies which cannot be resolved must be reported immediately as follows: i. Notify the DON, charge nurse, or designee and the pharmacy; ii. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted; iii. The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy and possibly the State Licensure Board for Nursing Home Administrators. f. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies .

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer (wounds caused by pressure) care for five residents (Resident #10, Resident #21, Resident 37, Resident #245, and Resident #250) of seven residents, resulting in a lack of implementation of resident-centered and/or planned interventions, timely assessment, inaccurate documentation/staging of wounds/pressure ulcers, care per professional standards of practice, Resident #245 developing a Deep Tissue Injury (DTI-unstageable pressure injury with unknown depth due to damage to underlying tissues) and Stage II (partial thickness loss of tissue presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcers, unnecessary pain, and the likelihood for decline in overall health status. Resident #245: An observation of Resident #245 occurred on 4/25/23 at 12:45 PM in their room. The Resident was laying in bed, positioned on their back with their heels directly on the mattress. An interview was completed at this time. Resident #245 appeared uncomfortable during the interview with noted facial grimacing. When asked if they were in pain, Resident #245 revealed they were and stated, I have a sore on my butt. Resident #245 was asked if they had any other pain, Resident #245 indicated they did but the wound on their buttocks was bothering them the most. When queried if they received interventions for pain relief, including medications, Resident #245 indicated they did not receive scheduled medication but were able to receive a pain pill when they ask nursing staff. Resident #245 was then asked how frequently staff reposition them in bed and revealed they are only repositioned when staff check their brief and/or provide incontinence care. When queried how frequently that occurs, Resident #245 revealed it is usually once or twice during a shift. Resident #245 was then asked how often they get out of bed and/or leave their room and replied, Don't leave (their room) to do anything. When asked if they are able to move their legs and feet, Resident #245 revealed they had limited mobility on their own and depended on staff to assist them. When queried regarding their heels being positioned directly against the mattress and if staff elevate their feet and heels off of the bed, Resident #245 revealed they do not and stated they used to have boots that they would wear in bed but did not know what happened to them. With permission from the Resident, an observation of their room was completed, and no heel/positioning boots were present in the room. At 2:20 PM on 4/24/23, Resident #245 was observed laying on their back in bed with their heels positioned directly on the mattress. An interview was completed with Certified Nursing Assistant (CNA) KK on 4/25/23 at 2:24 PM. When queried regarding Resident #245, CNA KK revealed the Resident required staff assistance to turn and reposition in bed and for Activity of Daily Living (ADL) care. When asked if staff work eight or 12-hour shifts, CNA KK specified shifts are scheduled for eight hours. CNA KK then stated, I'm staying over until 6:00 PM because of low staffing. With further inquiry, CNA KK revealed there would only be one aide working on the North and Medbridge units if they did not stay over (24 Residents reside on the units). When asked, CNA KK revealed the facility was frequently short staffed. On 4/26/23 at 10:04 AM, Resident #245 was observed in their room. The Resident was in bed, positioned on their back with their heels directly against the mattress. An interview was completed with LPN MM on 4/26/23 at 8:24 AM. When asked if any Residents they were assigned to care for had wounds and/or wound treatments, LPN MM stated, Resident #245 has an open wound on their coccyx. Record review revealed Resident #245 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Parkinson's disease, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and was totally dependent upon staff for all ADL's with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development, did not have any pressure ulcers, but did have Moisture Associated Skin Damage (MASD- skin damage caused by prolonged exposure to excessive moisture). Review of Resident #245's Electronic Medical Record (EMR) revealed the Resident did not have a resident centered care plan pertaining to their wounds with personalized interventions. A care plan entitled, Resident is at Risk for skin breakdown (Initiated: 4/7/23) was present in the EMR. The care plan included the interventions: - Assist with bed mobility to turn and reposition routinely (Initiated: 4/7/23) - Assist with routine toileting (Initiated: 4/7/23) - Preventative skin care as ordered/indicated (Initiated: 4/7/23) - Skin inspection weekly and as needed, document and notify MD of abnormal findings (Initiated: 4/7/23) Additional review of Resident #245's Electronic Medical Record (EMR) revealed the following documentation: - 4/6/23: Nursing Admission/Readmission Evaluation . Skin Conditions . Groin MASD . Right buttock MASD . Right thigh (front) inner MASD . Right toe(s) lateral great toe red blanchable area tx (treatment) in place . Left toe(s) tip of great toe old, discolored area . - 4/7/23: History and Physical (Physician) . came to this facility after a recent hospitalization . here for rehab and medical care . Positive: Fatigue, Low energy . Skin . Negative . Changes in skin color . Bruises, Rash . Open lesions . Skin: No rash or bruises noted . Negative: Changes in hair or nails, Changes in skin color, Swelling, Itching, Bruises, Rash, Mass, Open lesions . - 4/10/23: Progress Notes (Nurse Practitioner) . Skin: No acute changes . - 4/12/23 at 7:56 AM: Non-Pressure Ulcer - Weekly Observation . (Lock Date: 4/21/23) . Coccyx . MASD . Unchanged . Dry . Drainage: None . Length: 8.5 (centimeters [cm]) . Width: 5.5 (cm) . Current treatment plan: Apply barrier cream Q (every) shift . Wound Progress: Unchanged . - 4/12/23: Progress Notes (Nurse Practitioner) . Skin: No acute changes . - 4/14/23 at 3:26 PM: Weekly Nursing Summary . Weekly Skin Assessment . 1. Resident skin condition: Warm and dry . 2. Skin turgor . a. Normal turgor . 4. Indicate any current tissue injury . No Current Issues . - 4/17/23: Progress Notes (Nurse Practitioner) . Skin: No acute changes . - 4/19/23 at 7:51 AM: Non Pressure Ulcer - Weekly Observation . (Lock Date: 4/21/23) . Coccyx . MASD . Unchanged . Dry . Drainage: None . Length: 5.5 (cm) . Width: 5.5 (cm) . Describe any changes to treatment plan in the last week: Treatment changed to Hydrogel (wound dressing used for partial and full thickness loss wounds and wounds with slough [moist white/yellow colored wound exudate wound exudate] or eschar [necrotic tissue]) . 2. Current treatment plan: Cleanse coccyx with wound cleanser apply hydrogel cover with border gauze daily and PRN (as needed) . Wound Progress: Unchanged . - 4/20/23 at 1:49 PM: IDT . Risk Review . Reason for review: Weekly Follow-up . IDT Recommendation: IDT team met to discuss resident's plan of care for wound care treatments. Resident presents with 2 wounds: one on buttocks and one on right inner thigh. Coccyx wound unchanged new treatment started, inner right thigh resolved. There are no changes to diet order at this time, new treatment order . for buttocks. Resident is currently not on any additional supplements. Will continue to monitor. - 4/20/23: Progress Notes (Nurse Practitioner) . Skin: No acute changes . - 4/21/23 at 7:28 PM: Weekly Nursing Summary . Weekly Skin Assessment . 1. Resident skin condition: Warm and dry . 2. Skin turgor . a. Normal turgor . 4. Indicate any current tissue injury . No Current Issues . - 4/24/23: Progress Notes (Nurse Practitioner) . Skin: No acute changes . Review of Resident #245's Health Care Provider orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) revealed the following wound care treatments: - Apply house barrier cream to (B [bilateral]) buttocks, coccyx, right inner thigh, and peri-area every shift with incontinent episodes. May keep at bedside to be reapplied as needed every shift (Ordered: 4/6/23; Start Date: 4/7/23) - Cleanse coccyx with wound cleanser pat dry apply hydrogel cover with border gauze daily and PRN (as needed) for wound care (Ordered: 4/21/23; Start Date: 4/21/23). The treatment was not completed on 4/21/23. - Cleanse coccyx with wound cleanser pat dry apply hydrogel cover with border gauze daily and PRN every day shift for wound care (Ordered: 4/21/23; Start Date: 4/22/23) - Cleanse right lateral great toe with wound cleanser pat dry apply skin prep to right great toe daily every day shift for wound care (Ordered: 4/7/23; Start Date: 4/8/23) On 4/27/23 at 11:16 AM, Resident #245 could be heard from the hallway of the facility yelling Help me, help me repeatedly. Upon entering the Resident's room, Resident #245 was observed laying in bed, positioned on their back with their heels directly against the mattress. The Resident's call light was hung over the dresser next to their bed and not within their reach. When queried what was wrong, Resident #245 replied, The pain in my buttocks. Resident #245 was visibly uncomfortable, unsuccessfully attempting to move in the bed and non-verbal signs/symptoms of pain including facial grimacing. When asked if they had informed staff of their pain, Resident #245 revealed they had. Resident #245 stated, It been hurting since they changed me around 8:00 (AM). Resident #245 continued, I be hollering, and they get on me about that. When asked what that meant, Resident #245 revealed that facility staff told them to stop that hollering. When queried how that made them feel, Resident #245 revealed they did not like it and asserted, I can't (stop) because of the pain. Resident #245 was asked when they were last repositioned in bed and revealed it was when they were last changed around 8:00 AM. When asked to rate their pain on a scale from zero to 10, with 10 being the worst pain imaginable, Resident #245 stated their pain was a 10. While speaking to Resident #245, Unit Manager Licensed Practical Nurse (LPN) TT entered the Resident's room at 11:18 AM and administered Tylenol to the Resident. LPN TT did not assess the Resident's pain level/location nor provide any non-pharmacologic interventions including repositioning prior to exiting the room. Resident #245 revealed they were going to be discharged home today. When queried if their wound care treatments had been completed, Resident #245 answered they did not recall their wound care dressing being changed. Review of Resident #245's MAR and TAR revealed the Resident's wound care treatments had not been documented as completed on 4/27/23. An interview was completed with LPN TT on 4/27/23 at 11:26 AM. LPN TT was queried regarding Resident #245's pain level and stated, Five (out of 10). When asked what time they had assessed the Resident's pain level at five out of ten, LPN TT did not provide a response. When LPN TT was informed the Resident had stated their pain was at a 10/10, they did not provide further explanation. LPN TT was then queried if Tylenol was the only medication Resident #245 had ordered for pain and indicated they were only able to receive Tylenol at this time. A request to observe Resident #245's skin and wound care treatment prior to their discharge was requested with LPN TT at this time. LPN TT indicated the Resident's nurse had informed them they had already completed the treatment. When asked why Resident #245 did not recall the treatment being completed and the treatment was not documented as completed on the Resident's MAR/TAR, LPN TT revealed that was the first time they had seen the Resident that day and would let the Resident's nurse know. Further review of Resident #245's MAR and TAR revealed the following medication orders for pain management: - Hydrocodone-Acetaminophen (Norco- narcotic medication to treat moderate to severe pain) Oral Tablet 5-325 mg (milligram) . Give 1 tablet by mouth every 6 hours as needed for pain (Start Date: 4/6/23). Per the MAR, Resident #245 reviewed the medication multiple times during the month of April 2023 for pain levels ranging from zero to seven. The Resident had last received the medication on 4/6/23 at 7:31 AM. - Acetaminophen (Tylenol) Oral Tablet . Give 500 mg by mouth every 6 hours as needed for pain (Start Date: 4/7/23). Per the MAR, Resident #245 had received Tylenol once during their admission on 4/27/23 at 11:18 AM when administered by LPN TT. At 11:40 AM on 4/27/23, Resident #245 was observed laying in bed, positioned on their back with their heels directly on the mattress. On 4/27/23 at 11:42 AM, an observation of Resident #245's wound care treatment was completed with LPN MM and CNA CC. Upon entering the room, Resident #245 was observed in the same position in bed with their heels positioned directly against the mattress. When the facility staff were preparing the turn the Resident to complete the wound care treatment, discolored skin was observed on the medial aspect of the Resident's left heel. Upon request, an observation of the Resident's skin on their bilateral feet was completed. The area of Resident #245's left heel which had been positioned directly against the mattress was noted to be deep/dark red and black in color. When queried if the tissue was blanchable, LPN MM pressed the deep/dark red colored area of the skin, and the tissue was observed to be non-blanchable (lack of blood perfusion). When LPN MM pressed the skin on the Resident's heel, Resident #245 yelled, Ouch! and their facial grimacing was observed. When asked, Resident #245 revealed their heel hurt when touched. LPN MM was asked if the tissue was blanchable and replied, No. With further inquiry regarding the wound, LPN MM indicated they do not stage wounds. When asked if the area was caused by pressure and if it was a pressure ulcer, LPN MM confirmed it was and reiterated they did not stage pressure ulcers. On Resident #245's right foot an open area, approximately the size of a dime, was present on the Resident's right great toe. The wound bed was shallow with visible tissue loss and was shiny and pink in color. There was no dressing in place over the wound and noting in place to prevent the blankets from rubbing on the wound. When asked, Resident #245 revealed their pain level was a nine or 10 out of 10. LPN MM indicated they were going to wait to complete the wound care treatment. Following the observation, Resident #245 remained positioned on their back in bed. An interview was completed with Unit Manager LPN TT on 4/27/23 at 12:05 PM. LPN TT was asked when Resident #245 developed a pressure ulcer on their heel and stated, (Resident #285) doesn't have one. LPN TT was informed of skin observation completed with LPN MM and revealed they were unaware of the Resident having any new skin concerns. An observation of Resident #245's left heel was completed with Unit Manager LPN TT at this time. When queried regarding the skin alteration, LPN TT stated, It's a DTI. Definitely a DTI pressure injury. When asked if Resident #245 was at risk for pressure ulcer development, LPN TT confirmed they were. When queried regarding observations of the Resident's heels being directly on the mattress, lack of repositioning, and lack of planned interventions to prevent pressure ulcers, LPN TT was unable to provide an explanation. When queried regarding the frequency in which skin assessments are completed by nursing staff, LPN TT revealed skin assessments are completed weekly and documented in the EMR. When asked if skin observations are also completed when Resident's received showers, LPN TT revealed CNA's observe the skin and report any abnormalities to nursing staff. When asked about documentation of showers, LPN TT revealed showers are documented in the EMR and CNA's also fill out paper shower sheet forms. Resident #245's paper shower sheets were requested at this time. Review of Resident #245's shower documentation revealed the Resident had not received a shower in the past 30 days at the facility. An interview was completed with the Director of Nursing (DON) on 4/27/23 at 12:16 PM. When queried if they were aware Resident #245 had a new, facility acquired DTI pressure ulcer identified today during the requested skin observation by this Surveyor, the DON confirmed they had been made aware by facility staff. The DON then stated, It has been almost a week since the last skin assessment was completed. When queried if they were saying that Resident skin is only observed during the weekly skin assessment, the DON did not respond. When asked if Residents skin should be observed when daily care and showers are completed, the DON replied, They should. The DON was then asked if it was acceptable that the area had not been identified by staff, the DON stated, No. The DON was asked how often dependent Residents, such as Resident #245 should be repositioned per standards of care, the DON revealed Residents should be repositioned every two hours. The DON was then asked about observations of Resident #245's heels being directly against the mattress and not being repositioned in bed and was unable to provide an explanation. When queried if they were aware and agreed that it was a concern Resident #245 had developed a facility acquired pressure ulcer and the lack of interventions to prevent pressure ulcers, the DON stated, I know. At 12:44 PM on 4/27/23, an observation of Resident #245's coccyx wound care treatment was completed with LPN MM and CNA KK. Upon entering the room, Resident #245 remained positioned on their back in bed. The facility staff repositioned Resident #245 on their side to complete the dressing change and wound care treatment. The dressing in place on the Resident's coccyx was undated. LPN MM proceeded to remove the dressing and a moderate amount of off-gray colored; foul smelling drainage was noted on the removed dressing. The exposed wound bed had two distinct wound areas. The skin on Resident #285's sacrum/buttocks was red/maroon in color. The area was approximately two and a half inches long and two inches across. A separate, open wound was present directly over the Resident's coccyx. The wound bed was irregularly shaped and approximately the size of a dime. The wound bed had visible tissue loss and depth. The wound bed was pink and white and coated with white/yellow slough with attached edges. Following wound care observation, the following documentation was added in Resident #245's EMR: - 4/27/23 at 12:19 PM: Pressure Ulcer- Weekly Observation . Left heel . Length: 4.5 (cm) . Width 4 (cm) . 2a. Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired . 2b. Date acquired: 4/27/23 . What stage does ulcer currently present as? a. DTI (Suspected Deep Tissue Injury -pressure injury with unknown depth often seen as a localized area of discolored, intact skin due to damage of underlying tissue) . middle of left heel non-blanchable and firm . Describe any changes to treatment plan in the last week: Skin prep to be applied to left heel and profo boots to be worn while in bed . - 4/27/23 at 1:22 PM: Pressure Ulcer- Weekly Observation . Coccyx . Length: 5.3 (cm) . Width 5 (cm) . What stage does ulcer currently present as? c. Stage 2 . 5a. Overall Impression: d. Worsening . Drainage . None . Peri- Wound Tissue . intact . Describe wound edges and shape: well-defined . Wound Progress: Progressed . On 4/28/23 at 8:36 AM, an interview was conducted with the DON. When queried regarding Resident #245's coccyx pressure ulcer, the DON confirmed the wound was a pressure ulcer not MASD. The DON then stated, Nurses assess (skin) weekly and indicated the Resident's skin assessment had not been completed for the week yet. The DON continued, The nurse would have caught it when the assessment was completed. When asked why the change in the wound was not identified and documented by the floor nursing staff who completed daily dressing changes, the DON replied, The nurse noticed the change (in the wound) but didn't change the classification. When asked if they were referring to the wound care treatment being changed from barrier cream to hydrogel on 4/21/23, the DON verified they were. When asked why the treatment order was not changed until 4/21/23 and not implemented until 4/22/23 when the wound (Non-Pressure Ulcer - Weekly Observation) assessment completed on 4/19/23 specified the wound treatment was changed to Hydrogel, the DON did not provide an explanation. When queried why the wound was documented as MASD and not a facility acquired pressure ulcer following the change in the wound, the DON reiterated the nurse did not change the wound classification after identification of the change. When queried if the pressure ulcer was a facility acquired pressure ulcer, the DON confirmed it was. The DON was then asked if stage two pressure ulcers have slough in the wound bed and indicated they did not. When asked why Resident #245's pressure ulcer was documented as a stage two pressure ulcer when the wound bed had visible slough, the DON was unable to provide an explanation. (Note: Stage three pressure ulcers have full thickness tissue loss and slough may be present). Resident #10: On 4/26/23 at 11:30 AM, Resident #10 was observed in their room in bed with their eyes closed. The Resident was positioned on their back with their heels directly on the mattress. An alternating air mattress was in place on the Resident's bed. The alternating air mattress was not making any noise and there were no lights on. Closer inspection of the air mattress controller revealed the power switch was in the off position and the alternating air mattress was turned off. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), bipolar disorder, epilepsy, dysphagia (difficulty swallowing), and gastrostomy (tube inserted into the stomach through a surgically created opening in the abdominal wall for the insertion of food). Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total assistance to complete all ADL's with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development and had one stage two pressure ulcer. Review of Resident #10's care plans revealed a care plan entitled, Resident has impaired skin integrity right buttocks small, scabbed area left buttocks MASD (Initiated: 3/22/23; Revised: 3/23/23). The care plan included the interventions: - Assess and document skin condition, notify MD of signs of infection (redness, drainage, pain, fever) (Initiated: 3/22/23) - Assess for pain and treat as indicated (Initiated: 3/23/23) - Assist with bed mobility to turn and reposition routinely (Initiated: 3/23/23) - Assist with toileting (Initiated: 3/23/23) - Check for incontinence and provide incontinent care as needed. Notify nurse of any redness or irritation (Initiated: 3/23/23) - Notify MD of worsening or not improvement in wound (Initiated: 3/23/23) - Pressure reducing/redistributing cushion in chair (Initiated: 3/23/23) - Pressure reducing/redistributing mattress on bed (Initiated: 3/23/23) - Wound treatment as ordered (Initiated: 3/23/23) Review of Resident #10's Health Care Provider orders revealed the Resident did not have an active wound care treatment order. The following active orders related to pressure ulcer prevention were in place: - Pressure reduction mattress every shift . (Ordered: 3/22/23) - Pressure reduction cushion to wheelchair every shift . (Ordered: 3/22/23) - Apply house barrier cream to (B [bilateral]) buttocks, coccyx, and peri-area every shift with incontinent episodes. May keep at bedside to be re-applied as needed (Ordered: 3/22/23) There were no orders in the EMR specifying the settings for the Resident's alternating air mattress. Review of documentation in Resident #10's EMR detailed the following: - 3/23/23: Progress Notes . Acute . new admit . seen today to establish care . recently admitted to the hospital for altered mental status, slurred speech, diarrhea, cough and weakness. Pt (patient) treated for aspiration pneumonia . R (Right) buttock wound - wound care to follow . - 4/5/23 at 12:16 PM: Non-Pressure Ulcer Note . Left Buttock . Acquired . 3/22/23 . MASD on left buttock, unable to measure . Apply barrier cream Q (every) shift . pressure reducing mattress . pressure reducing chair cushion . - 4/5/23 at 1:06 PM: Pressure Ulcer Note . Right buttock - stage 2, 2 x 1 x 0 (cm) . Stage 2 (pressure ulcer) . Worsening . - 4/6/23 at 1:08 PM: IDT . Weekly Follow-up . Met with IDT team to discuss progress of resident's wound treatment. Resident currently presents with MASD on left buttock which resident was admitted with. Due to the nature of the wound, measurements were not able to be obtained. Overall, the wound looks unchanged. In addition, also has a stage 2 wound on right buttocks that appears to be worsening, compared to last week's measurements. This week measurements read 2 x 1 x 0 (cm) compared to last week 1.5 x 1 x 0 (cm) . - 4/12/23 at 11:10 AM: Non-Pressure Ulcer Note . left buttock . admitted . resolved . - 4/12/23 at 11:14 AM: Pressure Ulcer - Weekly Observation . Right buttock . Resolved . Stage 2 . Healed . Preventative measures/special equipment . Pressure reducing mattress . On 4/27/23 at 3:02 PM, Resident #10 was observed laying in bed, positioned on their back with their heels directly against the mattress. Upon saying the Resident's name, they opened their eyes. When asked questions, Resident #10 made eye contact but did not provide meaningful responses to questions when asked. The alternating air mattress controller was in the same position at the end of the bed with the power off. At 3:07 PM on 4/27/23, LPN MM was asked to enter Resident #245's room to check the alternating air mattress. When asked what was wrong with the alternating air mattress, LPN MM did not immediately identify that the mattress power was off. When asked if the mattress was on, LPN MM did not respond. After pointing out where the power switch was on the alternating air mattress, LPN MM flipped the switch, the alternating air mattress motor was heard, and the mattress began to inflate. LPN MM then confirmed the mattress had been off. When queried who was responsible to ensure the mattresses were turned on and functioning, LPN MM did not provide a direct answer. On 4/27/23 at 3:10 PM, an interview was completed with Unit Manager LPN TT. When queried regarding facility policy/procedure related to monitoring of alternating air mattress function and staff responsibility, LPN TT replied, Nurses should check. LPN TT was informed of observation of Resident #10's alternating air mattress being off on 4/26/23 and 4/27/23, LPN TT was unable to provide an explanation. When queried what the settings were supposed to be on Resident #10's alternating air mattress, LPN TT revealed they did not know and there was no order/documentation of what the settings are supposed to be set at. An interview was conducted with the DON on 4/28/23 at 8:44 AM. When queried regarding the facility policy/procedure related to monitoring and use of alternating air mattresses, the DON replied, Nurses and CNA's. The DON revealed they were aware of the concerns related to air mattress not being on and lack of orders/staff awareness of settings. The DON then stated, (Air mattress monitoring/settings) are on the TAR task now. When asked if they were saying the task was added, the DON revealed they added the orders/tasks the previous day. The DON stated, We did an order and put it on the TAR and care plans that includes the settings. When queried if the mattress had to be turned on and at appropriate settings in order to provide optimal pressure reduction and relief, the DON confirmed it did. When queried regarding Resident #10's air mattress being observed off on 4/26/23 and 4/27/23 and staff not identifying the mattress being off, the DON stated, There is no excuse. On 5/3/23 at 9:57 AM, Resident #10 was observed in their room in bed. The Resident was positioned on their back with their heels directly against the mattress. Resident #10 smiled and made eye contact when spoke to but did not verbally respond to questions. Resident #21: On 4/25/23 at 3:14 PM, Resident #21 was observed in their room. The Resident was sitting in a wheelchair with their feet on the floor. Non-slip socks were present on the Resident's feet and their left foot was notably larger than their right and both lower extremities appeared edematous. A family visitor was present in the room. An interview was conducted with Resident #21 and their family member at this time. An alternating air mattress was present on the Resident's bed. The mattress was set to 1000 pounds. When queried if they had any wounds, Resident #21 stated, My butt hurts. With further inquiry, Resident #21's family member revealed they assisted with the Resident's care and stated, Not sure what the sore is. When asked if they had any other wounds, Resident #21 revealed they had a dressing in place on their left foot. Resident #21's wheelchair did not have a pressure reduction pad in place on the wheelchair seat. Resident #21 was asked if they were able to reposition themselves in the wheelchair and revealed they needed staff assistance to move and transfer. When asked how long they had been sitting in their wheelchair, Resident #21 and their family member both revealed the Resident had been in the same position since 12:30 PM. When queried if facility staff had assisted them to reposition in the chair since they had been sitting up, Resident #21 and their family member stated that staff had not repositioned them in their chair. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, sleep apnea, arthritis, depression, anxiety, and open wound on their left foot. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required extensive to total assistance to complete all ADL's with the exception of eating. The MDS further detailed the Resident was at risk for pressure ulcer development but did not have any pressure or venous ulcers but did have wound care treatment/dressings in place related to an infection in their foot. Review of documentation in Resident #21's EMR included the following: - 4/5/23: Pressure Ulcer - Weekly Observation . Left lateral foot stage 3; measures 3 (cm- length) x 4.5 (cm-width) x 0 (cm- depth) . Stage 3 . improving . - 4/12/23: Pressure Ulcer - Weekly Observation . Left lateral foot . Length: 2 (cm) . Width: 1 (cm) . Depth: 0 (cm) . What stage does ulcer currently present as . Stage 2 . Cleanse left lateral foot with wound cleanser apply skin prep to peri wound, apply double layer of Xeroform to wound bed cover with 4x4 wrap with kerlix and secure with tape daily and PRN . improving . - 4/19/23: Pressure Ulcer - Weekly Observa [TRUNCATED]

Based on observation, interview and record review, the facility failed to prevent and monitor weight loss for one resident (Resident #70), resulting in the likelihood for continued weight loss and prolonged illness. Findings include: Record review of the facility 'Weight Monitoring' policy dated 3/2023, revealed weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: (a.) Identifying and assessing each resident's nutritional status and risk factors (b.) Evaluating/analyzing the assessment information (c.) Developing and consistently implementing pertinent approaches (d.) Monitoring the effectiveness of interventions and revising them, as necessary. Resident #79: In an interview and observation 04/25/23 1 at 2:56 PM with Resident #79's family member revealed that the resident had lost weight since admission to the facility. The family member revealed that Resident #79 use to be around two hundred pounds and now is below 150 pounds. Resident #79 does have a tube feed tube in his abdomen. Resident #79 walked over to show the surveyor his PEG tube with no dressing in place and crusty material around the opening. The family member stated that Resident #79 is takes food by mouth and that the tube has not been used for a while. Record review on 5/4/2023 of Resident #79's electronic weight log from admission in October 2022 revealed a weight of 176.4 pounds. The Resident #79 was stable through March 3, 2023, weight of 170 pounds. April 5, 2023, weight was documented as 139. That was a 31-pound weight loss within a 34-day time period. The Electronic Medical Record (EMR) documented a 19.4% weight loss in 30 days. Record review of the facility 'Weight Monitoring' policy dated 3/2023, revealed (#5.) A weight monitoring schedule will be developed upon admission for all residents: (a.) Weights should be recorded at the time obtained. Mathematical rounding should be utilized (i.e., if weight is X 0.5 pounds [lbs] or more, round weight upward to the nearest whole pound. If weight is X 0.1 to X 0.4 [lbs] round down to the nearest whole pound). (b.) Newly admitted residents - monitor weight weekly for 4 weeks (c.) Residents with weight loss - monitor weight weekly (d.) If clinically indicated - monitor weight daily (e.) All others - monitor weight monthly (#6.) Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: (a.) 5% change in weight in 1 month (30 days) (b.) 7.5% change in weight in 3 months (90 days) (c.) 10% change in weight in 6 months (180 days). In an interview and record review on 05/04/23 at 08:27 AM with Registered Dietician (RD) BB of Resident #79's electronic medical record review of the resident's weight log of 3/3/2023 weight of 170.0 pounds was noted. On record weight of 139.0 that was a 31-pound weight loss in 30 days, and a 35-pound weight loss since admission. RD BB stated that Resident #79 was NPO (nothing by mouth) at the time due to the tube feedings resident was getting. The tube feedings were increased, and he was stable in his weight. On 2/27/2023 he had a video laryngeal test that noted reduced swallow with aspiration risk. The RD BB was getting agitated and seeking out food. He was restless, getting up and down, seeking out food, hanging out at nurse station near food carts. Resident #79 was wanting to eat food items. Weights are once a month when stable. We met in April with the guardian (Father or brother), and he wanted the resident to have regular diet with food items and to hold the tube feedings. The Resident #79's care plan was updated. Record review of Resident #79's care plans pages 1-21, revealed that tube feeding care plan intervention dated initiated 3/3/2023 weigh as ordered and as needed. Record review of nutrition care planned initial date of 10/5/2022 and revision date of 3/3/2023 revealed only one intervention: Diet as ordered; resident is NPO (nothing by mouth) receives nutrition via his G-tube. Record review on 05/04/23 at 11:32 AM of the facility weight loss policy revealed that the resident with the 31-pound weight loss should be weighed weekly, the last documented weight was on 4/13/2023, was 141 pounds, which was 3 weeks ago.

This Citation pertains to Intake Number MI 544. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its 1) Failure to accurately assess for elopement risk and assess for injury after an elopement occurred, 2) Failure to prevent an elopement,3) Failure to respond to a door alarm in a timely manner, 4) Failure to follow the elopement protocol, 5) Failure to ensure a safety care plan, and 6) Failure to ensure that door alarms were audible to staff for one resident (Resident#2) of three residents reviewed for the potential for elopement, resulting in an Immediate Jeopardy when Resident #2, who was a cognitively impaired Resident, suffered from dementia and an impaired gait, exited the building on [DATE] at night without staff knowledge for an undetermined amount of time. The Resident was dressed in a hospital gown, pants, a hat and gripper socks. The temperature outside was at or below freezing and there was snow on the ground. The Resident was observed outside the building at approximately 9:55 PM in the parking lot of the facility as staff for the oncoming shift was driving into the parking lot . Facility staff did not respond appropriately to audio alarms and did not search the perimeter of the building timely, implement effective care planning interventions for safety, prevention and monitoring, assess the Resident upon return into the building and ensure door alarms were audible to staff. This deficient practice resulted in the likelihood for serious harm, injury, and/or death. Immediate Jeopardy (IJ): The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM and a plan to remove the immediacy was requested. The IJ was abated/removed on [DATE] based on the facility's implementation of the abatement/removal plan, as verified onsite on [DATE]. Findings Include: Resident #2: A review of Resident #2's medical record revealed an admission on [DATE] with diagnoses that included Covid-19, [CONDITION(S)] and collapse, muscle weakness, difficulty in walking, other symptoms and signs involving cognitive functions and awareness, [CONDITION(S)], and dementia. A review of the Minimum Data Set assessment revealed the Resident had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 8 and had wandering behavior that occurred 1 to 3 days. Further review of the MDS included Balance During Transitions and Walking with the Resident walking Not steady, only able to stabilize with human assistance and Surface-to-surface transfer not steady, only able to stabilize with human assistance. Further review of Resident #2's medical record revealed the following: -Progress note, Visit Type: Follow Up, dated [DATE], .Patient is alert this morning, She is in no acute distress, She is able to answer questions although unsure how accurate her responses are . Neuro: Moves all 4 extremities, alert and oriented x 1 . Unspecified dementia without behavioral disturbance: She is confused at her baseline ., author Nurse Practitioner. -Progress note, dated [DATE] at 10:29 PM, Pt (patient) was redirected by staff attempting to leave the building. Wander guard in place and functioning pt safe in bed at time of note will cont (continue) to [NAME] (monitor), author Nurse V. -Progress note, dated [DATE] at 10:18 AM, Obtained order from physician for wander guard. -Progress note, Visit Type: Telehealth, Nurse is requesting a wander guard for patient continues to wander off and is afraid she will either leave facility and/or get hurt. Wander guard order approved. Care team notified, signed date [DATE] 10:32 AM. -Wandering/Elopement Risk Scale document in Resident #2's medical record with a lock date on [DATE] revealed the Resident scored an 8 that indicated Low risk. The section History of Wandering revealed 5. Exit seeking behaviors documented and the section Diagnosis revealed, The resident has: 0. NO diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength, was indicated on the form. The response 5. Medical diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength was not indicated. -Wandering/Elopement Risk Scale, signed [DATE] at 9:37 AM, . Category: High Risk to Wander. Score: 13 . -Brief Interview for Mental Status (BIMS), dated [DATE], .Summary Score . 5 ., no author signature. -State of Michigan Probate Court . Report of Physician or Mental Health Professional, . 2. I last examined the individual on [DATE]. 3. Based on that examination and her/his medical record, the individual suffers from the following physical or psychological infirmities: [CONDITION(S)] [stroke], cognitive impairment. 4. These infirmities interfere in the following ways with the individual's ability to receive or evaluate information in making decisions: Patient lack insight into medical decision making . 6. I believe the individual due to these described conditions, is not presently able to make informed decisions in the following areas: (all areas indicated) Determining where to live. Consenting to supportive services. Handling personal financial affairs. Authorizing or refusing medical treatment . signed by Physician MM. Review of the medical record revealed a lack of documentation of the elopement, skin assessment after elopement, and notification of Physician and family of the elopement. Review of Resident #2's care plan revealed a lack of Focus, Goal and Interventions for elopement and wandering or the use of a WanderGuard. On [DATE] at 12:25 PM, an observation was made of Resident #2 in her room lying on the bed. The Resident was dressed in a shirt, pants and a hat on her head. The Resident did not wake when her name was called. The Resident's lunch tray was on the bedside table, not eaten and the breakfast tray was positioned on top of the hamper and appeared to be partially consumed. On [DATE] at 12:35, an interview was conducted with Nurse W regarding Resident #2's wandering behaviors. The Nurse indicated that the Resident walked unassisted or used a wheelchair that she propelled herself, had a WanderGuard (A device on a wrist or ankle band that sounds an alarm when a resident approached or goes through a door.) on her ankle, and had exit seeking behavior of pushing on the doors to get out of the building. When asked how long the Resident had wandering and exit seeking behaviors, the Nurse stated, She exit seeks all day, and reported the behaviors were since admission. When asked about elopements, the Nurse reported Resident #2 had one last month when she exited the building but did not remember the specific date. An interview was conducted on [DATE] at 12:50 PM with Nurse X regarding Resident #2's elopement from the facility. The Nurse indicated she had gotten report from Nurse BB that Resident #2 had gotten out of the building the night before, on [DATE], on second shift (afternoon shift) but did not know the time or how long the Resident had been out. The Nurse indicated she got in report that a WanderGuard was on the resident. The Nurse stated, I wanted to visually see it. When I looked for it, it wasn't on her. When asked about one staff to resident monitoring, the Nurse indicated that in the morning, there was no staff assigned one to one and that they were not able to provide that until later in the morning when staff was available. The Nurse indicated she should have had one to one, we were just watching her, she was exit seeking. We didn't have many aides, staff wise. We kept a close eye on her until staff was enough to accompany her. The Nurse reported that the nightshift had not had the Resident with one to one staffing but when she came in to shift, the Resident was at the Nurses station with the Nurse present. When asked if she had done a skin assessment on the Resident, the Nurse stated, No I didn't do any assessments on her. I didn't notice anything different with her, and indicated the assessment would be done by the nurse after she was found outside. The Nurse indicated that documentation would include a report for the incident, skin assessment, notification of the incident to the Administrator, family, doctor and Director of Nursing. When asked what charting would be completed, the Nurse indicated a progress note would be done of what happened, how was the Resident found, who was notified and talked to, assessments, vital signs and any changes in skin. When asked about the WanderGuard, the Nurse reported she had checked the Resident and she did not have one on, did a text message to get the order for the WanderGuard placement, had not discussed the elopement with the Physician and the Resident continued to wander and exit seeking to get out of the building. When asked regarding behaviors prior to the elopement, the Nurse reported the Resident was known to wander, was confused and should not be out unattended. On [DATE] at 3:37 PM, an interview was conducted with Nurse BB was assigned care of Resident #2 on [DATE] and worked the 10:00 PM to 6:00 AM shift. The Nurse indicated she had gotten in report that Resident #2 had attempted to get out of the building, but Nurse V did not report she had eloped outside. The Nurse reported that after approximately two hours into the shift she heard the Resident had been out for a period of time. When asked what the weather was like that night, the Nurse indicated it was cold out and snow was on the ground. When asked if the Resident had a WanderGuard on, the Nurse reported the offgoing nurse reported she had a WanderGuard on but had not checked for one until the morning when giving report to the next shift and stated, I was told she had one on, he passed it on in report that she had one on, but she didn't have one on in the morning when I checked for it. I just assumed she had one on, and reported she had not done an assessment on the resident that night. When asked about the Resident's behaviors of wandering, the Nurse indicated she had been assigned her care a couple times before, and She usually slept through the night, but this night she was out way more. She was up with us the whole night. The Nurse reported the Resident walked unassisted and around the unit by herself. When queried if the Resident was oriented, the Nurse reported she was confused but could answer some questions. When asked if the Resident was safe to be out of the building by herself the Nurse stated, No. On [DATE] at 9:58 AM, an interview was conducted with Certified Nursing Assistant (CNA) KK, regarding recent education or in-services. The CNA indicated they had elopement in-service. When asked why the training had occurred, the CNA stated, I heard (Resident #2) got out to the parking lot. When asked about the elopement, the CNA indicated she didn't remember who had told her and that was all she had heard about it. On [DATE] at 10:13 AM, an observation was made of Resident #2 in her room. The Resident was dressed in a shirt, pants and had a hat on. The Resident was unable to answer most questions appropriately. When asked if the Resident went outside, the Resident stated, I go outside everyday. When asked if she went out of the room or out of the building, the Resident did not answer then stated, I go myself. When asked if she had eaten breakfast, the Resident indicated she didn't know. When asked if she knew what time of day it was, the Resident did not answer. On [DATE] at 10:18 AM, an interview was conducted with the Agency that employed Nurse V who was assigned care of Resident #2 on the afternoon shift on [DATE] when the Resident had eloped. Nurse V was contacted multiple times but did not answer or provide a call back to the surveyor. The Agency indicated that the facility had sent an email regarding Nurse V to not return to work at the facility with a start date on [DATE] and indicated that it did not indicate an elopement of a Resident. The Agency indicated they would attempt to contact the Nurse. On [DATE] at 12:06 PM, an interview was conducted with Nurse X regarding Resident #2's elopement from the facility. The elopement and prior interview was reviewed with the Nurse. When asked about the weather on [DATE], the Nurse indicated she remembered it had been very cold out and snowy, and that she remembered because it was her birthday weekend. When asked if the Administrator had been notified, the Nurse reported the Administrator had been in that morning, was talking to the previous nurses and had an education packet for elopement that she wanted signed. On [DATE] at 12:43 PM, an interview was conducted with Confidential Person GG, who wanted to remain confidential, regarding Resident #2's elopement on [DATE]. The Confidential Person reported the Resident got out on [DATE], out the front door, approximately 8:00 PM and was found in the parking lot about 10:00 PM by the next shift coming in. When questioned who had brought the Resident back in, the Confidential Person stated, (Nurse Q) brought her back in. The Confidential Person reported that it was snowy out and very cold temperatures. The Confidential Person reported that (Nurse V) was not made aware of the Resident outside the building and was not told until later. The Confidential Person reported the Administrator and the Director of Nursing were aware of the elopement but did not investigate what really happened, did not report it to the State Agency and was trying to hid it, charting was not corrected and the Doctor and family were not notified. On [DATE] at 2:17 PM, an interview was conducted with CNA HH, regarding [DATE] and Resident #2's elopement. The CNA indicated it was the end of the shift when the Resident was found and brought back into the facility by Nurse U. The CNA was asked what time they had seen the Resident and reported they had worked with another CNA to do check and change of Residents and had started about 8:00 PM and completed just after 9:00 PM and had seen Resident #2 during that time period. When asked about the Resident's behavior for wandering, the CNA reported the Resident was confused, wanders all over, they redirect her but she keeps wandering . Ever since she came (admitted into the facility) she keeps wandering. The CNA indicated the Resident walked by herself and had a slow shuffling gait. When asked if a door alarm had sounded that night, the CNA stated, The ringer was going off constantly. When asked how long the alarm was going off before they started to check for the Resident, the CNA indicated they were unsure but about five minutes. The CNA indicated they had not checked the door that was alarming and indicated they thought the Nurse had checked it and when he came back, he asked for a search for Resident #2. The CNA indicated that they had looked approximately 10 minutes before Nurse U was bringing her back in. When asked if the CNA remembered if the Resident wore a WanderGuard, the CNA reported the Resident did not have a WanderGuard on prior to the elopement. On [DATE] at 2:45 PM, an interview was conducted with Nurse Y who indicated she had worked on [DATE] when Resident #2 had eloped out of the facility. When asked regarding door alarms sounding that night, the Nurse stated, A buzzer was going off on a door. They go off all the time. The CNA's usually go check, and indicated the CNA's usually turn them off and that she did not check the door alarms that night. The Nurse reported that she had been told that Resident #2 had gotten out and was found in the parking lot. The Nurse indicated that she did not know where the Resident's Nurse (Nurse V) was at the time and had not seen him. When asked about her last elopement training or elopement drills prior to [DATE], the Nurse indicated she did not remember having any. On [DATE] at 3:30 PM, an interview was conducted with Nurse AA who indicated she had worked on [DATE] when Resident #2 had eloped out of the facility. When asked about hearing door alarms around the time the Resident had eloped, the Nurse was unsure if she had heard any door alarms and stated at the end of the shift, she was getting dressing changes completed on Residents, did not hear door alarms or respond to door alarms. The Nurse indicated the Administrator was aware because she came in the morning, at 6:00 AM, she was already there, and had us sign an in-service for missing Residents. When queried regarding the content of the in-service, the Nurse reported with door alarms, they were to do a hall sweep, check the door, check outside around the building, count the residents, call overhead. The Nurse was queried regarding previous elopement training and drills and stated, Not that I remember. On [DATE] at 7:08 PM, an interview on the phone was conducted with CNA II who indicated she had worked the night Resident #2 had eloped from the facility. The CNA reported that she was with other CNAs at the end of the shift taking out the garbage and when they got back to the unit the front door was alarming. The CNA was unsure how long the alarm had been going off and she had gone to check the door with Nurse V checking the door at the same time. The CNA stated she had turned the alarm off and had looked outside the door with the Nurse but did not see anyone. The CNA reported they did not go out and circle the building but had come back inside and went to the unit. The CNA reported that the Nurse had asked where Resident #2 was and they determined she was not on the unit or in her room. The Nurse left and the CNAs started to look for the Resident for approximately 15 minutes when the Resident had returned with Nurse U. The CNA indicated the Resident had non-skid socks on and that it was cold, snowy and dark outside. When queried when she had last seen the Resident, the CNA stated Between 9 and 9:30 at night. The CNA was asked what the Nurse had been doing when they went to take the trash out and indicated she thought he was passing medications. The CNA indicated that in the beginning of the shift, Resident #2 had been looking for her son and trying to go home to babysit the grand kids. The CNA reported that when she saw the Resident with Nurse U, the Nurse had her her arm around her and rubbing her and stated, I remember her rubbing her like she might have been cold. On [DATE] at 7:16 AM, another call was made to Nurse U and an interview was conducted regarding Resident #2's elopement out of the facility. The Nurse reported she was coming into work in her vehicle and had seen someone by the facility doors and thought it was a staff member trying to get into the building. The Nurse indicated she had parked her vehicle and went in to clock in for her shift then came back out to back into a parking space, other staff were arriving at that time. When she was parking, the headlights shined on the person she had seen when she first arrived at the facility and that person was now in the parking lot when she realized it was Resident #2. The Nurse reported that a third shift CNA was backing her car up and she was afraid they might hit the Resident but the CNA had stopped in time. She reported she had jumped out of her car and stated, I knew who she was (Resident #2), and escorted her back into the building. The Nurse stated, She (Resident #2) was freezing, and did not have a coat on, was wearing pajamas, socks and a hat. When she got her to the North hall, CNA HH took her to her room. The Nurse reported she had texted the Administrator and the Director of Nursing to let them know what happened. I used the numbers that were on the sheet at the nurse's station to contact them. I looked for her Nurse but could not find him. The Nurse indicated she had not talked to her Nurse after finding the Resident and that CNA HH was aware the Resident had been outside. The Nurse stated, It was bitter cold outside and she didn't have a coat or shoes on, she was in the parking lot and could have gotten hit by a car. She could have died out there. The Nurse reported the Resident had dementia and should not have been outside by herself, and stated, I looked for her Nurse but I couldn't find him. When asked about the documentation that the Resident had attempted to leave the building, the Nurse stated, That was not the truth. She was outside in the parking lot. I seen her when I first pulled in over by the East doors but didn't know it was her until I seen her in the parking lot. The Nurse reported she had texted the Administrator at 10:09 PM on [DATE] that the Resident in (resident's room number) was outside since 8 or 9 PM and she had no WanderGuard and no shoes on. The Nurse indicated she had not got a call back from the Administrator or from the Director of Nursing that night, but had talked to the Administrator about the incident on the following Monday. The Nurse stated, Her hands were the coldest, but had not done a skin assessment and indicated that Nurse BB was her Nurse that night and was aware the Resident had been outside. On [DATE] at 9:45 AM, the Administrator was asked for the investigation report for Resident #2's elopement from the facility. At 10:10 AM, an interview was conducted with the Administrator (NHA), the Director of Nursing (DON) and Corporate Nurse JJ regarding Resident #2's elopement. The investigation report included the following: Description: Administrator and DNS (DON) were notified at 8:21 am of a resident leaving the building. This resident is her our (own) responsible party. Her BIMS is an 8. She was out in the parking lot around 10:00 pm when staff saw her and brought her back in the building. She was wearing PJ pants, a gown, gripper socks and a hat. [DATE]-a head count was done, and all residents have been accounted for [DATE]- (no time indicated) a skin assessment was completed on (Resident #2) and there are no signs of bruises or skin tears or discoloration to skin observed. [DATE]- resident was placed on 72-hour charting. [DATE]-(no time indicated) Medical Director was notified [DATE]-(no time indicated) a wander evaluation was completed and a WanderGuard was placed at once, Prior to this resident triggered a low risk for elopement, and order was obtained. [DATE]- (no time indicated) All residents have had a new wander/elopement evaluation started. [DATE]- (no time indicated) a room change was done so that this resident can be in a high visible place. [DATE]- (no time indicated) the WanderGuard system was checked and is in working order, by taking a WanderGuard to each door. [DATE]- (no time indicated) care plan has been updated and once the other evaluations have been completed the other care plans will be updated as well (no date/time indicated completion) [DATE]-Resident was interviewed and said she was looking for her grandchildren and wanted to go home. During an interview done on [DATE] at 10:10 a.m., The Administrator stated I was told she (the resident) went out the front door. She was exit seeking that day and night. Her son was at the facility that day; she was looking for grandbabies. During an interview done on [DATE] at 10:10 a.m., the Administrator stated, I was notified by the DON (Director of Nursing). I did speak with (Nurse, LPN U), she said there was no alarm sounding at the front door; (Nurse U) was coming in (coming into work)and saw her. The Nurse (Nurse, LPN V) said at 9:45 p.m. his meds (medication pass) was done; he heard the door alarm, he didn't know when the alarm went off. I talked with (Nurse, LPN V) on Sunday, he went to the front of the building and went out driving around (looking for the resident). During an interview done on [DATE] at 10:10 a.m., the Director of Nursing/DON stated I got a text message at about 10:30 p.m. that night. I got it off my phone in the AM and called the Administrator. We educated (staff) about giving us phone calls, not text messages. I called the facility to make sure she was safe. The nurse (Nurse, LPN U) was gone by then (went home); they needed to do a head count. At 10:12 a.m. on [DATE], we got an order from the doctor for a wander alarm and moved her closer to the nurses station. A review of Resident #2's care plan revealed a lack of a safety care plan and lack of a wandering/elopement care plan in the medical record. When asked about the lack of care plans the DON and NHA did not have an answer. A review of the medical record revealed a lack of skin assessment completed after the elopement. The NHA indicated she thought that one had been done and was unsure why it was not in the medical record. The timeline of events, collected by the surveyors, were reviewed and the investigation report lacked a definitive time of when the Resident had eloped, which door she eloped from and how long she was outside that indicated an undetermined amount of time the Resident had been outside. The NHA reported she had been told the Resident had left the building out the front door and that she had been exit seeking throughout the day and night. The Wandering/Elopement Risk Scale document in Resident #2's medical record with a lock date on [DATE] revealed the Resident scored an 8 that indicated Low risk. The section History of Wandering revealed 5. Exit seeking behaviors documented and the section Diagnosis revealed, The resident has: 0. NO diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength, was indicated on the form. The response 5. Medical diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength was not documented. The Resident's diagnoses that included [CONDITION(S)] and collapse, muscle weakness, difficulty in walking, other symptom and signs involving cognitive functions and awareness, and dementia was reviewed with the NHA, Corporate Nurse and DON. The Wandering/Elopement Risk Scale was not documented correctly, if the diagnosis section was documented correctly, the score would be 13, with the scoring of 11-above High Risk For Elopement. The NHA and DON did not have a comment regarding the inaccurate Wandering/Elopement Risk Scale document. The progress note, dated [DATE] at 10:29 PM, revealed, Pt was redirected by staff attempting to leave the building. Wander guard in place and functioning pt safe in bed at time of note will cont to [NAME], author Nurse V, was reviewed with the NHA, Corporate Nurse and DON. When queried why the documentation was not correct, the Corporate Nurse stated, He should have written accurate information. When queried why the Nurse was not asked to come in to make correct documentation, the NHA indicated the Nurse was a DNR and was not to return to the facility. The NHA was questioned why Administration did not ensure accurate account of the incident in the medical record, the NHA did not have an answer. The lack of documentation that the Physician and family was notified of the elopement was reviewed. The NHA indicated that the Physician was notified when they got the order for the WanderGuard and stated, The Resident was her own responsible party. The NHA was asked where the rational for the WanderGuard was and did not have an answer. When queried why the elopement was not reported to the State Agency, the NHA indicated the Resident was her own responsible party and stated, We have the right to make bad decisions. When asked who she indicated was making bad decisions, the NHA stated, The Resident made the bad decision of leaving. On [DATE] at approximately 10:50 a.m., Prior to observation of the facility grounds, the way the resident went out and door she was brought back through, the Administrator was requested by this surveyor to activate the front door alarm. The Administrator, DON nor this surveyor could hear the alarm with the conference room door shut and when open, the alarm was barley heard. Observation of the outside of the facility: Observation done on [DATE] at approximately 12:10 p.m., of the outside route the resident took when she eloped. Done with Corporate Nurse, RN JJ, Administrator, DON and two surveyors. This surveyor and the above persons left the building through the front alarmed door. The front door did alarm, however it was hard to hear from a distance or when unit hallway doors were shut. The alarm went off, but staff did not immediately respond to the alarm. Observation of the facility outside sidewalk and parking lot was done. Loose gravel/stone and broken cement was on both sides of the sidewalk. Several areas of large broken off pieces of cement was noted on the driveway side of the sidewalk. The sidewalk was uneven, and several potholes were observed in the driveway. The driveway was connected to the residential road and a school was directly across from the facility; the speed limit was 25 miles an hour in the road. At the point where the sidewalk turned to the right to go to the back of the facility, there was a very large [NAME] on the ground (trip hazard). There were several uneven drains in the parking lot noted. Corporate Nurse JJ measured the distance from the facility front door to the back door were (Nurse U) brought the resident back into the facility. Two ways were measured, the greatest distance was 359 feet and the least distance was 156 feet. Activation of the East Door on [DATE]: On [DATE] at 12:20 p.m., the Administrator, Corporate Nurse JJ and two surveyors opened the East Door, activating the door alarm. A short hallway from the door lead to the Central Unit main hallway. Nursing Assistant K was in the Central Hall passing meal trays at the time and did not go and answer the door alarm. During an interview done on [DATE] at 12:30 p.m., CNA K was asked by this surveyor if she had heard the door alarm and she stated, I didn't hear it. CNA K was approximately 70 feet from the activated door alarm at the time. The facility door alarms were not loud enough to be heard by staff. On [DATE] at 1:30 PM, an interview was conducted with the NHA regarding elopement drills. The NHA presented elopement drills for first shift on [DATE] at 12:,d+[DATE]:10 PM, second shift on [DATE] at 2:,d+[DATE]:06 and third shift on [DATE] at 5:00 AM to 5:20 AM. There were no elopement drills presented that were done prior to Resident #2's elopement from the facility. When queried regarding the lack of elopement drills, the NHA reported that according to Maintenance, Nursing would do the elopement drills, and indicated there was no documentation on the drills being completed. On [DATE] at 3:03 PM, an interview was conducted with Nurse V regarding Resident #2's elopement from the facility on [DATE]. The Nurse reported that on [DATE], he was passing medication at the end of his shift and indicated the time was approximately 9:55 PM. The Nurse indicated that he was in a Resident's room and when he came out of the room, he realized a door alarm was sounding and had gone to the panel at the Nurses' station to determine which door was sounding, went to the door where CNA II was approaching, the CNA turned off the alarm and he had gone out the door to look but did not see anyone and returned into the building. Upon coming back to the Unit, he realized Resident #2 was not in her room. The Nurse left the Unit and went through the building to where he had parked his car and proceeded to look for the Resident by driving around the building. The Nurse was asked if he or the CNA had done a full sweep of the building grounds when first approaching the alarmed door. The Nurse reported they did not, but went through the building to get his car. The Nurse reported that when he came back to the Unit, the Resident was in bed. The Nurse stated, No one told me she had gotten out of the building. I didn't know that until I talked to the Administrator the next day. The Nurse indicated that the Nurse who found the Resident out in the parking lot had not talked to him regarding finding

This Citation Pertains to Intake Numbers MI 771, MI 773, MI 806, MI 356, and MI 680. Based on observation, interview and record review, the facility was placed in Immediate Jeopardy due to the facility's systemic collapse of the Infection Prevention and Control program with failure to follow evidence-based practices for Infection Control, including collection and analysis of surveillance data to identify trends and patterns and implement appropriate interventions, including Transmission Based Precautions to prevent the spread of infections, including the Covid-19 virus. The failure to maintain infection control practices resulted in a likelihood for a serious adverse outcome including infectious illness and death if appropriate Infection Prevention and Control Standards of Practice were not enacted. The facility failed to institute and operationalize appropriate Infection Control Standards of practice in accordance with the Centers for Disease Control and Prevention's (CDC) recommended measures to prevent exposure and transmission of Covid-19 to residents and staff. Immediate Jeopardy: The Immediate Jeopardy began in [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE]. The IJ Abatement (Removal) Plan was approved on [DATE] with a Removal Date of [DATE]. Findings include: On [DATE] at 1:50 PM, during the survey Entrance Conference with the Administrator, she said 50 residents had tested positive for Covid-19 from a facility census of 94 residents. The Administrator said the 50 residents were still residing in the building on the Medbridge/North units that were enclosed to create a Covid-19 unit. The Administrator was asked who was overseeing the Infection Prevention and Control program and she said the Director of Nursing was in charge of the IPC program. The Administrator was asked for copies of the Infection Surveillance data for [DATE] and [DATE] and various Infection Control (IC) policies, including Covid-19 policies. The Administrator said she would request the Infection Surveillance from an out-of-state Corporate Infection Control Nurse QQ; He would send the information to the facility. On [DATE] at 2:15 PM, The Director of Nursing (DON Q) was observed working as a Floor Nurse. She was asked if she often worked on the floor and she said, Yes. DON Q introduced Nurse OO, whom she said had recently been hired to assume the Infection Prevention and Control (IPC) Nurse role. He did not have training and had worked at the facility for 2 days. The facility did not have an Infection Prevention and Control Nurse. The DON said she tried to oversee the IC Program. Centers for Disease Control and Prevention (CDC), [DATE], Infection Prevention and Control Program: Assign One or More Individuals with Training in Infection Prevention and Control to Provide On-Site Management of the IPC Program. This should be a full-time role for at least one person in facilities that have more than 100 residents or that provide on-site ventilator or hemodialysis services. Smaller facilities should consider staffing the IPC program based on the resident population and facility service needs . On [DATE] at 3:10 PM, the Administrator provided a Covid-19 surveillance report from the out-of-state IC Nurse QQ. There was no additional Infection Surveillance received for other infections. For (example: fever, cough, wounds, rash, diarrhea, [CONDITION(S)] etc.) from [DATE] to [DATE]. There was no respiratory monitoring for Influenza. Centers for Disease Control and Prevention (CDC): COVID-19: Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes- Nursing Homes and Long-Term Care Facilities, Updated Feb. 2, 2022, Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as [CONDITION(S)]-CoV-2. A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Even as nursing homes resume normal practices, they must sustain core IPC practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. The Association for Professionals in Infection Control and Epidemiology (APIC), [DATE] provided, Surveillance of healthcare-associated infections (HAI) is the cornerstone of an effective infection prevention program. By definition, surveillance is a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the healthcare team to assist improving those outcomes and processes . Facility staff were testing themselves for Covid-19 at the nurses' desk with other staff and residents in close proximity, potentially exposing others to Covid-19. The facility is not consistently tracking Covid-19 test results for residents or staff. The facility did not have a complete Line List (surveillance) for Covid testing for residents and staff. The facility did not track test dates with results, if negative. They only recorded Covid-19 positive test results. Agency Nurse K was observed on the Central Unit, on [DATE] at 2:15 PM. She was at the nurses desk talking to the DON Q about her schedule, several nurse aides and nurses were also present at the desk. At 2:40 PM, Nurse K went to the East hall to receive report from the day shift nurse and count narcotics on 2 carts. The nurse was interviewed about medication administration processes on the unit and then Nurse K was observed while touring the medication room. It was after this that a Covid test in process, awaiting results, was observed on the Nurses desk with several staff nearby. This surveyor asked who's Covid test was on the desktop and Nurse K said, That's mine. The nurse was asked if she was Covid positive or negative and she looked at the test and said, I'm negative. The nurse was asked if she always tested at the desk and she said, Yes. On [DATE] at 3:10 PM, the Administrator was interviewed related to where the staff were supposed to complete Covid tests and she said, In the conference room or at the front door when they are screened. Explained that the nurse was Covid testing at the nurse's desk and if she was positive, she would have exposed all of the nearby staff and residents. The facility was not following accepted Standards of Practice for Transmission Based Precautions: Staff were not wearing appropriate PPE, including a gown and gloves when entering the Covid Unit. Staff did not know what PPE was required for the Observation Unit (Yellow zone). Dietary staff were observed transporting food carts from the kitchen through the Covid Observation Unit to other non-Covid areas of the building, while residents were observed in the hallways without PPE (masks). On [DATE] at 1:50 PM, Aide NN was observed unzipping the plastic barrier to the antechamber to the Covid positive unit (Red zone) he did not don PPE (Personal Protective Equipment)- no isolation gown or gloves, He had on a kN95 mask and face shield. He walked through the antechamber to the next zipped plastic barrier. He unzipped it and stepped into the Covid unit. He did not sanitize his hands or don a gown or gloves. He asked out loud to staff on the unit about staffing needs and turned around, rezipped the plastic barrier to the unit, walked through the antechamber and began to exit through the outside zipped barrier. The transportation aide was asked if he was supposed to wear PPE to enter the Covid unit and he looked around the antechamber and stated, This is for taking off your equipment. He was asked if he was supposed to wear PPE? There were clear signs on the outside barrier to the antechamber, Stop and another sign with wording and pictures of the necessary PPE and in what order to put them on. The employee was asked about the signs on the plastic, and he said he didn't think he had to wear the PPE because he was just standing in the doorway to the unit. Pointed out that he had entered with his body when he stepped into the unit. The Aide was asked if he had received education related to Infection Control practices, PPE, Covid policies and procedures and he said, No. On [DATE] at 4:54 PM, a loud noise was heard in the hallway outside the conference room. A Dietary aide was observed pushing a dietary cart with trays through the door of the Yellow unit (Covid-19 observation unit- Staff were to wear PPE in the resident rooms and residents to wear a Facemask when leaving their rooms). He had no PPE except for a Face shield and mask. Residents were observed in their wheelchairs and some walking without masks in the hallway of the unit, as the Dietary cart was pushed by them. The aide pushed the cart down the hall out the exit door down to the side walk to an outside door to the Assisted Living Building. On [DATE] at 4:56 PM, the Administrator and Registered Dietitian (RD) E were interviewed. This surveyor explained to them the dietary staff were observed transporting meal trays from the kitchen through the Covid observation unit and then to the Assisted living residents. The Administrator said, They could have went through the Green unit (Non-Covid-19 unit). She asked the RD to educate the dietary staff on not using the observation unit as a transport area. On [DATE] The facility was not tracking employees' or agency staff signs or symptoms of illness. They only track confirmed cases of Covid-19. Facility staff were testing themselves for Covid-19 at the nurses' desk with other staff and residents in close proximity, potentially exposing others to Covid-19. The facility is not consistently tracking Covid-19 test results for residents or staff. The facility did not have a complete Line List (surveillance) for Covid testing for residents and staff. The facility did not track test dates with results, if negative. They only recorded Covid-19 positive test results. A serious adverse outcome occurred. 11 facility residents tested positive for the Covid-19 virus in [DATE]. 52 facility residents tested positive for the Covid-19 virus from [DATE] through [DATE] (16 days). 14 of the 52 positive residents had to be hospitalized for Covid. 3 of the 52 positive residents died from Covid. 4 facility staff tested positive for the Covid-19 virus in [DATE]. 20 facility staff tested positive for Covid-19 from [DATE] through [DATE]. The facility's failure to 1) Complete infection surveillance of residents and staff with signs and symptoms of illness including Covid-19, 2) Conduct appropriate testing and tracking of test results and 3) Act in compliance with Transmission Based Precautions, made it likely that a significant number of residents and/or staff became symptomatic or infected with the highly contagious Covid-19 virus The facility needs to take immediate action to contain the scope and severity of the current Covid-19 outbreak to prevent further cases for both facility residents and staff. The Immediate Jeopardy began in [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified on [DATE] of the Immediate Jeopardy that began on [DATE]st, 2021. The IJ Abatement (Removal) Plan was approved on [DATE] with a Removal Date of [DATE]. CDC, Long-Term Care (LTC) Respiratory Surveillance Line List, [DATE], 'The Respiratory Surveillance Line List provides a template for data collection and active monitoring of both residents and staff during a suspected respiratory illness cluster or outbreak . Using this tool will provide facilities with a line listing of all individuals monitored for or meeting the case definition for the outbreak illness . Each row represents an individual resident or staff member who may have been affected . The information . capture data on the case demographics, location in the facility, clinical signs/symptoms, diagnostic testing results and outcomes . ' Information gathered on the worksheet should be used to build a case definition, determine the duration of outbreak illness, support monitoring for and rapid identification of new cases and assist with implementation of infection control measures . Per the CDC, [DATE], Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions (Standard Precautions are used for all patient care. They're based on a risk assessment and make use of common sense practices and personal protective equipment use that protect . from infection and prevent the spread of infection from patient to patient.) for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission . Source: Guidelines for Isolation Precautions. SHEA/APIC (Society for Healthcare Epidemiology of America/The Association for Professionals in Infection Control and Epidemiology) Guideline: Infection prevention and control in the long-term care facility, [DATE] AJIC (American Journal of Infection Control), provided . Because of the impaired immunity of elderly person, [CONDITION(S)] respiratory infections that generally mild in other populations may cause significant disease in the institutionalized patients. Examples include influenza, respiratory syncytial virus (RSV), parainfluenza, coronavirus, rhinoviruses, adenoviruses and recently discovered human metapneumovirus . Rapid identification of cases in order to promptly initiate treatment and isolate them to prevent transmission remains the key . An outbreak or transmission with in the facility may occur explosively . Outbreaks in LTCF's (Long Term Care Facilities) accounted for a substantial proportion (15%) of reported epidemics . CMS (Centers for Medicare and Medicaid Services) regulations address the need for a comprehensive infection control program that includes surveillance of infections; implementation of methods for preventing the spread of infections including use of appropriate isolation measures . An ICP (Infection Control Practitioner) is an essential component of an effective infection control program and is the person designated by the facility to be responsible for infection control . Infection surveillance in the LTCF involves the systematic collection, consolidation, and analysis of data on HAI's (Healthcare associated infection) . resources that include practice guidance for surveillance identifying seven recommended steps . 1. Assessing the population, 2. Selecting the outcome or process for surveillance, 3. Using surveillance definitions, 4. Collecting surveillance data, 5. Calculating and analyzing infection rates, 6. Applying risk stratification methodology and 7. Reporting and using surveillance information . The surveillance process consists of collecting data on individual cases and determining whether or not a HAI is present by comparing collected data to standard written definitions (criteria) . One recommended data collection method . Walking rounds . collecting concurrent and prospective infection data that are necessary to make infection control decisions . should be done on a timely basis . may use house reports from nursing . chart reviews, laboratory or radiology reports, treatment reviews, antibiotic usage data and clinical observations . On [DATE] at 10:15 AM, Corporate Nurse DD and Corporate IC Nurse CC were interviewed about the Infection Control Program at the facility. Corporate Nurse DD stated, There was an IPC at one point. (unsure of the date or whom). (Corporate IC Director QQ is Offsite (out-of-state). There has not been a nurse solely in the IC role. DON assuming duties. (Corporate IC QQ) stated he trained the (DON) and she was responsible. During the interview, reviewed the facilities Infection Control and Covid-19 Policies with Corporate IC Nurse CC. The policies were greater than 1 year since they were created or reviewed. IC Nurse CC did not know when the policies had been reviewed. Some of the policies were dated 2018. During the interview, IC Surveillance was reviewed with the Corporate Nurse DD and Corporate IC Nurse CC on how the Infection Surveillance data was gathered, sources, employee call ins, contract services. The facility was only using antibiotic reports for the Infection Line lists. They were not monitoring for signs and symptoms of infections. When asked if staff illnesses were monitored, Corporate Nurse DD said they were not allowed to track employee illnesses. The Corporate Nurses were asked if staff signs and symptoms of illness were tracked to aid in monitoring the potential spread of infection to the residents, she said, No. They only tracked Covid-19 infections. Corporate IC Nurse CC said they had discussed using a Change of condition form: we discussed earlier we think that would be our process. None of the change of condition was placed in the line listing or any surveillance. Employee illnesses were not tracked; Neither was contracted employee illness. The majority of nurses at the facility (approximately 75, which was over 90%) were Agency staff. Corporate nurses CC and DD were asked if they received education on the facilities process for Infection Prevention and Control and said they were not educated or oriented to the facility's policies and procedures for Covid-19 or Infection Control. Corporate Nurse DD stated, We don't have any control over them. They are not our employees. When asked if the facility provided education to ensure the facilities policies were followed, she stated, The agency educates them or they learn it in school. On further review of surveillance data there was no surveillance or analysis or summary of data for trends from September to [DATE]. There was some Covid surveillance data from January to- [DATE]. Per the Corporate nurses, that was prior to the facilities current ownership taking over in [DATE]. Infection Surveillance had not been accurately completed since then. Reviewed green, yellow, red zones for management of resident admissions, Covid-19 exposures and positive Covid-19 cases. Corporate IC Nurse CC stated, Green zone: No signs and symptoms of infection, mask- depends on positivity rate. That is sent to us every morning; Yellow zone: Possible exposure: PPE mask, face shield, gown gloves to enter a resident room- resident with masks in the hallway; Red zone: positive Covid-19- Full PPE to enter the unit. During the interview, reviewed Covid-19 testing. Could not locate Resident Covid-19 test results in the resident charts. Corporate IC Nurse CC stated, The results are not in the medical record. Discussed with Corporate IC Nurse CC if the facility was testing for Influenza and she stated, I do not know the answer for that. They should be in progress notes. Corporate IC Nurse CC was asked if anyone was performing IC Rounds and stated, When I'm in the building, I do the rounds. There were no documented rounds by IC in the building. Reviewed with the Corporate Nurse and Corporate IC Nurse if Infection Prevention and Control surveillance data, analysis and trends was reviewed either in an Infection Control Committee or at the QAPI (Quality assessment and process improvement) meetings. They said no IC surveillance analysis or summary data was reviewed, but it would be in the future. On [DATE] at 3:15 PM, the Administrator said prior DON QQQ left employment at the facility on [DATE]. She was overseeing the IC program and then DON Q became the Director of Nursing and assumed duties for IC on [DATE]. DON Q did not have training in Infection Prevention and Control. On [DATE] at 3:03 PM Agency Nurse A was interviewed and asked if she received orientation or training on the facilities policies and procedures for infection control and said she had None. She said the agency provided a skills test, but no education. On [DATE] at 11:20 AM, Corporate Nurse CC said, We didn't have any surveillance, but we are working on it now. On [DATE] at 4:24 PM, Agency Nurse Z was asked about orientation to the facilities Infection Control practices and stated, There is no orientation. A lot of people have a hard time. The agency doesn't provide it either. A review of the facility policies provided the following: Policies and Practices-Infection Control, dated ,d+[DATE], The facilities infection prevention and control program is designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . The facilities infection control policies and practices apply equally to all personnel, consultants, contractors . All personnel shall be trained on our infection control policies and practices . Surveillance for Healthcare-Associated Infections, dated reviewed/revised ,d+[DATE], The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAI's) and epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative measures. 1. The purpose of the surveillance of infections is to identify both individual cases and trends in the transmission of epidemiologically significant organisms and Healthcare-Associated Infections, to permit interventions to try to slow or stop the transmission of such infections . Nursing staff will monitor residents for signs and symptoms that may suggest infection . The nurse will notify the Attending Physician and the Infection Preventionist of suspected infections . The Infection preventionist will collect data . The Infection Preventionist or designee will gather and interpret surveillance data. The surveillance should include a review of any or all of the following information to help identify possible indicators of Healthcare-Associated Infections: laboratory records, skin care sheets, infection control rounds or interviews, infection surveillance sheets, temperature logs, pharmacy records, transfer log/summaries . all positive blood cultures . wound cultures . urine cultures . positive sputum . other cultures . All Group A streptococcus cultures . organize the data on a tracking log . Identify predominant organisms or sites of infection . compare prevalence . summarize the information . review . at the facilities QAPI monthly meetings . COVID-19 Resident Policy, dated [DATE] and updated [DATE], Policy: To implement infection control procedures to minimize chance for exposure to COVID-19 and to prevent the spread . Utilize CDC LTC Respiratory Surveillance Line List in addition to the infection control daily surveillance log, when there is an increased number of respiratory illnesses regardless of suspected etiology . positive Covid . don (put on) the following personal protective equipment (PPE) prior to entering the room: Gown, Face Mask, Eye protection . Gloves . The IJ Removal Plan was reviewed on [DATE] at 12:57 PM, with the Administrator, Corporate Nurse and Corporate Infection Control Nurse and contained the following: [DATE] The corporate/regional onsite IP nurse began to maintain the Infection Surveillance (Line listing) tracking for the residents and staff. The IC tracking and surveillance form began review five days per week in the IDT meeting to ensure completion and accuracy. Trends to be reviewed and addressed immediately with education and or increase surveillance. The line listing to be reviewed monthly in the QAPI meeting. [DATE] An ICP trained leader will be in the building until the ADN/IPC nurse has completed and received certification training will consist of the online CDC Infection Preventionist training through the Train Learning Network and orientation to the ICP role in the facility. [DATE] The facility tracker for employee's illnesses will be completed by each department head and will be forwarded to the IP nurse daily. The facility currently monitors staff signs and symptoms through the (Covid Screening) prior to clocking in. Education of the Department heads, Nursing Department, Kitchen, Housekeeping, Therapy, has been completed [DATE] and they began to educate their staff [DATE] on the updated call-in tracking log information. The tracking form was given to department heads for tracking call ins. The Covid screening system alerts facility leadership when any person entering the building identifies that they have symptoms of an illness. [DATE]-The orientation/education, of Infection Control for agency staff started [DATE] and will continue until the building is no longer requiring agency usage or if new agency staff is obtained. [NAME] Staff and Ancillary staff began education [DATE] prior to the start of their shift and monthly thereafter for all staff in-services on infection control practices as deemed appropriate. Education will include Covid Policies and procedures, as well as the CDC and CMS training materials on proper PPE donning and doffing, proper utilization based on Covid status and community positivity rates along with the facility policy. [NAME] Care staff will complete a monthly COVID in service in Relias and this in service. All agency staff will be required to sign off stating that have completed COVID-19 education prior to working at the facility. [DATE] Education included appropriate IC practices including, use of PPE for all staff including a gown and gloves when entering the Covid unit, correct PPE per unit (Yellow) for staff, hand washing, donning and doffing. All staff began education using the COVID zone stop lights. Stop lights to be prominently displayed for staff reference. Each room door will have a sign identifying red, yellow, green with the required PPE needed to enter, based on Covid-19 requirements. [DATE] Dietary staff were educated on what hall to use when transporting food carts. Dietary staff members were educated how to transport food while limiting the potential for cross contamination between zones. In the month of February 2022, staff began training on computer modules for PPE and Infection Control Policy review in conjunction with current education. [DATE] Re-education was completed with staff regarding proper PPE usage: including the proper way to wear a mask, what PPE is required for each zone and proper donning and doffing. [DATE] facility staff began education on when the Covid testing will take place and where on Tuesday and Fridays, from 8 am to 4 pm for staff in the large conference room. Notes will be posted on where and when the Covid test will be completed. All tests will be performed by trained care team members. Education regarding social distancing during testing. [DATE] The facility began scanning the results of the Covid testing into the Resident's medical record. It was also placed on the line listing for the tracking of infection for the residents. [DATE] The line listing for Covid residents was completed and ongoing, the line listing for other infections will continue to be monitored and updated daily. The facility is now tracking negative and positive results for the residents. This information will be reviewed five days per week in the IDT meeting. [DATE] AD HOC QA was completed for the IJ on Infection Control. [DATE] An ICP trained leader will be in the building until the ADN/ICP nurse has completed and received the certification of completion and ongoing orientation with the regional ICP nurse. Substantial compliance has been achieved.

Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to maintain a sanitary kitchen and its failure to not prepare food in that unsanitary kitchen where dietary employees were observed walking through and pushing food carts through a known unsanitary contaminant on the floor from two broken drains. This deficient practice affects all 93 facility residents. Immediate Jeopardy: The Immediate Jeopardy (IJ) began on 01/21/2022. The IJ was identified at 3:10 PM, on 01/25/22. The Administrator was notified on 01/26/22, at 8:52 AM. A plan of correction was requested to remove the IJ. The IJ was removed at 5:15 PM, on 01/25/22 when the facility closed the kitchen for use and submitted the acceptable Plan of Correction that was implemented and verified on site by the survey team. Findings include: On 1/25/22, at 3:10 PM, observation of the kitchen was conducted. The floor was discolored with a grey residue in the grout of the tile of approximately 10 foot by 10 foot section which was the main walkway located between the 2 compartment sink and prep table. There were food carts rolled on top of the dirty floor. There were kitchen workers walking on the dirty floor and all throughout the kitchen. There was visible water, a large amount of [NAME] substance greyish in color measuring approximately 2 foot by 6 foot under the 2 compartment sink with visible muddy water in the drain. The floor drain near the food prep table had water leakage along the grout of the tile approximately 2 foot by 2 foot area with a 4 inch area of dark black sludgy substance. On 1/25/22, at 3:12 PM, an interview with Assistant Dietary Manager (AM) B of kitchen services was conducted in the kitchen. AM B , was asked why the ice machine was off and AM B stated, the ice machine is off because of the sewer drain backing up on Friday. AM B was asked who they alerted and AM B stated that they notified Dietary Manager F on Friday who notified the housekeeping supervisor who then called the sewer people. AM B was asked to explain the leakage smell and appearance and AM B stated, there was a strong feces smell on Friday when the leak started with no visible stool solids. AM B further offered that the leakage on Friday went all through kitchen along the 2 compartment sink, the juice table covering the entire walkway and leaked out into the dining room under the doorway of the kitchen. AM B denies being educated as to what to do if there was a leak in the kitchen. On 1/25/22, at 3:17 PM, an interview with Kitchen Worker C was conducted in the kitchen. Kitchen Worker C stated, the drains leaked both Friday and Saturday of a light grey watery substance under the 2 compartment sink and the floor drain near the prep table had about a 2 foot by 2 foot area of leakage that was black in color and smelled like sewage. Kitchen Worker C stated that both drains ended up going down on their own but if they use the hand washing sink it backs up and the leak gets worse. Kitchen worker C denied mopping or sanitizing the floor. On 1/25/22, at 3:20 PM, an observation along with AM B was conducted in the kitchen of the mop bucket which had dark grey dirty water inside. AM B was asked if they had mopped the floor and AM B stated that housekeeping supervisor came in the kitchen and told them they needed to mop the floor themselves but No, they did not mop the floor. On 1/25/22, at 3:25 PM, an interview with Kitchen Worker G was conducted while they were standing at the prep table prepping sandwiches. The floor drain is on the opposite side of the prep table near the end close to the walkway. Dietary worker G stated that they worked on Saturday, Sunday and Monday and that the floor was leaking all those days, smelled like sewer each day and on Monday morning the floor drain by the prep table even had black leakage around the drain. Kitchen Worker G denied being told to mop and sanitize the floor and stated that they did not mop or sanitize the floor. On 1/25/22, at 3:30 PM, an interview with Maintenance Lead (ML) D was conducted regarding the kitchen. ML D stated, they were off Friday but came in Saturday early and attempted to snake the drain. ML D further offered that (the plumbers) were called on Friday by the housekeeping supervisor and came out but was unable to fix the drain. ML D further offered that (the plumbers) needed to come back on Monday with a better pipe camera. ML D stated, that they shut off the water to the hand washing sink in the kitchen, the ice machine in the dining room and that the staff are able to use the employee break room for ice. On 1/25/22, at 3:32 PM, An observation of the ice machine in the break room along with ML D was conducted. The ice machine was off and was overflowing water onto the floor. ML D was unaware the ice machine was not working and was asked to provide all communications from the facility with (the plumbers) regarding the kitchen. On 1/25/22, at 3:35 PM, an observation along with ML D of the kitchen drains was conducted and ML D was asked why the floor was still dirty with the leakage and ML D stated, they would clean it. ML D walked over to the hand washing sink and shut off the water supply. On 1/25/22, at 3:45 PM, a record review along with ML D of the Kitchen Proposal repair plan was conducted. The proposal was dated 1/24/22. ML D offered that the proposal was emailed later in the evening after they had gone home. ML D further offered that they emailed it to the company lead and was awaiting approval. On 1/25/22, at 4:00 PM, the Administrator was asked if they were aware of the kitchen drain leaks and the Administrator stated that they were told it was a water leak on Monday morning and did not know it was a drain leak. The Director of Nursing (DON) who was in the Administrator's office offered that they did not know about the leak until survey. The Administrator was asked to provide the contract for the kitchen, education provided to the kitchen staff regarding what to do in case of a drain leak and the cleaning policy. On 1/25/22, at 4:30 PM, the administrator and ML D entered the conference room and offered that they had texted the company lead regarding the approval for the kitchen and was awaiting their response. ML D received a telephone call while in the conference room approving the kitchen proposal. On 1/25/22, at 4:45 PM, Registered Dietician (RD) E was interviewed regarding the kitchen leak. RD E stated that they did not know anything about the kitchen drain leaks and that the Administrator just alerted them 5 minutes prior to the interview. RD E was unaware the kitchen staff had not cleaned or disinfected the floor, continued to prepare food while walking over the contaminated floor and pushing the food carts over the dirty floors out into the hallways of the facility. RD E stated they had been working since 8:30 AM in the morning and hadn't been in the kitchen. On 1/25/22, at 4:47 PM, an observation of the kitchen along with RD E was conducted. The floor under the 2 compartment sink had been wiped clean of the greyish [NAME] substance. The tiles in the walkway remained of grey residue. The floor drain near the prep table remained wet with the black sludge material. There was a bright green substance that appeared to have been poured into the drains. The grey residue remains on the tile and had not been cleaned off. Kitchen worker G offered that ML D had just been in and cleaned the floor under the 2 compartment sink and poured the cleaner into the drains. Kitchen Worker G was asked if the entire kitchen floor had been mopped and kitchen worker G stated, no. RD E was asked if they had offered any education to the kitchen staff on how to clean up after a drain leak and RD E denied and offered that they had worked with the kitchen staff on cleaning . RD E was asked if there was anything the facility could have done differently and RD E stated, Yes, you don't do service until it's cleaned. O 1/25/22, at 5:00 PM, ML D was in the Administrator's office and was asked if they had mopped the entire kitchen floor and ML D stated, I don't know if they cleaned the floor after I left. ML D was asked what area of the floor did they clean and ML D stated, I just cleaned the area near the sink. On 1/25/22, at 5:15 PM, RD E offered that the facility stopped service in the kitchen until it can be fixed. The facility planned to utilize the assisted living kitchen and planned for an alternative dinner meal. On 1/26/22, at 8:30 AM, the Administrator entered the conference room and stated that ML D was trying to get (the plumbers) to come out sooner seems the kitchen is closed and stated, we're getting an IJ aren't we. ON 1/26/22, at 10:00 AM, an interview with Dietary Manager (DM) F was conducted regarding the drain leaks in the kitchen. DM F offered that during the day on Friday there was water under the 2 compartment sink going all the way out the dining room door. DM F offered they notified ML D about 6:20 PM because it was still leaking. DM F stated that it leaked again on Saturday, Sunday and again on Monday ant it appeared to be wet sand coming from under the 2 compartment sink. The DM F did not mention the leak from the floor drain near the prep table. DM F stated, that (the plumbers) did come out and confirm a broken pipe under the floor so they had called their regional leader who said they may need to go to a cold simplified menu. DM F was asked who they assigned to clean and disinfect the floor and DM F stated, nobody and that they used bath blankets to mop up the water and to keep it from going into the dining room. DM F was asked again who was told to clean and disinfect the kitchen floor and DM F stated, nobody the floor was not mopped or sanitized. On 1/26/22, at 1055 AM, the Administrator was asked again if there was any education offered to the kitchen staff on what to do with a drain leak and the Administrator stated, education was just started yesterday after this all blew up. On 1/26/22, at 11:00 AM, RD E was observed in the hallway with two kitchen workers. RD E was asked if there was any education offered to the kitchen staff on what to do with a drain leak prior to the leak and RD E stated, I'm doing it right now. On 1/26/22, at 11:05 AM, a record review of the Culinary Services Agreement provided by the facility revealed . (contracted kitchen company) shall be responsible for routine cleaning and housekeeping in the food preparation areas (excluding dining rooms), including culinary service equipment, kitchen floors . There was no noted information on what the kitchen staff should do in an emergency of a drain leak. On 1/26/22, at 11:10 AM a record review of the facility provided (contracted kitchen company) revealed no mention as to what the kitchen staff should do in an occurrence of drain back flow leakage. The following plan of correction was submitted by the facility. On 1-21-22 Dietary manager noticed a water backing up in the kitchen, she notified the Environmental Director at approximately., 1:00 pm and he was unable to unclog the drain where the water was coming from. [NAME], plumbers, was contacted. They arrived at the facility and was unable to correct the problem due do needing another technician to come out, at that time Maintenance was notified. [NAME] told staff that they would be back on Monday to correct the problem. At 5:30 pm the water went down in the drain. Maintenance was off due to Covid and he placed a call to [NAME] from home after he was notified of the plugged drain. On 1-22-2022 at 4:00 am Maintenance Director came into the building and tried to snake the drain, but it didn't work. On 1-24-2022 at 9:00 am Administrator was made aware of the drain problem. [NAME] came out and can a quote on the repairs. At 7:08 am the quote was emailed to the Regional Director of Operations, who was on vacation with a 3-hour time difference. The surveyor went into the kitchen, at 3:51 pm a text message was sent to the RDO for approval on the quote for approval. At 4:30 pm a text was sent to the Corp Environmental Supervisor for Approval. At 4:34 pm the approval was obtained. At 5:12 pm, the Regional Culinary Service Director was called and made aware of the situation. At 5:13 pm, the decision was made to have the food prepared at the Assisted Living Kitchen until the SNF kitchen was fixed. At 5:15 pm the Kitchen was closed. At 5:30 pm Pizza was ordered for the residents as well as salad and dessert At 6:15 pm the pizza arrived. Residents were monitored for signs and symptoms GI problems, which none have been noted as of 1-27-2022. On 1-26-2022, [NAME] was to come and repair the kitchen, repairs will take longer to complete as expected, so the SNF kitchen remains closed, and the Assisted Living Kitchen continues to be used. Modernistic was called and will be doing the cleaning of the kitchen once [NAME] is completed with the work. Education was completed on 1-25-2022 by the RD to the dietary department on the following: The different zones, food cart travel, proper PPE, how to response the leaks in the kitchen, and cleaning the kitchen once leaks occur. The Dietary Director and Maintenance Director was educated to notify the Administrator at once when events like this occur, at that time the Administrator will notify the RDO. The Dietary Director will monitor the drain and will report findings immediately to the Administrator. If this occurs again, the kitchen will be immediately closed, will cleaned immediately, and sanitized prior to resuming food preparation in that area. The maintenance director will notify the administrator and will obtain a quote for any new repairs. Substantial compliance has been achieved on 1-25-2022 The Administrator is responsible for maintaining compliance.

This Citation pertains to Intake Numbers MI 771, MI 773, and MI 680 Based on interview and record review, the facility is placed in Immediate Jeopardy for 1) Failure to properly assess and monitor Resident #4's blood glucose levels while administering antidiabetic medication (Insulin), 2) Failure to comprehensively and timely assess and monitor Resident #29's change in condition, and 3) Failure to consistently and timely assess and monitor Resident #32. Both Resident #29 and Resident #32 died at the facility. This deficient practice placed all residents at significant risk of not being comprehensively, competently, and timely assessed, monitored, and treated by facility staff for their life-threatening health conditions and change in condition, with a high likelihood that residents will continue to suffer harm, injury and/or death. Immediate Jeopardy: Resident #4 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] Resident #4 had a change in condition with an alteration in mental status and unresponsiveness. LPN A recorded blood glucose levels in SBAR (summary change in condition) note on [DATE] and used the value from [DATE], which was 6 days prior. He was transferred to the hospital on [DATE] and assessed to have a Blood glucose level of 40 (very low). Resident # 29 was admitted to the facility on [DATE] and had a change in condition on [DATE]. When alerted by staff at 5 PM on [DATE] that Resident #29 was in respiratory distress (described as a death rattle by resident's nursing assistant), LPN A did not obtain current vital signs, check respiratory status, perform nursing assessments, or transfer resident out to an acute care setting timely. LPN A used previous vital signs and assessments from 7:16 AM and 10:47 AM to complete the SBAR form and notify the on-call provider about Resident #29's change in condition. The vital signs used in the report were obtained approximately 11 hours before Resident #29 's change in condition and did not reflect the resident's new condition. Resident #29 died on [DATE] at 10:41 PM after going into [CONDITION(S)] without assessments performed or timely nursing interventions attempted. Resident #32 was admitted to the facility on [DATE] and had a change in condition on [DATE] with a low oxygen saturation of 72%-90% on 4 L of oxygen with a pulse of 42 to 83 BPM. Resident #32 was transferred to the hospital. The transfer form was blank. There was no nursing documentation or assessment performed when the resident returned to the facility on [DATE]. The last vital signs (blood pressure and pulse) were recorded on [DATE]. On [DATE] Resident #32 was found unresponsive in his room at 2:50 PM and died . During his stay in the facility. Resident #32 had no vital signs taken or assessments performed from [DATE] until his death on [DATE]. Resident #32 had multiple missed medication doses, lacked diabetes monitoring, and lacked nursing assessments. The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 1:00 PM and instructed to provide a plan of correction to remove the immediacy. The Immediate Jeopardy was abated or removed on [DATE]. Findings include: According to admission face sheet, Resident #29 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29 had a peg tube in place and was documented as Nothing By Mouth (NPO) status on admission. According to Minimum Data Set (MDS) dated [DATE], Resident #29 was not scored on the Cognition Assessment, indicating severe cognition impairment. The MDS also reflected that Resident #29 required 2 person staff assist for bed mobility, toileting, and required limited assist with transfers. Record review on [DATE] at 1:23 PM revealed nursing admission progress note documented on [DATE]: Resident has right sided weakness. [ ] Resident is incontinent and total assist. No signs of pain or respiratory distress. Progress note by mid-level provider, nurse practitioner, on [DATE] (no time recorded) indicated Patient is being seen today at request of nursing for cough/congestion. Upon exam patient is sleeping in bed. Patient was easily awakened. No congestion, SOB (shortness of breath), dyspnea (difficulty breathing), or distress noted. He appears comfortable. Patient denies any chest pain, palpitations, SOB, dyspnea nocturnal dyspnea, fatigue, n/v (nausea or vomiting), headache, dizziness, change in vision, changes with bowel/bladder habits, or any acute pain/discomfort. Bilateral lungs are CTA (clear to auscultation), respirations are regular and non-labored. He is using regular respiratory effort. Patient reported that he coughed but it was not an ongoing cough. Patient is in pleasant mood, he is calm and cooperative with exam. Nursing has no other acute concerns. Note was signed on [DATE] at 10:22 AM (after resident #29 died on [DATE]). On [DATE] at 5:00 PM during interview with CNAs R and AAA both stated that Resident #29 did not look good at the beginning of their shift (2 PM) on [DATE]. Both nursing aids were covering North Hall where resident #29's room was located. CNA R said that around 5 PM she could hear in a hall Resident #29's gurgling breathing. His room was next to the nursing station, and she could hear him loudly breathe even at the nursing station. CNA R notified LPN A about her findings and received directions from LPN A to clean the resident because she (LPN A) was planning to send him out. CNAs R and AAA did not recall LPN A taking Resident #29's vital signs or delegating this task to CNAs. Both CNA R and AAA went and cleaned Resident #29. He wasn't acting in the usual way, he was lethargic, his eyes were glassy. CNA AAA stated they were afraid to lay him completely flat because of his breathing. Nurses aids shared that from 5 PM till CNA R discovered Resident #29 unresponsive around 9:40 PM LPN A did not assess her resident or provided nursing interventions. She was waiting for the response from on-call provider for further instructions. Both CNAs R and AAA shared their understanding that LPN A did not act timely and failed Resident# 29 in her nursing judgment and actions. Interview was conducted with LPN N on [DATE] at 3:20 PM. She stated that she worked double shift on [DATE]. LPN Y was working with her till 6 PM and was passing afternoon medications. LPN A was at the nursing station doing new admissions. LPN N recalled nurse A started passing medication around 7:30 PM. LPN N remembered nurse A being upset with how Resident #29 was positioned flat in his bed while his tube feeding was running. She (LPN N) recalled nurse A stating that Resident #29 is not breathing normal and questioning if she should send him out. Later in a shift LPN N remembers one of the aids (CNA R) calling for help and saying that Resident #29 is dead. LPN N went in resident's room along with CNA R and checked his pulse. She did not feel any pulse. She went to the nursing station and asked LPN A if Resident #29 was a full code. After confirming the code she went back and began CPR. During interview with LPN A on [DATE] at 3:49 PM she indicated that during her medication pass on [DATE] on evening shift she heard Resident #29 in his room breathing abnormally. She called it 'Stridor'. LPN A was asked to clarify 'Stridor' and said Bubbling or gurgling sounds. (According to medical definition of Stridor defined as: abnormal, high-pitched, musical breathing sound, caused by blockage in the throat/voice box (larynx) most often heard when taking a breath). LPN A said it was loud enough to hear without the stethoscope at the nursing station. LPN A verbalized she went in the room and looked at Resident #29. LPN A said he was not elevated to ,d+[DATE] degrees in bed, and that his tube feed was actively running. LPN A remembers being upset about the head of the bed being down flat. LPN A verbalized that she raised the head of the bed up. LPN A said she went and called upper management and sent a Tiger page to provider on call. LPN A also said she took air pod into the room to let upper management hear that Resident #29 was making gurgling noise and in distress. LPN A then indicated she got called to another room to deal with other resident issues. LPN A stated she was planning to send Resident #29 out of the facility. Review of Resident #29's medication record administration showed LPN A administered following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications that were due at 4 PM were given by LPN Y. Further Review of Progress Notes reflected an Interact SBAR form entered by LPN A and dated [DATE] at 21:54 PM (9:54 PM), documented: Situation: The Change In Condition/S reported on this CIC Evaluation are/were: Respiratory arrest Shortness of breath Unresponsiveness Change in skin color or condition. At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP ,d+[DATE] - [DATE] 07:16 Position: Lying l/arm - Pulse: P 88 - [DATE] 07:16 Pulse Type: Regular - RR: R 17.0 - [DATE] 10:47 - Temp: T 97.9 - [DATE] 10:47 Route: Tympanic - Weight: W 203.0 lb - [DATE] 16:39 Scale: - Pulse Oximetry: O2 95.0 % - [DATE] 10:47 Method: Room Air - Blood Glucose: Resident/Patient is in the facility for: Long Term Care Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Relevant medical history is: Dementia Diabetes Code Status: FULL CODE Advance directives are: N/A Resident/Patient had the following medications changes in the past week: N/A Resident/Patient is on [MEDICATION(S)]/[MEDICATION(S)]:No The result of last INR: Date: Resident/Patient is on anticoagulant other than [MEDICATION(S)]: No Resident/Patient is on: Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Unresponsiveness - Functional Status Evaluation: Other - Behavioral Status Evaluation: - Respiratory Status Evaluation: Shortness of breath Other respiratory changes - Cardiovascular Status Evaluation: - Abdominal/GI Status Evaluation: - GU/Urine Status Evaluation: - Skin Status Evaluation: No changes observed - Pain Status Evaluation: Does the resident/patient have pain? - Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: Resident was found at 8:30 pm with Stridor on extortion.[SIC] On call was notified at 8:30 and finally provided orders and confirmed them at 9:50 pm. Staff found resident unresponsive at 9:50 pm. One nurse began CPR after the check the code status.[SIC] 911 was called at 9:50 . The unresponsive code was called at 9:50 as well. Staff joined other nurse to perform CPR until EMS arrived. EMS called time of death at 10:41 pm. Medical examiner will arrive within an hour to perform an investigation. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: On call ordered a nebulizer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . As evident in the SBAR documentation, LPN A did not obtain vital signs or perform nursing assessments to reflect resident #29's change in condition. Vital signs documented by LPN A were taken greater than 12 hours prior to the incident and were from 2 different nurses that had assessed Resident #29 earlier in the morning on [DATE]. LPN A notified the On-Call Provider about Resident #29 change in condition and used the vital signs that did not reflect current changes in resident's condition. Further Review of the clinical record reflected General Progress Notes, dated [DATE] at 22:17 (10:22 PM), documented by Licensed Piratical Nurse A that Resident was found at 9:50 pm unresponsive by both second shift nurses. Resident was warm to touch. One nurse started CPR and the nurse called 911 after checking his code status. The code was called overhead. Both nurses continued CPR until EMS arrived at 10:18 PM. According to Prehospital Care Report issued by Mobile Medical Response and reviewed on [DATE] at 11:00 AM, 911 call from facility was received on [DATE] at 21:56 (9:56 PM). EMS unit arrived at Resident #29 at 22:07 (10:07 PM). Per report, cardiac (presumed) arrest was not witnessed, primary symptom listed as respiratory arrest. CPR care was provided prior to the EMS arrival by healthcare professionals (non-EMS), with continuous compressions and use of bag valve mask. AED (automated external defibrillator) was not used prior to EMS arrival. Resident #29 expired on [DATE] at 22:41 (10:41 PM). Review of Progress Notes dated [DATE], documented a Teleheath Visit by FNP (Family Nurse Practitioner) at 11:11 PM, as Notified by nursing that Resident had Stridor with effort, TF (tube feed) patient, CXR (chest X-ray) and Albuteral Neb (breathing treatment) ordered. Also documented was 'Addendum Details' as: pt vitals were requested, not updated in the chart. Then notified that resident became unresponsive at 9:50 PM. CPR was started at 9:50 PM. Time of Death was called at 10:41 PM, by EMS. (The creation date for the addendum was documented as [DATE] at 23:23 (11:23 PM), post death of Resident #29). As evident by documented notes breathing treatment and chest X-ray was ordered by provider on call due to communication of inaccurate vital signs and nursing assessment that did not reflect Resident #29's critical condition, respiratory distress and ultimately [CONDITION(S)]. Facility Policy for Acute Condition Changes- Clinical Protocol ( revised [DATE]) under Assessment and Recognition indicated: In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs; b. Neurological status; c. Current level of pain, and any recent changes in pain level; d. Level of consciousness; e. Cognitive and emotional status; f. Resident's age and sex; g. Onset, duration, severity; h. Recent labs; i. History of psychiatric disturbances, mental illness, depression, etc.; j. All active diagnoses; and k. All current medications. On [DATE] at 1:00 PM, the Immediate Jeopardy was presented to the facility Administrator, as it was identified on [DATE]. The facility provided an Abatement Plan that was reviewed and accepted on [DATE], by State Agency Survey Manager. The IJ was removed on [DATE], based on the facility's implementation of the Removal Plan as verified onsite. The Abatement Plan was as follows: Abatement of the IJ F-864 Event date: [DATE] [DATE] The Director of Nursing/designee will ensure that current assessments have been started for all residents in the facility, which include vital signs, BP, temp, lung sounds, respiratory and mental status. [DATE] The Director of Nursing/designee will ensure that education was started with licensed nurses on how to perform an assessment, change in condition, S-BAR, assessments needed on admission and re-admission, and the need for current vitals at all assessments as ordered. The on-call/nurse practitioner will be notified of the current condition and assessment. Educate on signs of [CONDITION(S)] and [CONDITION(S)] regarding DM. [DATE] The Director of Nursing/designee will ensure that all DM residents have routine and PRN glucose monitoring orders. [DATE] The Director of Nursing will monitor during the morning clinical meeting to ensure compliance. The Director of Nursing/designee will maintain compliance. Substantial compliance was obtained on [DATE] Resident #29 According to admission face sheet Resident #29 was an [AGE] year old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29 had a peg tube and received Enteral Nutrition via peg tube and was documented as Nothing By Mouth (NPO) status on admission. According to Minimum Data Set (MDS) dated [DATE], Resident #29 did not receive a score on the Cognition Assessment indicating severe cognition impairment. The MDS also reflected that Resident #29 required 2 person staff assist for Bed Mobility, and toileting, and limited assist with transfers. An interview was conducted with Licensed Practical Nurse A on [DATE] at 3:49 PM, related to Resident #29. LPN A was asked if she was the nurse in care of Resident #29 on [DATE], and said she was. LPN A was asked if she remembered Resident #29 and said Yes, he was the tube feed guy that was not fed for 3 days. LPN A went on to say that she was in care of Resident #29 on [DATE], after 6 PM, when she took over after the previous nurse had left. LPN A verbalized she was at the nurse station and had been working on several admits on the North hall. LPN A indicated that was during the time Resident #29 experienced a change in condition, on [DATE], Coded and died . LPN A indicated she had been working on several admission on the North hall, then was up passing medications, after 6:00 PM. LPN A said Resident #29 resided in room [ROOM NUMBER], near the nurse station. She verbalized on [DATE], a she could hear Resident #29 having what she called 'Stridor'. LPN A was asked to clarify 'Stridor' and said Bubbling or gurgling sounds. (According to medical definition of Stridor defined as: abnormal, high-pitched, musical breathing sound, caused by blockage in the throat/voice box (larynx) most often heard when taking a breath). LPN A said it was loud enough to hear without the stethoscope at the nursing station. LPN A verbalized she went in room [ROOM NUMBER] and looked at Resident #29. LPN Asaid he was not elevated to ,d+[DATE] degrees in bed, and that his tube feed was actively running. LPN A verbalized she was upset about the bed being down flat. LPN A verbalized that she raised the head of the bed up. LPN A said she auscultated Resident #29's lungs and documented in Progress notes her findings. LPN A was asked if she checked Oxygen sats or applied oxygen and said she raised the bed up. LPN A verbalized she went and called upper management. LPN A said she took air pod into the room to let upper management hear that Resident #29 was making gurgling noise and in respiratory distress. LPN A then indicated she got called to another room to deal with another resident issue. LPN A verbalized she was planning to send Resident #29 out of the facility around 8 PM. I started a tiger text to on-call. I did not know his code status at that time. My first intervention was to raise the head of the bed up ,d+[DATE] degrees. I got called away to another room after that, by one of my new admission's family members. One of the Aids went to check on him during that time, and came out of the room and said he is silent and not making that noise. Something is wrong. I went back to the desk checking for a tiger text. I had called the unit manger, who called the former DON, then called me back and said, Do all the interventions before you send him out. I went back in the room. He was pale. Not blue. I did not auscultate him. I could not get a pulse. Another nurse from the other hall was in there now. She stayed with the Resident. I left the room to check Code Status and the other nurse had started CPR, as I was running back to the room. There were other nurses present taking turns doing compressions. I don't remember who brought the crash cart. I don't remember who documented the code. Someone should have been taking notes. The crash cart did not have any AED pads on it, and the Oxygen tank was almost empty. We ran out of oxygen during the code. There was only one crash cart on the unit. No one went and got another crash cart. I was continuing compressions. There was no oxygen for the ambu bag, it was being done manually. LPN A said I don't typically wait to send someone out. I did this time. LPN A was asked about an assessment and vital signs done by her and said, I documented them in the progress notes. I am sure I did. LPN A was asked if she checked oxygen saturations at any time, and said, I am sure I did. LPN A was asked when the last time she seen Resident #29 responsive and said she could not remember. LPN A was asked why she texted on-call instead of calling and said 'I don't know. LPN A was asked if she was current with her CPR and said yes, I did it online, not with a healthcare provider though, just online. LPN A was if she applied oxygen to Resident #29 when she noted respiratory distress and said, I just raised the head of the bed. LPN A was asked if there was something more she could have done and said, Yes, I could have sent him out when he started having breathing problems. I was told not to send him out right away. The other nurse that was helping did not assess him either. He was my patient though. She was in there helping. 911 was called and we provided a report to EMS when they got here. An interview was conducted on [DATE] at 2:48 PM, with LPN N related to Resident #29. LPN N verbalized she was an Agency Nurse, but worked in the facility doing double shifts on 2nd and 3rd shifts weekly. LPN N said that on [DATE], she was the other nurse working the long hall on North unit and LPN A was working the other hall. LPN A was Resident #29's nurse that day. LPN N said she had been called to look at a wound from a family member on another resident, when one of the nursing assistants said Something is wrong. I think he is dead. There was also another nursing assistant close by. I hit the room. He was gone. I left out (the room) and asked LPN A is he a full code. She said yes. I said call the Code. No one moved quick enough for my liking. I remember LPN A coming out of Resident #29's room earlier in the shift and was talking out loud. She said He is laying flat and shouldn't be. I said Why you telling me. Send him out. She was mad at the aids. LPN A had been at the desk for quite some time because there were 3 admits. This happened around 8:00 PM. LPN N said that LPN A did not do good job during the code, and that the AED did not work, because there were no pads in the crash cart. We should have went in together to assess him earlier and got him out. We did not go in together. One of the nursing assistants was in the room helping me. An interview was conducted on [DATE] at 2:33 PM with RN Q (former DON). RN Q was asked if she could recall Resident #29 and said He was the tube feed guy. I don't remember a lot about him. I remember one of the nurses being mad about his head being down flat in bed with tube feed running, and called me or texted me, and the unit manager, and said she put his head of bed up. Then someone told me he had a change in condition and died . I said, Oh my, was he a full code and did they do CPR. I reminded the nurse to document details of the code, notify physician and family. I was not informed of any problems with the code. I know the nurse called the Unit Manager before starting CPR and said, 'He is dead'. The Unit Manager told her to hang up the phone and go start CPR. RN Q was asked about AED machines and verbalized There is one for every crash cart, and it is the night nurse's responsibility to check the crash cart. There is a list kept in a book or clip board. The cart is to have backboard, suction machine, AED, portable oxygen tank and other items in drawers., They are stocked and ready to go. RN Q was asked about previous codes in the facility and verbalized that Agency Nurses are not proficient in codes. RN Q talked about a code that had happened in [DATE], and when she entered to room to help manage the code, that no one was doing compressions or anything. They were on their phones making calls. I took over and was able to get him back (could not recall who the resident was). No one documented anything. There was no one next to the resident. No one was checking for a pulse. I was upset with the way they managed the code. An interview was conducted on [DATE] at 3:45 PM with Agency Nursing Assistant CCC related to Resident #29. NA CCC verbalized she had been working at the facility for a couple of years before the current corporation took over and that she had been working as an Agency Aid for 3 or 4 months. NA CCC indicated she remember working with Resident #29 and that on [DATE], I came on shift and seen blood in his brief and in his stool. He was fighting us during care. He pulled the tube feed pole over him while he was in bed. He was hard to care for. The next day he passed away at night. It was hectic. LPN N was on one end and LPN A was on the other end. Around 8 PM, LPN A was at the nurse station. The other Aid was rounding on her residents and told LPN A that Resident #29 had a gurgling sound. This was around 8 PM. The nurse said I am going to send him out. Clean him up and change his brief. She went to the desk. We continued doing are rounds after cleaning him up. The other aid went to check on Resident #29 somewhere before 10 PM. She came back out of the room and said He is not making that noise anymore. Something is wrong and alerted us that something was wrong. Me, the other Aid and LPN N ran in the room. LPN N started CPR and I helped her. LPN N was doing compressions. Then I took over doing CPR. I did one cycle. LPN A was at the desk and paged a code. She came back without the crash cart and only carrying an Ambu bag. No crash cart. They did not use an AED. LPN A did not do any compressions. The other staff came to help, but not immediately. EMS showed up and I left to take care of my other residents. An interview was conducted on [DATE] at 4:15 PM, with LPN P. LPN P was asked if she knew about the code for Resident #29 that occurred on [DATE]. LPN P verbalized only what the other nurses told her about the day Resident #29 had coded on [DATE]. LPN P also verbalized she was told that Resident #29 had been found lying flat with tube feed running on [DATE], by one of the nurses who was mad at the nursing assistants. An interview was conducted on [DATE] at 12:14 PM, with LPN S. LPN S was asked if she remembered Resident #29 and said she did. He was non-verbal, tube feed, feisty and combative at times. LPN S verbalized that 2 Aids told her on [DATE], that a resident had been throwing up and that they cleaned him up. They never said the name of, or who the resident was. I said ok. I was told on the 6th or the 7th of January that Resident #29 passed away. I was shocked, and the 2 Aids said, that was the guy we cleaned up after he threw up. LPN S went on to talk about the code that occurred on [DATE]. LPN S verbalized that she was called in the evening somewhere between 9 and 11 PM, by LPN A who indicated I just walked in this man's room and he laying flat, gurgling, and his tube feed is running. I can hear a 'death rattle' going on. It is very deep. She wanted to send him to the hospital. I directed her to use nursing interventions first (lung sounds, vital signs, oxygen saturation, and set him up). She tiger texted the doctor and was waiting for a response and wanted to send him out. I told her I was calling the DON. I said get his lung sounds and make sure you can wake him up. Get off the phone. She called me 30 minutes later and said He is dead. I said what is his code status and she said Full code. I said, Oh My God. Get the F off the phone and go start CPR, call 911. I called the DON back and told her what was happening. She said is there a bunch of F ing idiots in the building. I called the nurse back who informed me that the other nurse had started CPR. I relaxed at that point and went back to bed. The next day, we went over it with the Administrator, DON, and the Unit Manager. I told them how things went. My issue with the nurse was, she was told about the emesis and never said she took vital signs or what she did about it. When I spoke with the nurse then next day, she said the crash cart did not have everything. I told the DON, who was suppose to be refilling/stocking the crash cart This was a few days after resident #29 passed. An interview was conducted on [DATE] at 1:55 PM, related to Resident #29 with Nursing Assistant R. NA R was asked what she remembered about [DATE]. NA R said she cleaned Resident #29 up around 8 PM because the nurse was going to send him out and with help from another Aid. The next time I seen him, he was struggling to breathe, the nurse was informed. The next time i checked on him was around 9:40 PM, he was unresponsive. The other nurse (LPN N) and Aid started CPR before the other nurse (LPN A) told them the code status. The crash cart was next to the nurse station and another nurse brought the crash cart. LPN A did not do CPR. She brought an AMBU bag with out the crash cart. After the other staff came, I left the room. Review of Progress notes in the clinical record, reflected there was not an entry in the notes made by nursing from [DATE] through [DATE]. Review of General Progress Notes [DATE] at 21:00 (9 PM), and a creation date of [DATE] at 21:51(9:51) PM, reflected a documented entry Resident was found lying flat in bed while tube fed was actively running. Resident was repositioned to the high fowlers position immediately. Resident Stridor continued. On call was notified the resident's condition. Report will be given to the third shift nurse to watch for orders from On- call. Management notified of this situation. LPN A made the entry. Review of an Interact SBAR dated [DATE] at 21:54 PM (9:54 PM) documented : Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Respiratory arrest Shortness of breath Unresponsiveness Change in skin color or condition At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP ,d+[DATE] - [DATE] 07:16 Position: Lying l/arm - Pulse: P 88 - [DATE] 07:16 Pulse Type: Regular - RR: R 17.0 - [DATE] 10:47 - Temp: T 97.9 - [DATE] 10:47 Route: Tympanic - Weight: W 203.0 lb - [DATE] 16:39 Scale: - Pulse Oximetry: O2 95.0 % - [DATE] 10:47 Method: Room Air - Blood Glucose: Resident/Patient is in the facility for: Long Term Care Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Relevant medical history is: Dementia Diabetes Code Status: FULL CODE Advance directives are: N/A Resident/Patient had the following medications changes in the past week: N/A Resident/Patient is on [MEDICATION(S)]/[MEDICATION(S)]:No The result of last INR: Date: Resident/Patient is on anticoagulant other than [MEDICATION(S)]: No Resident/Patient is on: Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Unresponsiveness - Functional Status Evaluation: Other - Behavioral Status Evaluation: - Respiratory Status Evaluation: Shortness of breath Other respiratory changes - Cardiovascular Status Evaluation: - Abdominal/GI Status Evaluation: - GU/Urine Status Evaluation: - Skin Status Evaluation: No changes observed - Pain Status Evaluation: Does the resident/patient have pain? - Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: Resident was found at 8:30 pm with Stridor on extortion.[SIC] On call was notified at 8:30 and finally provided orders and confirmed them at 9:50 pm. Staff found resident unresponsive at 9:50 pm. O[TRUNCATED]

This Citation pertains to Intake Number MI 773 Based on interview, and record review, the facility was placed in Immediate Jeopardy (IJ), when the facility 1) Failed to ensure that Resident #29's dietary nutritional orders were entered correctly in the proper format upon admission by nursing and 2) Failed to ensure that Resident #29 received Enteral Nutrition and hydration (tube feeding) as ordered, from the admitted [DATE], through [DATE], while receiving 2 diabetic medications, without Enteral feeding or hydration being administered, (which was the only source of nutrition), resulting in Resident #29 going 7 days without receiving Enteral Nutrition or hydration. On [DATE], Resident #29 had a change in condition (8th day). Resident #29 was noted by staff to be in Respiratory Distress and [CONDITION(S)], resulting in his death on [DATE] at the facility. Immediate Jeopardy: The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy (IJ) F-600 was identified on [DATE], at 4:57 PM, upon review of the clinical record and other pertinent documents. The Administrator was notified of the Immediate Jeopardy on [DATE] at 9:55 AM, and was instructed to provide an Abatement Plan to remove the immediacy. The facility also needs to take immediate action to enter nutritional orders upon admission correctly and in a timely manner, and to provide residents with essential nutrition and hydration. The facility also needs to ensure that nursing staff are properly trained on executing dietary admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IJ Abatement/Removal plan was accepted on [DATE], with a removal date of [DATE], as verified by onsite date of [DATE]. Findings include: According to admission face sheet, Resident #29 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29 had a peg tube and received Enteral Nutrition via peg tube and was documented as Nothing By Mouth (NPO) status on admission. According to Minimum Data Set (MDS) dated [DATE], Resident #29 was not scored on the Cognition Assessment, indicating severe cognition impairment. The MDS also reflected that Resident #29 required 2 person staff assist for Bed Mobility, and Toileting, and required Limited Assist with transfers. Review of Hospital Discharge orders for Resident #29, reflected under 'Nourishment', order # 368 to administer 150 cc of free water every four hours, dated [DATE]. Also noted, was order # 344 to provide Glucerna 1.5 (diabetic) at 60 ml per hour with a start time of 11:35. The stop time was documented as 'until specified'. Review of Facility orders, December, 2021, for Resident #29, reflected an order: Glucerna 1.5 at 60 ml/hr with 37.5 ml/hr H20 flush. Under 'Directions' documented as no directions specified. Under 'Category' was documented as 'Other'. (format nutritional orders entered in into Point Click Care). Under 'Status' was documented as 'discontinued'. Under 'Start Date' was left blank (there was no documented start date, start/stop time, for administering the tube feed). The end date was documented as [DATE], for that order). Review of December, 2021, Medication Acceptance Record (MAR), reflected an entry on the MAR for: Glucerna 1.5 at 60 ml/hr with 37.5 ml flush of H20/hr, to start on [DATE]. Review of the MAR reflected no start or stop time documented, and no entry for nursing to initial in the MAR that the feeding was started or stopped. Review of dates [DATE], [DATE], and [DATE], reflected Resident #29 did not receive any Enteral Nutrition (tube feeding) or hydration as ordered. (Resident #29 received no nutrition) Further review of Resident #29's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Glipzide 5 mg one tab via peg tube twice a day, for diabetic management, with a start date of [DATE]; and [MEDICATION(S)] HCI tablet 1000 mg via peg tube two times a day for diabetic management, with start date of [DATE]. (Review of MAR reflected Resident #29 received the medications as documented by nursing.) Review of Resident #29's orders January, 2022, reflected an order dated [DATE], for Enteral Feeding to flush tube with 50 cc of water every hr (hour) of tube feed infusion (20 hrs) for total of 1000 ml, and formula Glucerna CC/HR as 70 X 20, on at 1600 (4 PM), and off at 1200 (noon), for total volume 1400/ml/24 hours, dated [DATE] at 11:56 (AM/PM not specified). Review of January, 2022's MAR, reflected an order started on [DATE], for Glucerna 1.5 to be administered at 70 cc/hr times 20 hrs, with a start time of 1600 hrs, and stop time of 1200 hrs. Review of the MAR reflected the first Enteral Feeding for Resident #29 was administered on [DATE] at 2:15 PM, (8th day post admission), by Licensed Practical Nurse N, who is an Agency Nurse. An interview was conducted with Registered Dietician on [DATE] at 10:53 AM, with another Surveyor present. RD E was asked about Resident #29, and indicated he was admitted on [DATE], and deceased on [DATE]. RD E said she really did not remember this resident as she has 300 residents to review in other buildings. RD E was asked if any nurses in the facility contacted her and questioned the nutritional orders for Resident #29. RD E verbalized that she thought a nurse did contact her about Resident #29, but could not recall the conversation. I was in a different building at the time. RD E was asked to clarify the process for tube feed order entry, and indicated I don't do orders. Nursing does. They put them in. I give my orders and they enter them. RD E verbalized she went in and seen Resident #29 on [DATE], and reviewed his orders for clarification. RD E then indicated that the nurse who did the admission for Resident #29 enter the nutritional orders under 'Other' which was not the proper format for entering nutritional orders for tube feeding, because it will not always populate (pull over) on the MAR. RD E said It should have been entered under 'Enteral Orders' and not Other. RD E also verbalized she is not an expert on nursing orders, and would often ask the Director of Nursing to check on certain orders. RD E verbalized again that nursing entered Resident #29's nutritional orders under the wrong format as 'Other' and not in the proper category. RD E was asked when Resident #29's Enteral Feeding orders should have been started and verbalized, The Enteral Feeding orders ideally should have been started on [DATE] at 3:30 PM. RD E was asked if nursing informed her that the tube feeding for Resident #29 had not been running in days, and verbalized No one told me. RD Ewent on to say that she seen the order had been written vaguely and not to the Standard that I like it to be. A second interview was conducted on [DATE] at 11:07 AM, with RD E for clarification on entering orders into the system on admission. RD E indicated she sometimes had to ask the previous DON to clarify the Enteral Feeding orders due to nursing not entering in the proper format, and it had been an ongoing problem. RD E indicated that for Resident #29 she had asked the previous DON to clarify Resident #29's Enteral Feeding orders, but not until [DATE]. RD E verbalized that was when the Enteral Feeding had begun for Resident #29 at 70 cc per hour. (Admission on [DATE], 8 days after admission.) An interview was conducted with LPN A on [DATE] at 3:01 PM. LPN A was asked how it was working Agency in the facility, and then verbalized several issues that were happening in the building. LPN A verbalized that at times 5 to 7 admissions would come through the doors on one shift, without any additional help, and that it took up to 2 hours to complete the admissions by the nurse working that shift. LPN A also verbalized that if you couldn't finish everything for that admission, the next on coming nurse was supposed to finish it. LPN A indicated a lot of things were not getting done and that most of the admissions were coming on second shift, or later in the evening. LPN A had to end the interview on this day due to personal obligations. A second interview was conducted on [DATE] at 3:49 PM, related to Resident #29. LPN A was asked if she was the nurse in care of Resident #29 on [DATE], and said she was. LPN A was asked if she remembered Resident #29 and said Yes, he was the tube feed guy that was not fed for 3 days. LPN A was asked how she knew that he had not been fed tube feeding. LPN A indicated another nurse had told her that information. (gave the name of the nurse). LPN A went on to say that she was in care of Resident #29 on [DATE], after 6 PM, when she took over the care after the previous nurse had left. LPN A verbalized she was at the nurse station and had been working on several admits on the North hall. LPN A indicated that was during the time Resident #29 experienced a change in condition, on [DATE] and died . LPN A indicated she was up passing medication, and Resident #29 resided in room [ROOM NUMBER], near the nurse station. She verbalized on [DATE], she could hear Resident #29 having what she called 'Stridor'. LPN A was asked to clarify 'Stridor' and said Bubbling or gurgling sounds. (According to medical definition of Stridor defined as: abnormal, high-pitched, musical breathing sound, caused by blockage in the throat/voice box (larynx) most often heard when taking a breath). LPN A said it was loud enough to hear without the stethoscope at the nursing station. LPN A verbalized she went in room [ROOM NUMBER] and looked at Resident #29. LPN Asaid he was not elevated to ,d+[DATE] degrees in bed, and that his tube feed was actively running. LPN A verbalized she was upset about the bed being down flat. LPN A verbalized that she raised the head of the bed up. LPN A said she auscultated Resident #29's lungs and documented in Progress notes her findings. LPN A verbalized she went and called upper management. LPN A said she took air pod into the room to let upper management hear that Resident #29 was making gurgling noise and in distress. LPN A then indicated she got called to another room to deal with other resident issues. LPN A verbalized she was planning to send Resident #29 out of the facility. An interview was conducted on [DATE] at 2:48 PM, with LPN N related to Resident #29. LPN N verbalized she was an Agency Nurse, but worked in the facility doing double shifts on 2nd and 3rd shifts weekly. LPN N was asked if she was working on [DATE], and verbalized she was the other nurse working the Long Hall with LPN A. LPN N was asked if she remembers Resident #29 and said she did, and went on to say that LPN A came out of Resident #29's room and said he was laying flat, and was mad about it. LPN N was asked if she was aware that Resident #29 had not been fed for days, and verbalized I had heard from other nurses that his tube feeding had not been hooked up and running. LPN N verbalized it (tube feed formula) was hanging on the pump, and the water was there too. no one hooked him up or turned on the pump. LPN N then verbalized she was involved with the Code that occurred with Resident #29 on [DATE], in the evening. LPN N was asked if she received any training on completion of admissions/orders and entering nutritional orders into their system, and verbalized No, I just figured it out along the way. LPN N verbalized various issues that had been happening in the facility, and indicated she did not receive any training when initially working in the facility. LPN N indicated she had to ask other staff often about how things were done. I had to ask what is this, and what is that. No one ever gave me any training on orientation. LPN N verbalized initially she was uncomfortable with the conditions in the facility, and indicated she had to ask the previous Director of Nursing how to do certain things. I did a lot of complaining. LPN N indicated, If a new admit came in, and the nurse was not able to complete it, the next nurse was supposed to. There were times when residents did not get there medications for 2 days. There were up to 7 admits that came on 2nd shift, at one time, with no help. Things got missed a lot. It was not do-able. We did not always have access to everything, especially on weekends. Residents were not getting meals and proper care. There were many resident and family complaints. Things have gotten a little better recently since you guys are here. An interview was conducted on [DATE] at 4:15 PM, with Licensed Practical Nurse P related to Resident #29. LPN P verbalized she was an Agency Nurse that had been working in the facility. LPN P was asked how it was at the facility and indicated It is not been the best experience. LPN P was asked why, and verbalized there are a lot of things going on there, and not good things, such as missing medications and poor resident care. LPN P was asked if she remembered Resident #29 and said she did. LPN P verbalized she had cared for Resident #29 a few times before he died , and recalled he was supposed to receive tube feeding and did not. LPN P indicated the orders for Resident #29's tube feeding administration were not clear. LPN P verbalized what she could recall was that when she went into care for Resident #29, the tube feeding was never running and verbalized from 6 AM through 2 PM, the tube feed was off. The MAR did not have and Up or Down (Start/Stop) time documented. I would say Ok, every day there is a full bottle of feeding and water, and nothing is running LPN P said the MAR did not specify what time to hang it, turn it on, or take it down. So, I talked to the Registered Dietician. We went in and seen Resident #29. The Registered Dietician showed me how to check the volume to be infused on the pump. I did not know how to do that. No one had ever shown me that. The Registered Dietician went and told the Director of Nursing that Resident #29's tube feeding had not been started for days. I started his tube feeding and got him running. It was in the beginning of January. When the RD and I checked the tube feeding pump, it was discovered that nothing had been infused to Resident #29, there was no volume infused. The tube feed was hanging. The water flush was hanging. The pump had not been programmed to infuse the rate of feeding or anything. He did not get his feeding for days. The Registered Dietician was angry about Resident #29 not getting his feeding. She went to the DON who blew her off. I am not really sure how long it was going on, but I know it was for several days. LPN P then verbalized what the other nurses told her about the day Resident #29 had coded on [DATE]. LPN P also verbalized she was told that Resident #29 had been found lying flat with tube feed running on [DATE], by one of the nurses who was mad at the nursing assistants. LPN P was asked if she received any training on orientation and verbalize no, not on anything. LPN P reiterated again that things were pretty bad at the facility, and said that residents are not being fed, not getting medications, not getting cleaned up, and that there are a lot of admissions that are coming through the doors. LPN P said that she was responsible to care for 40 residents with only 2 aids by herself. We could not get it all done. The other nurse has to care for 30 residents with 2 aids and 4 or 5 admissions come through the door. No one comes to help us because we are Agency and they tell us You make more money than we do, do it your self, or do your job. The other nurse on the other hall has 39 residents and 2 aids. An interview was conducted on [DATE] at 12:14 PM, with LPN S. LPN S was asked if she remembered Resident #29 and said she did. He was non-verbal, tube feed, feisty and combative at times. LPN S verbalized that 2 Aids told her on [DATE], that a resident had been throwing up and that they cleaned him up. They never said the name of, or who the resident was. I said ok. I was told on the 6th or the 7th of January that Resident #29 passed away. I was shocked, and the 2 Aids said, that was the guy we cleaned up after he threw up. LPN S went on to talk about the code that occurred on [DATE]. LPN S was asked about the tube feeding orders for Resident #29. LPN S said she had been told by the former DON, that Resident #29 had not been fed for three days and was crying. She was asking How did this happen. LPN S indicated that one of the Agency Nurses had been hiding admission packets, behind printers, placing in drawers, because there were so many admissions coming through the doors. LPN S said that a lot of things were not being entered in the computer on the day of admissions for residents. They were not getting their medications, or diets, and other things. LPN S was asked about the tube feeding order for Resident #29 and indicated the nurse that did the admission did not enter the order correctly into the system, which resulted in no start or stop time. The tube feed order was not the right order. I am not sure how long he was not fed, but I was told 3 days. One of the nurses finally contacted the Registered Dietician for clarification on the feeding order. LPN S indicated when there are 7 admissions coming through the doors, a lot of things are left incomplete. LPN S indicated the tube feeding was started on [DATE], and he (Resident #29) died on [DATE]. LPN S talked more details about her involvement with the Code for Resident #29. An interview was conducted on [DATE] at 2:25 PM with the current Director of Nursing. The DON was asked how long she had been in the role and said only 2 weeks. The former DON left. DON was asked if she knew any information about Resident #29 and said she knew some. DON said what she knew was: Resident #29 passed away after a Code in the building on [DATE]. DON said she spoke with the Registered Dietician and was informed that Resident #29 had not been fed in roughly 6 days, due to lack of diet order because an Agency Nurse entered the order into the system incorrectly. The DON verbalized that if nursing enter the orders under the category as 'Other' it will not show up on the MAR. We have to make sure the nurses are educated. An interview was conducted on [DATE] at 4:00 PM, with Administrator. Administrator was shown that Resident #29 was admitted into the facility on [DATE] and did not receive any enteral nutrition or hydration until [DATE]. Administrator was asked if anyone had shared that information with her, and indicated she did not know. Administrator asked How does this happen. 18 or so nurses over a six day period did not feed this resident. An interview was conducted on [DATE] at 11:00 AM, with LPN T. LPN T who indicated she was an Agency Nurse and often worked a lot of hours in the facility. LPN T was asked how many residents she provides care to, and said 40 residents for herself and 2 aids. LPN T verbalized she stopped working on 2nd shift because that was when all the admissions were coming through the doors, and no one help with the admissions.There would be anywhere from 4 to 7 admissions depending on the day. LPN T was asked about Resident #29 and said she never took care of him, but was told by other nurses that he was not fed for days and then coded. LPN T was asked if she knew how to enter nutritional orders into Point Click Care (PCC) on admission, and said I just enter the orders under the category 'Other', sometimes it will populate over to the MAR with a start time or stop time, and sometimes it does not. I just put in what I have for an order in under 'Other' and when the Dietician comes back to the building on her next day, she will usually clarify what and how she wants the order. LPN T was asked what happens if the resident is admitted on a Friday or weekend. LPN T said the next Monday, the Dietician will clarify the order. It is hard to do. I did not receive any training on how to put the orders into the system. My training with PCC was from another building that I worked in before, but not from this facility. Review of Progress notes in the clinical record, reflected there was not an entry in the notes made by nursing from [DATE] through [DATE]. The first entry in Progress notes was made by the admission nurse on [DATE], and did not have any orders entered for tube feeding. There was no documentation entered during that time for Registered Dietician follow up, Unit Manager follow up, Physician/Provider follow up, or nursing to clarify start or stop time during that time frame. According to interviews by nursing staff, the tube feeding was hanging on the pump along with water flush, it just was never started. There was no entry in the medical record made by nursing until Resident #29 had a change in condition as documented on [DATE]. Review of General Progress Notes [DATE] at 21:00 (9 PM), and a creation date of [DATE] at 21:51(9:51) PM, reflected a documented entry Resident was found lying flat in bed while tube fed was actively running. Resident was repositioned to the high fowlers position immediately. Resident stridor continued. On call was notified the resident's condition. Report will be given to the third shift nurse to watch for orders from On- call. Management notified of this situation. LPN A made the entry. Further Review of Progress Notes reflected an Interact SBAR form, dated [DATE] at 21:54 PM (9:54 PM), documented : Situation: The Change In Condition/S reported on this CIC Evaluation are/were: Respiratory arrest Shortness of breath Unresponsiveness Change in skin color or condition. At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP ,d+[DATE] - [DATE] 07:16 Position: Lying l/arm - Pulse: P 88 - [DATE] 07:16 Pulse Type: Regular - RR: R 17.0 - [DATE] 10:47 - Temp: T 97.9 - [DATE] 10:47 Route: Tympanic - Weight: W 203.0 lb - [DATE] 16:39 Scale: - Pulse Oximetry: O2 95.0 % - [DATE] 10:47 Method: Room Air - Blood Glucose: Resident/Patient is in the facility for: Long Term Care Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Relevant medical history is: Dementia Diabetes Code Status: FULL CODE Advance directives are: N/A Resident/Patient had the following medications changes in the past week: N/A Resident/Patient is on [MEDICATION(S)]/[MEDICATION(S)]:No The result of last INR: Date: Resident/Patient is on anticoagulant other than [MEDICATION(S)]: No Resident/Patient is on: Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Unresponsiveness - Functional Status Evaluation: Other - Behavioral Status Evaluation: - Respiratory Status Evaluation: Shortness of breath Other respiratory changes - Cardiovascular Status Evaluation: - Abdominal/GI Status Evaluation: - GU/Urine Status Evaluation: - Skin Status Evaluation: No changes observed - Pain Status Evaluation: Does the resident/patient have pain? - Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: Resident was found at 8:30 pm with stridor on extortion.[SIC] On call was notified at 8:30 and finally provided orders and confirmed them at 9:50 pm. Staff found resident unresponsive at 9:50 pm. One nurse began CPR after the check the code status.[SIC] 911 was called at 9:50. The unresponsive code was called at 9:50 as well. Staff joined other nurse to perform CPR until EMS arrived. EMS called time of death at 10:41 pm. Medical examiner will arrive within an hour to perform an investigation. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: On call ordered a nebulizer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This entry was documented by Licensed Practical Nurse A, who is an agency nurse. (The vital signs documented in the SBAR, did not reflect LPN A obtaining any vital signs, or performing an assessment to reflect current status change in condition. Some of the vital signs documented above were taken greater than 12 hours prior to Resident #29's change in condition, and were from 2 different nurses that had assessed Resident #29 earlier in the day. LPN A never obtain any vital signs as documented in the clinical record. LPN A notified the On-Call Provider the vital signs that had been taken early in the day, not during her shift, while in care of Resident #29 to reflect current health status and change in condition.) Further Review of the clinical record reflected General Progress Notes, dated [DATE] at 22:17 (10:22 PM), documented by Licensed Piratical Nurse A that Resident was found at 9:50 pm unresponsive by both second shift nurses. Resident was warm to touch. One nurse started CPR and the nurse called 911 after checking his code status. The code was called overhead. Both nurses continued CPR until EMS arrived at 10:18 PM. Review of Progress Notes dated [DATE], documented a Teleheath Visit by FNP (Family Nurse Practitioner) at 11:11 PM, as Notified by nursing that Resident had stridor with effort, TF (tube feed) patient, CXR (chest X-ray) and Albuteral Neb (breathing treatment) ordered. Also documented was 'Addendum Details' as: pt vitals were requested, not updated in the chart. Then notified that resident became unresponsive at 9:50 PM. CPR was started at 9:50 PM. Time of Death was called at 10:41 PM, by EMS. (The creation date for the addendum was documented as [DATE] at 23:23 (11:23 PM), post death of Resident #29). Review of Policy Enteral Nutrition (undated) documented Adequate nutritional support through enteral nutrition is provided to residents as ordered .If the resident has a feeding tube placed prior to admission or returning to the facility, the provider and the interdisciplinary team will review the rationale for the placement of the feeding tube, the resident's current clinical and nutritional status, treatment goals, and wishes of the resident .the dietician monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. The nursing staff and provider monitor the resident for signs and symptoms of adequate nutrition, altered hydration, hypo-or [CONDITION(S)], and altered electrolytes. The nursing staff and provider also monitor the resident for worsening of conditions that place the resident at risk for above .The Nurse confirms the orders for enteral nutrition are complete. Complete orders include: -enteral nutrition product, -Delivery site, -Specific enteral access device, -Administration method, -Volume and rate of infusion, -Volume goals and recommendations, -Instruction for flushing (solution, volume, frequency, timing and 24 hour volume) The provider will consider the need for: -Conformation of tube placement, -Laboratory monitoring, -Nutritional Consultation, -Head of bed elevation, -oral care, and check for gastric residual volume. Staff caring for residents with feeding tubes are trained on potential adverse effects of tube feeding . Review of 'Abuse Prevention Policy' dated as revised 2018, documented Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, and involuntary seclusion, and any physical or chemical restraint . Neglect is the failure of the facility, its employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or mental illness . On [DATE] at 9:55 AM, the Immediate Jeopardy was presented to the facility Administrator, as it was identified on [DATE]. The facility provided an Abatement Plan that was reviewed and accepted on [DATE], by State Agency Survey Manager. The IJ was removed on [DATE], based on the facility's implementation of the Removal Plan as verified onsite. The Abatement Plan was as follows: Abatement of the IJ F-600 Event date: [DATE] [DATE]- All residents tube feed orders were evaluated, and orders have been checked by the RD and the Regional Director of Clinical Services. This ensured that every resident on tube feeding obtained the proper nutrition and the hydration orders. [DATE] All residents' nutritional orders were evaluated in PCC by the Regional Director of Clinical Services. [DATE]-current orders for residents on tube feeding are now correct in PCC [DATE]-new admissions that are tube fed will be forwarded via email to the RD at the time of admission so she can approve and make recommendations to the nutritional orders. The orders will be reviewed for approval by the Physician. Then the DON will ensure that the order is placed into the correct format and that it is visible on the MAR and the TAR. Admission Director will notify the RD, DON and Administrator at the time of the admission to ensure orders are placed as needed via email. We have hired an Admission Director and they will be responsible for clarification of hospital discharge orders. [DATE] Nurses will fill out the admissions dietary sheet per admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RD will review all dietary orders the following business day. [DATE] If there are any questions or concerns regarding the admissions orders the admitting nurse will reach out to the on call clinical leader [DATE]- education has been started on training licensed nurses on how to execute dietary admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RD will be notified for those residents at risk of dehydration. Nurses that haven't had the education will not take the floor until they are educated. Education will be ongoing. [DATE]- education has been started on medication administration via the peg tube. Nurses that haven't had the education will not take the floor until they are educated. Education will be ongoing. [DATE] After hours all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE]- All new admits will have the clinical assessments completed and audited for completion & accuracy by the Unit Mgr, DNS and/or designee within 24 hrs. Clinical assessments to be completed by the admitting nurse and will include Comprehensive nursing admission assessment, Braden assessment, Morse Pain, Elopement, Hydration and Fall assessment. [DATE] Licensed Nursing staff will be re-educated on admission process including expectation of completion of assessments and validation of orders. Nurses that haven't had the education will not take the floor until they are educated. Education will be ongoing. [DATE] Licensed Nurses will be re-educated on medication administration, medication assessment and nutritional values and change in condition. Nurses that haven't had the education will not take the floor until they are educated. Education will be ongoing. [DATE] Facility will print out a step-by-step guide in how to place admissions orders into PCC, and how to place tube feeding orders in PCC and how to run tube feeding pump and check for residual. Clinical responsibilities will be upheld by the Director of Nursing Services during the morning clinical meetings, where admits and readmits will be evaluated to ensure proper nutritional needs have been ordered and hydration assessments have been completed. Clinical services will monitor the orders within 24 hours after admissions or re-admission to ensure the correct diet orders are in PCC. Administrator and Director of Nursing Services is responsible for compliance Substantial compliance was obtained on [DATE] During interview with the Registered Dietitian E on [DATE] at 10:55 AM s [TRUNCATED]

This Citation pertains to Intake Numbers MI 773, MI 369, and MI 447 Based on interview, and record review, the facility 1) Failed to provide a safe environment to prevent falls resulting in serious injuries; 2) Failed to perform Neurological Assessments post-fall and 3) Failed to complete Incident/Accident reports post fall, for 3 residents (Resident #9, Resident #13, Resident #31) of 5 residents reviewed for falls, resulting in a fracture to the Left leg for Resident #13 requiring surgical repair, pain and suffering, laceration to the scalp and requiring staples for Resident #9 with transfer to the hospital, and facial and forehead contusions with bruising for Resident #31, leading to the likelihood to not recognize serious changes in Level of Consciousness (LOC) or other Neurological changes post falls and prevent further falls with serious injuries. Findings include: Resident #13: According to admission face sheet, Resident #13 was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses that included: Diabetes, [CONDITION(S)], Depression, Dementia, and other complications. According to Minimum Data Set (MDS) dated [DATE], Resident #13 was not scored on the Cognition Assessment, indicating severe Cognition Impairment. According to the MDS, Resident #13 required staff assistance with transfer, toileting, and bed mobility, and coded as balance not steady only stable with staff assistance. Resident #13 was also coded as a wanderer under 'Behaviors'. According to MDS, Resident #13 was coded as 'Yes for Falls, one with major injury.' Review of Resident #13's Nursing Admission reflected it was not completed until 12/2/21, Resident was admitted on [DATE]. Review of Progress notes reflected an entry dated 12/2/21 at 19:41 (7:41 PM), Resident found on floor, says going to smoke, fell going up stairs, broke her leg, going to closet to weigh herself. The Facility was asked to provide an Incident/Accident report and was not able to provide one by the end of Survey. The Administrator indicated one had not been completed for this fall on 12/1/21 and was not able to provide any Neurological Assessment for the unwitnessed fall An interview was conducted on 2/15/22, with the Complainant, who indicated that her family member was admitted to the facility on [DATE], and had a fall on 12/2/21, which resulted in a broken leg. Complainant indicated she and was told by nursing that Resident #13 was found in her room, underneath the other bed that was in the room. Complainant said that she seen her, before she was sent to the hospital, and her wheelchair was next to the bed on the other side of the room. I think she was attempting to climb up in the bed on the other side of room. I had asked the facility to get the bed out of there when she came in the facility. They told me the bed was broken and would not go down. It was left way up high in the air. I was told by staff that they couldn't move the bed because it was broken. They also kept shutting the door. I asked several times for staff to keep the door open so they could see her. They just continued to keep the door shut. The complainant verbalized that another family member had been in the facility to visit Resident #13 on 12/1/21, (day of admission) and that Resident #13 got out of her wheelchair and was scooting across the floor on her butt. My relative was trying to get help for my mom. Staff were just walking by, and not one person stopped to help her. My family member had to ask several staff for help to get her (mom) back in the wheelchair. Complainant said I got the phone call from the nurse in charge of her, on 12/2/21, who verbalized this is Nurse (gave name) from (gave name of different LTC facility) and said We are going to be sending Resident #13 to the hospital, looks like she broke her leg. Complainant went on to say that Resident #13 required surgery for repair the next day for a broken leg. Complainant verbalized that Resident #13 was transferred to a different facility upon discharge from the hospital. Complainant also indicated she was able to get to the facility with another family member before EMS took Resident #13 to the hospital, and that it had been about 30 minutes from the time she was called before EMS took her. I was able to go to the facility and see mom for myself. Her leg was messed up. I was angry. Review of Hospital notes (Emergency Department dated 12/2/21, documented Closed displaced spiral fracture of shaft of Left femur, as Initial Encounter, dated 12/3/21. Under Chief Complaint: Pt had a fall at nursing home today. Unwitnessed. Deformity noted to L. thigh. 50 mcg [NAME] PTA. Under History: Resident (gave name) is a [AGE] year-old female with history of dementia, diabetes, prior right femur fracture . prior subarachnoid hemorrhage, who presents for fall. Pt. had a fall at nursing home today that was unwitnessed. Pt. was found on the ground with left femur deformity. Unknown loss of consciousness or head trauma. Pt states she was attempting to open the door when she fell on her left side. Otherwise had been feeling well . X-ray Leg Left 2 view, Final result IMPRESSION: Acute, displaced fracture of left femur as above. This was electronically signed by the MD on 12/2/21 at 10:43 PM. Acute spiral fracture of the mid to left femoral shaft with significant angulation, displacement, override, and rotation. Under ED Course documented: [AGE] year-old female with history as above presenting with fall. Unwitnessed. Upon arrival, vitals reassuring. Exam is notable for obvious deformity to left mid-thigh. Neurovascularity intact distally. No other evidence of trauma. No focal Neurological deficits. Concern for left femur/hip fracture as well as possible dislocation. Will evaluate with x-ray pelvis, left hip, left femur, left knee, left tib-fib. Given patient is on aspirin and [MEDICATION(S)], will evaluate with CT of head and C-spine. Basic labs obtained. XR with acute spiral fracture of the mid to left femoral shaft with significant angulation, displacement, override, and rotation. No other lower extremity fractures. Orthopedics consulted and recommended CT LLE. Required multiple doses of [MEDICATION(S)] then [MEDICATION(S)] for pain. Surgery: 1. Intramedullary fixation left oblique femoral shaft fracture with previous sliding hip screw requiring removal of screws for placement of the nail. 2. Removal of superficial orthopedic hardware left leg, tibial traction pin. An interview was conducted with Licensed Practical Nurse N on 2/1/22 at 2:48 PM. LPN N was asked if she remembered Resident #13. LPN N said she was Resident #13's nurse when she was admitted to the facility. LPN N verbalized she remembered that Resident #13 had previous fracture that had healed on the right hip. LPN N verbalized that her daughter was going to Nursing Assistant school to help care for Resident #13, and also was a cop. LPN N indicated the daughter had been in visiting, and with another family member and, set up a tablet so they could talk to Resident and see her. LPN N went on to say she had worked a double shift. She (Resident #13) would wander up and down the hall in her wheelchair. I documented on her admission assessment she was a wanderer. I remember her being in bed when I left her. The door was closed. I heard her yelling short time later. There was a 2nd bed in the room. The bed was up high. Bed was not broken. The facility keeps the unoccupied beds up high when not being used. She (Resident #13) started screaming, I went in the room, and she was sitting on the floor, in front of the door. She must have got up and tried to walk to the door. She said, My leg is broke. The other nurse working came down, and we seen that her leg (left) was in the wrong position. It was extending outward. The lower part of her leg was bent the wrong way. I called 911. I called her daughter and left a message. I called the sister too, they both popped up on screen of the tablet. They seen Resident #13 on the floor. They came to the facility before EMS showed up and seen Resident #13. LPN N was asked if she completed an Incident/Accident report and said No, I should have but I did not. LPN N was asked if she performed any Neurological Assessment post fall for Resident #13 and said, No. I sent her to the hospital. LPN N was asked how long it took to get Resident #13 out to the hospital, and said almost 30 minutes., long enough for her two family members to get here and see her. LPN N was asked if 2 Neurological Assessments should have been completed if the Standard of Practice is to assess every 15 minutes for the first hour, and said, Yes, I should have performed a Neurological Assessment. LPN N was asked what safety precautions were in place, at the time of the fall, and said Resident #13 should have been 2 persons assist with transfers not one. She was confused and could not use the call light. She was self-transferring a lot. LPN N went on to say she was new to the facility and there was no Director of Nursing in place at that time of the fall. I did not know how to properly do a Fall Report. They never showed me any of that. I had been here only 3 or 4 days at that time. I had to do a Change in Condition to get resident out, at that time. That is why there is no fall packet. The paperwork on the units still have the old facility's name on it, not the new corporation. LPN N verbalized again that no one taught her to properly manage a fall in the facility. Review of Resident #13's Care Plans, reflected a Care plan initiated on admission for: At Risk for Falls and Fall related injuries. Resident will have reduced risk for falls and fall related injuries. Under Interventions documented: -Encourage and assist to wear appropriate nonskid footwear. -Keep call light and frequently used personal items in reach. - Assist with toileting. -Specify Resident specific interventions. Review of Resident #13's 'Nursing Admission/Readmission Evaluation' dated 12/2/21 at 05:07 (resident admitted on [DATE].) Under the heading of Falls: Question Number 1 asked if the resident had falls prior to admission. The box was left blank for 'Yes or No'. Under the heading of Memory Ability: The box was checked for 'memory problem'. Under the heading of Behavioral symptoms: the box was checked for Wandering. Under Level of Assistance needed for Ambulation , with device if utilized: The box was checked for Independent or Supervision. (MDS coded for staff assist.) Level of assistance for Transfers: the box was checked as Independent or supervision. Level of Assistance for Toileting was checked as: Independent or Supervision. Level of Assistance for Bathing: checked as Independent or Supervision. Under the section for Care Planning: ADLS: The box was checked for: The resident needs assistance with Activities of daily Living and the Goal: Resident will have care needs met daily with staff assistance. (Under assist with continence was left blank and not checked for staff assistance.) The box was checked for staff assistance with Toilet Use. For Transfer: checked as staff assistance. Under Fall prevention/Safety Boxes checked for: resident is at risk for falls or fall related injury: The box to assist with Transfer was left blank and was not checked for an intervention. (MDS has Resident #13 coded as staff assistance.) Review of Facility policy Fall Management dated as October, 2019, documented under Policy 'Purpose' : To prevent injuries related to falls. Under Procedure: Fall Risks will be assessed on admission, quarterly and with significant change .A care plan will be developed on admission with specific care planned interventions . Under Post Fall: Any Resident experiencing a fall will be assess immediately by the charge nurse for possible injuries . -a neurological assessment will be initiated on all unwitnessed falls every 15 minutes for 1 hour, then every 1 hour times 4 hours, then every 4 hours for 20 hours .then every 8 hours for 48 hours .A neurological assessment will be initiated on all residents with suspected head injury . Resident #31: On 1/31/22 at 9:30 AM during a tour of the North Unit, Resident #31 was observed lying in her bed. The right side of her face and forehead was dark purple and red. There were scattered abrasions on the right side of her face and cheek. Upon saying hello and asking how she was doing; Resident #31 did not answer. She was awake and alert but didn't not respond to questions. A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #31 indicated an admitted [DATE] and readmission of 1/26/22 with diagnoses: Dementia, [CONDITION(S)], anxiety, [CONDITION(S)], dysphagia, and Covid-19 infection on 1/17/22. The MDS assessment dated [DATE] revealed moderate cognitive impairment and the need for 1-person assistance with all care. A review of the assessments indicated there was no admission nursing assessment after the resident was admitted to the facility on [DATE]. There was a Transfer Form status In progress dated 1/26/22. It said the resident was transferred to the hospital on 1/26/22 at 4:10 AM due to a fall, with a hematoma on the right side of her face, bruised shin, skin tear on left index finger, and resident reports pounding headache related to fall that occurred earlier in the night. Further review of the assessments revealed there was no fall risk assessment either before or after Resident #31 fell . On 2/1/22 at 11:30 AM Resident #31 was observed in a wheelchair in the hallway with Physical Therapy Assistant X. Her facial bruising had spread to include most of her face. The therapist said the Resident was, Really active and moves around a lot. She fell in her room. Therapist X said Resident #31 needed assistance with transfers- contact guard and her walking was unsteady. Nurse W was interviewed on 2/1/22 at 11:45 AM related to Resident #31's facial injuries and fall and said the resident had fallen on the weekend. A record review of the progress notes revealed the following: 1/25/22 at 11:22 PM, At approximately (10:40 PM) resident called out to writer while writer was coming down the hall approaching med cart. As writer entered the room resident asked for a bandage for her finger and reported she fell earlier awhile ago. Resident and roommate reports he had assistance back in bed while writer completed skin assessment. Hematoma on right side of face, bruises/discolorations noted along left shin and skin tear and bruising noted on index finger of left hand. Director, off going nurse and on call provider notified. Neurochecks initiated . will continue to monitor. 1/26/22 at 4:51 AM, Resident sent out to (hospital) . after reporting severe headache and stiff neck . 1/26/22 at 12:02 PM, Resident has returned from ER with new order to start [MEDICATION(S)] (antibiotic for urinary tract infection) . The next progress note was completed by the provider on 1/27/22. There was no additional assessments or progress notes until 2/1/22 with an additional provider note. The nurses were not documenting assessments or notes related to the resident's condition. The neurological assessments were incomplete. A review of the physician orders on for Resident #31 identified 8 orders that were Queued but not completed: Non-skid footwear: 1/26/22; 5 TB test orders: 1/26/22; Activity orders: 1/26/22; Weekly Nursing Summary: 1/26/22. The orders were not enacted because they had not been completed. A review of the Care Plans for Resident #31 dated 1/26/22 after return from the hospital due to a fall with a head injury indicated the resident did not have a Fall or Safety care plan before or after the fall. There was a Activities of Daily Living Care Plan, dated 1/10/22 and an Impaired Mobility Care Plan dated 1/4/22 with one intervention dated 1/4/22 The resident requires by 1 staff for locomotion using wheelchair. Neither Care Plan was updated after the resident's fall. On 2/9/22 at 10:18 AM, Corporate Nurse DD was interviewed related to the lack of fall assessments, reassessments and an Incident and Accident report for Resident #31. Corporate Nurse DD stated, I know fall reports have not been written and assessments have not been completed. We are working on that. A review of the facility policy titled, Fall Management, dated October 2019 provided . Fall risk will be assessed upon admission, quarterly and with significant change. A Care Plan will be developed at time of admission with specific care plan interventions to address each resident's fall risk factors . Any resident experiencing a fall will be assessed immediately .A neurological assessment will be initiated on all unwitnessed falls; every 15 minutes for 1 hour then every 1 hour for four hours, then every 4 hours for 20 hours then every 8 hours for 48 hours. A neurological assessment will be initiated on all residents with a suspected head injury . The care plan will be reviewed and updated . Resident # 9: During interview with the family on 2/17/22 at 11:57 AM complainant shared that during her mother's (Resident # 9) stay in the facility she fell multiple times and was hospitalized with injury to her head. Complainant shared that she wanted to transfer her mother from the facility, but she (Resident #9) was very weak, lost so much weight, it wasn't safe to move her. According to admission face sheet Resident #9 was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included: hypo-osmolarity and [CONDITION(S)] (low blood sodium levels), chronic obstructive pulmonary disease, asthma, [CONDITION(S)], presence of cardiac pacemaker, neuromuscular dysfunction of bladder, major depressive disorder, and dementia. According to Minimum Data Set (MDS) dated [DATE], Resident #9 was scored on the Cognition Assessment at 7, indicating substantial cognition impairment. The MDS also reflected that Resident #9 required 2 person staff assist for bed mobility, and with transfers, and 1 person staff assist with eating and toilet use. Upon review of Electronic medical records (EMR) Care plan dated 10/8/21 at 23:56 (11:56 PM) indicates: Focus: Resident is at risk for falls or fall related injury. Goal: Resident will have reduced risk for falls and fall related injuries. Intervention: Encourage and assist to wear appropriate nonskid footwear; Keep call light and frequently used personal items within reach; Assist with toileting; Assist with transfers. Progress note dated 10/11/21 at 6:28 AM specifies: Resident is legally blind and calls out for someone to hold hand and stay in room with her. Will cont (continue) to monitor and reassure patient per writer's shift while maintaining safe. Call light within reach. On 10/18/21 at 12:08 PM note by nurse practitioner was charted Nursing staff notified provider that patient was noted with fall this AM. Neuro checks initiated. Upon assessment patient is alert and oriented x 1-2. She is confused, able to be verbally redirected. ROM (range of motion) and neuro checks are at baseline. She denies any acute pain or discomfort. Fall prevention measures reviewed with both patient and nursing staff. Will continue to follow. A review of Care Plans provided by the facility and dated 10/8/21 did not show any revisions or adjustments in Resident #9 goals or interventions regarding fall risk after resident fell on [DATE]. No incident report or neuro checks were found on record. Note by a healthcare provider was recorded on 10/25/21 Notified by RN patient sustained a fall with a laceration to her head. She is alert and oriented x 1, which is her baseline. They (staff) were unable to get the bleeding to stop from laceration and requested to send out for repair. Patient was sent out to repair laceration, will notify primary team. Nursing note on 10/25/21 at 2:53 AM regarding Resident #9 change in condition revealed At 1:45 AM the resident was discovered on her room floor by the writer crying and bleeding from the back of her head. She stated that she had to use the bathroom and fell . The bed next to her was displaced and the footboard was broken off and hanging. Upon further inspection she also complained of left hip and shoulder pain. Resident was sent to [NAME] hospital for treatment. Hospital records from 10/25/21 reveal emergency room assessment Approximately golf ball size hematoma located just left of the occiput with overlying laceration. There is a note about scalp wound closure with 3 staples. Resident was evaluated for fractures and brain injury/bleeding due to trauma and taking anticoagulant ([MEDICATION(S)]). She was sent to back to facility after evaluation. A review of the Care Plans for Resident #9 provided by the facility did not show any changes or indicated new fall prevention assessments/interventions after return from the hospital status post fall with a head injury. Incident report was filed by nurse. Neuro checks records were requested and were not found by the facility. On 11/16/21 at 4 PM note was filed patient fell at 15:15 (3:15 PM) full assessment done patient states chest pain and pain to left hip no other injury noted. Patient states that she wants to go to hospital. Daughter notified at 15:40. Note by Nurse Practitioner (NP) on 11/17/21 shows Patient was sent out to the hospital status post fall due to patient and daughter requesting her to be sent out and evaluated. She returned to the facility same day no follow up paperwork. Facility to get any follow up appointments/ instructions if any. She had full work up at the hospital. A review of the Care Plans for Resident #9 provided by the facility did not show any changes in intervention or indicated new fall prevention strategies after return from the hospital status post fall. Neuro checks records were requested and were not found by the facility. Electronic medical Record review showed no healthcare provider, nursing or follow up notes from 11/17/21 to 11/26/21 (for 9 days post fall and hospitalization ). There is a note on 11/30/21 at 10:57 AM Nurse found patient laying on the floor next to wheelchair in hallway by nurse's station, assessment completed, patient placed in wheelchair. NP notified of fall, patients daughter notified of fall. Upon record review no changes in Care plan for Resident #9 were noted or implemented. No neuro checks records or incident report were found. Record review revealed no provider or nursing notes from 12/17/21 to 12/28/21 (for 11 days) addressing Resident #9 health status. On 1/7/22 at 11:30 AM nursing note indicates The CENA came to this nurse and stated, The resident daughter packed all of her mother's items and took her mother out of here The daughter did not speak to this nurse at all. Daughter did talk to S.W. (social worker) that she was taking her mother home. Called the S.W. office to inform that the daughter took her out of the building AMA (against medical advice). During interview with the family on 2/17/22 at 11:57 AM complainant shared that her mother passed away on 2/12/22. She said She didn't live through all of it. I am so sad. It has been hard. She stated that facility did not provide her mother with a good care.

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure accurate assessment, documentation, implementation and monitoring of interventions to prevent the development and/or worsening of pressure ulcers (wounds caused by pressure) for seven sampled residents (Resident #7, Resident #27, Resident #46, Resident #77, Resident #82, Resident #88, and Resident #82) and four unsampled residents (Resident #1, Resident #2, Resident #3, Resident #4) of eleven residents reviewed. This deficient practice resulted in lack of facility staff/administration knowledge of pressure ulcer status, lack of assessment, monitoring, and documentation of pressure ulcers, lack of implementation and monitoring of interventions for pressure ulcer prevention, lack of treatment completion, lack of appropriate infection control procedures during wound care, development and worsening of Stage IV (full thickness tissue loss with exposed bone and tendon), unstageable/Deep Tissue Injury (DTI- pressure ulcer with unknown depth), and Stage II (open ulcer with partial thickness dermis loss) pressure ulcers for Resident #27 and Resident #82, and the likelihood for infection, unnecessary pain, and decline in overall health. Findings include: Review of the facility provided CMS-672 Form Resident Census and Conditions form detailed there were six residents with pressure ulcers, excluding stage one (intact skin, non-blanchable redness usually over a bony prominence) pressure ulcers. The CMS-672 form further detailed three of the six residents had pressure ulcers upon admission indicating three residents had developed pressure ulcers in the facility. Review of the facility provided CMS-802 Resident Matrix form only indicated two residents had pressure ulcers. Resident #27: On 2/15/22 at 9:27 AM, Resident #27 was observed in their room in bed. The Resident was wearing a hospital style gown and positioned on their back with their heels positioned directly on the mattress. Wound care dressing supplies were observed on the Resident's bedside table. An interview was conducted at this time. When queried regarding the wound dressing supplies in their room, Resident #27 revealed they had sores on their heels but were unable to provide any further information. Record review revealed Resident #27 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive two-person assistance for bed mobility, transferring, dressing, toileting, and personal hygiene. The MDS further indicated the Resident was at risk for pressure ulcer development but did not currently have pressure ulcers. An interview was conducted with Licensed Practical Nurse (LPN) R on 2/15/22 at 9:44 AM. When queried if Resident #27 had any wounds and/or pressure ulcers, LPN R indicated they were not aware of the Resident having a wound. When asked why the Resident had wound care dressing supplies in their room if they did not have a wound, LPN R indicated the supplies may have been for a different resident. An observation of the Resident's skin and/or daily care was requested to be completed at this time. LPN R indicated there was no staff available at this time but would contact this surveyor by phone when ready. LPN R did not contact this surveyor to complete observation. A list of residents with wounds was requested from the facility Director of Nursing (DON) on 2/15/22 at 11:30 AM. The DON was asked to delineate which wounds were pressure ulcers and which pressure ulcers were facility acquired versus community acquired on the list. On 2/15/22 at 1:35 PM, the requested list of residents with wounds was received from the DON. The list was titled, Wound Rounds and included 12 residents. The type of wound was not defined on the list. Resident #27 was not included on the provided list. An interview was conducted at this time. When queried regarding the wound etiology of the resident wounds provided on the list, the DON revealed they did not know. The DON indicated they would have to look into it and follow-up. When asked about the discrepancies identified between the CMS-672 and CMS-802 forms, the DON was unable to provide an explanation. Review of Resident #27's care plans revealed the following care plans and interventions: Care plan: Alteration in skin integrity related to immobility and weakness with hx (history) of abscess to left groin secondary to [CONDITION(S)] (urinary tract infection), right lateral foot, right 2nd toe, left plantar foot, left great toe, left lateral calluses present upon admission (Initiated: 2/8/16; Revised: 6/4/21). The care plan included the interventions: - Encourage and assist as needed to turn and reposition; use assistive devices as needed (Initiated: 2/8/16; Revised: 12/26/20) - Prafo boots (boots which prevent/treat pressure and foot drop contractures) on while in bed (Initiated: 1/13/21; Revised: 8/28/21) - Use pillows and/or positioning devices as needed (Initiated: 12/26/20; Revised: 7/12/21) Care plan: At risk for alteration in skin integrity/pressure ulcers related to decreased mobility, increased skin moisture, decreased sensory perception of pressure, potential for nutritional deficits secondary to chronic disease and incontinence (Initiated: 6/1/18; Revised: 6/4/21). The care plan included the included the interventions: - Barrier cream to Buttocks and peri area (Initiated: 6/9/16; Revised: 8/28/21) - Float heels as tolerated (Initiated and Revised: 8/30/17) - Pressure relieving mattress and pad on bed/chair (initiated and Revised: 10/30/19) Care plan: Resident has impaired skin integrity to left buttocks . (Initiated: 9/8/21; Revised: 9/13/21). The care plan included the interventions: - Assess and document skin condition, notify MD of signs of infection . (Initiated: 9/8/21) - Assist with bed mobility to turn and reposition routinely (Initiated: 9/8/21) - Wound treatment as ordered (Initiated: 9/8/21) - Notify MD of worsening or not improvement in wound (Initiated: 9/8/21) - Check for incontinence and provide incontinence care as needed. Notify nurse . (Initiated: 9/8/21) Care plan: ADL Self Care deficient related to decreased functional mobility, reduced balance, chronic pain in knees, [CONDITION(S)], [CONDITION(S)] . (Initiated: 7/28/15; Revised: 6/4/21). The care plan included the intervention, Trapeze to bed to increase mobility (Initiated: 7/15/20; Revised: 8/28/21). Note: Resident #27 did not have a trapeze on their bed. Review of Resident #27's progress note documentation in the Electronic Medical Record (EMR) revealed the following related to altered skin integrity and wounds: - 9/7/21 at 9:26 PM: General Progress Note . returned via EMS from (hospital) approx @ 1930 (7:30 PM) post (cardiac procedure) . Post procedure res c/o (complain of) pain to buttocks . drainage noticed from L (left) buttocks. Orders given to keep area clean + dry with frequent brief changes and f/u (follow up) with wound care, per nursing staff. Area assessed upon returned clean and dry, no drainage noted during shift . - 11/26/21 at 1:48 PM: General Progress . Draining cyst observed to resident's right buttocks . - 11/27/21 at 12:25 AM: Skilled Nursing Late Entry . patient resting but awakens easily complaining of discomfort from boil on right buttocks. skin area raised and filled with fluid tender to touch . - 11/27/21 at 9:36 AM: General Progress Note . Alert and oriented to baseline . Remains on oral antibiotics r/t (related to) fluid filled cysts on right buttocks . Small amount of red odorous drainage is observed . - 11/29/21 at 12:30 AM: Skilled Nursing Late Entry . patient awakens easily and is oriented to situation. Boil on right buttocks draining mod (moderate) amount serosanguinous drainage . - 11/30/21 at 11:50 AM: Skilled Nursing . (Resident) took shower this morning on [MEDICATION(S)] (antibiotic) for boils on buttocks moderate drainage from boils . -1/4/22 at 3:07 PM: General Progress Note . Phoned (Physician O) explained resident has been having emesis for two weeks and is requesting to be sent to the hospital. (Physician O) stated wasn't aware of the emesis and agreed that resident should be sent to the hospital to be checked over . - 1/6/22 at 12:23 AM: General Progress Note Late Entry . Resident returned from (Hospital) no new order . - 1/28/22 at 10:58 PM: General Progress Note . Resident returned from hospital via ambulance, Resident is Covid recovery. Resident present with PICC (Peripherally Inserted Central Catheter- catheter inserted in the body through the arm that extends to the heart and utilized for long term administration of intravenous medications) in (right) upper arm . - 1/31/22 at 12:00 AM: Progress Notes . Visit Type: Acute . Chief Complaint . Follow-up ER visit . seen today in follow-up on ER visit. Unfortunately, records are not available, and I am unsure why (Resident #27) was in the emergency room . Patient does have multiple wounds. (Resident #27) is also noted to have a left buttocks wound . (Authored by Nurse Practitioner (NP) Q) - 2/1/22 at 1:47 PM: Skilled Nursing . Pt (Patient) wound care order was reinstated until wound consult can be done. (Physician O) was called multiple times to obtain orders. Wound cleaned and dressed. (No) acute issues to note at this time will cont. to monitor. - 2/8/22 at 2:00 AM: eINTERACT SBAR Summary . Change in Condition . Skin wound or ulcer . Skin Status Evaluation: Pressure ulcer/injury . Pain Status Evaluation: Does the resident/patient have pain? Yes . Nursing observations, evaluation, and recommendations are changed 4*4 needs a wound consult notified on call . Date and time of clinician notification: 2/7/22 at 2:00 AM . Recommendations: wound consult . Review of Assessment/Evaluation documentation in Resident #27's medical record revealed the following: - 1/28/22 at 11:10 PM: Nursing Admission/Readmission Assessment . Skin Conditions . Site . R (right) heel has opening on it . covered with a dry clean dressing . Coccyx: open red areas coved with a dry clean dressing . Other: R buttocks has open area with tunneling . Review of Historical data within the Nursing Skin Assessment documentation detailed the following: - 10/13/21: Other . Site: (Blank) . - 10/20/21: Other . Site: (Blank) . - 10/22/21: Admission . Site: (Blank) . - 12/21/22 Other . In Progress . Site . Right Buttocks . Description: Fluid filled and draining cysts . - 2/6/22: Other . Site . Left buttocks . Description (Blank) . - 2/8/22: Admission . Site . Left Heel . Description (Blank) . Right Trochanter (hip) . Description (Blank) . - 2/9/22: Admission . Site: (Blank) . - 2/14/22: Admission . Site: (Blank) . - 2/8/22 at 2:00 AM: eINTERACT Change in Condition Evaluation . Skin Status Evaluation: Pressure ulcer/injury . Describe the pressure ulcer/injury . New onset Grade 2 or higher pressure ulcer/injury, OR progression of pressure ulcer/injury . Document location and details . left heel has an ulcer . Documentation of wound measurements were not present in Resident #27's medical record. Review of Resident #27's Census records revealed the following discharge and readmitted s during the previous year: - discharged : 9/3/21; readmitted : 9/7/21 - discharged [DATE]; readmitted : 1/5/22 - discharged : 1/15/22; readmitted : 1/28/22 - discharged : 2/9/22; readmitted : 2/10/22 Review of Resident #27's Healthcare Provider orders as well as Medication Administration Record (MAR) and Treatment Administration Record (TAR) detailed the following wound care orders/treatments: - Apply Medi honey to coccyx and R heel, apply bordered foam Q (every) evening shift and as needed every evening shift for wound care (Ordered: 2/20/22; Start: 2/21/22) - Resident is in need of wound consult. One time only for wound until 02/10/22 . left heel (Ordered: 2/8/22) - Clean and dry right buttock, pack with [MEDICATION(S)] packing strip, cover with gauze and border gauze. Change daily and as needed every day shift for tunneling wound (Start: 12/16/21; Discontinue: 1/5/22; Start: 1/6/22; Discontinue: 2/2/22; Start: 2/3/22). Review of the MAR/TAR for December 2021, January 2022, and February 2022 revealed the following blank documentation on the MAR/TAR (indicating treatment was not completed) on 1/12/22, 1/14/22, 1/15/22, 1/28/22, 2/1/22, 2/12/22, and 2/15/22. The following discontinued orders were also noted: - Cleanse right lateral foot, right 2nd toe, left plantar foot, left great toe, left lateral foot with NS (Normal Saline), pat dry, apply skin prep every night shift . (Start: 1/14/21; Discontinue: 1/28/22) Treatment documentation was blank on 1/4/22 and 1/28/22. - Apply Chamosyn (skin barrier product which nourishes skin, relieves discomfort, and calms discomfort) with honey to coccyx leave OTA (Open to Air) Q (every) shift and as needed (Ordered: 2/18/22; Discontinued: 2/20/22) There was no documentation of completion on the MAR/TAR. - Right Buttocks: Cleanse draining cysts with NS, apply TAO (Treatment as Ordered) and cover with dry dressing until resolved every day shift for skin care (Start: 11/28/21; Discontinued: 12/15/21) Treatment documentation was blank on 12/9/21. Review of facility provided list of Residents with pressure ulcers detailed the following for Resident #27, 1/28/22 Right buttock on admission has reported wound. Order in place but not classified as wound type 'Tunneling'. Note: Resident #27 was readmitted to the facility on [DATE] and the treatment was in place prior to their discharge to the hospital. Upon request for healthcare provided documentation of Resident #27's pressure ulcers, the facility provided the following: - Note authored by NP Q on 1/31/22 identified and reviewed previously. - Note dated 1/14/21 and authored by NP S. The note dated 1/14/21 detailed, Wound care consulted for the evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Right lateral foot had an intact corn/callus which was easily removed . no drainage and area is completely closed . Right second toe callus is completely closed and without drainage . Left plantar callus is complete closed and without drainage . Left lateral foot callus is completed closed and without drainage . Left hallux resembles and old DTI (Deep Tissue Injury - pressure ulcer with unknown depth). This wound measures 1.3 (centimeters-cm) X 1.7 (cm) X 0 cm . completely closed and without drainage . appears to have purple center under thick callused skin . Diagnosis . Pressure ulcer of left foot, unstageable . Plan: Issues will not be followed by wound care team but recommend consultation to podiatry . Resident #77: An observation of Resident #77 occurred on 2/14/22 at 3:34 PM in their room. The Resident laying in bed, uncovered and a fitted sheet was not observed on the bed under them. An alternating air mattress was present on the bed. The settings on the alternating air mattress were firm. An interview was completed at this time. When queried regarding their bedding, Resident #77 revealed the fitted sheet was bunched up under them and stated, It pulled off the corners. Resident #77 continued, They (staff) put the wrong size sheet on it. When asked, Resident #77, I don't like it but they ain't gonna do nothing about it. When asked if they had any wounds, Resident #77 indicated their buttocks was sore, but they did not think it was an open wound. When queried regarding the mattress settings, Resident #77 revealed staff did not check the mattress. Record review revealed Resident #77 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to limited assistance to perform all ADLs with the exception of eating. Review of Resident #77's care plans revealed a care plan entitled, At risk for alteration in skin integrity related to [CONDITION(S)] (Cerebral Vascular Accident - stroke) with left sided weakness, impaired mobility . (Initiated: 5/14/21; Revised: 7/7/21). The care plan included the intervention, Pressure relieving mattress and pad on bed/chair (Initiated: 7/11/19; Revised, 5/18/21). Review of Resident #77's MAR and TAR for February 2022 included the task, Body audit on Wednesday & Saturday Evening Shift every evening shift every Wed (Start Date: 7/14/21). The task was documented as administered on 2/2/22 and 2/9/22. There was no corresponding documentation in the assessment/evaluation and/or progress note sections of the Resident's medical record related to skin assessment. Task documentation within Resident #77's EMR included the task, Bed - Pressure Relieving mattress to bed with the question, Was the pressure reducing device placed on the bed while the resident was in it? For February 2022, No was documented on 2/2/22, 2/4/22, 2/5/22, 2/6/22, 2/13/22, 2/14/22, 2/15/22, 2/16/22, and 2/18/22. Resident #82: On 2/15/22 at 7:51 AM, Resident #82 was observed in their room. The Resident's touch call light was on the floor behind the head of the bed. The Resident was positioned on their back in bed, wearing a hospital style gown and CNA J standing on the left side of the Resident's bed obtaining vital sign measurements. Resident #82 did not respond, verbally or non-verbally, when spoke to. Resident #82's eyes were coated with a white colored, viscous appearing substance. A dark rusty brown colored dried substance with the appearance of dried blood was present on the Resident's lips. The Resident's mouth was open, and their tongue and mucous membranes were visibly dry. The Residents bedding and hospital gown were visibly soiled with unknown substances. When asked the Resident's name for confirmation, due to the name plate outside of the door being blank, CNA J stated, I am actually from agency (staffing company) and revealed they did not know the Resident's name. When queried, CNA J revealed they had worked at the facility previously as an agency CNA and had cared for Resident #82 before. CNA J was asked if Resident #82 had any pressure ulcers and stated, On their left hip and butt. With further inquiry, CNA J revealed they changed it last week when were assigned to care for Resident #82. When queried how they knew what care the Resident required when they did not even know their name, CNA J did not provide an explanation. At this time, NP Q entered the Resident's room. When queried regarding Resident #82's non-responsiveness and wounds, NP Q revealed the Resident was more lethargic than when they had previously seen them. NP Q reviewed Resident #82's medical record and confirmed the Resident had multiple pressure ulcers. When asked if they were assessing the pressure ulcers today, NP Q revealed they were not. An alternating air mattress was present on Resident #82's bed. The mattress controller was set at Static (non-alternating air) and Firm 350 lbs. (pounds). The Alarm Reset light was also on. A container of [MEDICATION(S)] (wound care treatment) was present on the dresser next to the Resident's bed. Record review revealed Resident #82 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required two-person extensive to total assistance to perform ADLs. The MDS further revealed the Resident was at risk for pressure ulcer development and had one stage 4 pressure ulcer that was present upon admission/reentry. Review of Resident #82's care plans revealed a care plan entitled, Resident has impaired skin integrity Sacrum Pressure Ulcer (Initiated: 6/23/21; Revised: 9/23/21). The care plan included the interventions: - Assess and document skin condition, notify MD of signs of infection (redness, drainage, pain, fever) (Initiated: 9/23/21) - Assess for pain and treat as indicated (Initiated: 9/23/21) - Assist with bed mobility to turn and reposition routinely (Initiated: 9/23/21) - Check for incontinence and provide incontinent care as needed. Notify nurse of any redness or irritation (Initiated: 9/23/21) - Notify MD of worsening or not improvement in wound (Initiated: 9/23/21) - Pressure reducing/redistributing mattress on bed (Initiated and Revised: 9/23/21) - Wound Location: Sacrum (Initiated and Revised: 9/23/21) - Wound treatment as ordered (Initiated and Revised: 9/23/21) Resident #82 had another care plan titled, At risk for alteration in skin integrity related to generalized weakness, impaired mobility, physical limitations .dementia . (Initiated: 5/14/21; Revised: 8/2/21). The care plan included the interventions: - Barrier cream to peri area/buttocks q (every) shift (Initiated: 4/29/21; Revised: 6/24/21) - Diet and supplements per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - Elevate heels as able (Initiated: 4/29/21; Revised: 6/24/21) - Encourage fluids (Initiated: 4/29/21; Revised: 6/24/21) - Encourage to reposition as needed; use assistive devices as needed (Initiated: 4/29/21; Revised: 6/24/21) - Heels up while in bed (Initiated: 7/7/21; Revised: 8/28/21) - Observe skin condition with ADL care daily; report abnormalities (Initiated: 4/29/21; Revised: 6/24/21) - Obtain Labs as ordered and report results to physician (Initiated: 4/29/21) - Pressure redistributing device on bed: APM (Alternating Pressure Mattress) (Initiated: 4/29/21; Revised: 5/14/21) - Use pillows/positioning devices as needed (Initiated: 4/29/21; Revised: 6/24/21) A third care plan entitled, Resident has Stage IV pressure ulcer to sacrum, present upon admission (Initiated and Revised: 4/30/21). The care plan included the following interventions: - Administer analgesics as needed (Initiated: 4/30/21) - Daily body audit (Initiated: 4/30/21) - Dietary consult (Initiated: 4/30/21) - Friction reducing transfer surface (Initiated: 4/30/21) - Incontinence management (Initiated: 4/30/21) - Pain evaluation prior to treatment (Initiated: 4/30/21) - Pressure redistributing support surface (Initiated: 4/30/21) - Repositioning during ADLs (Initiated: 4/30/21) On 2/16/22 at 9:03 AM, observation of ADL care for Resident #82 was completed with CNA X and CNA Y. Prior to beginning care, the Resident was noted to be in bed, positioned on their back. The alternating air mattress remained set at Static (non-alternating air) and Firm 350 lbs. (pounds) with the Alarm Reset light on. When CNA X and CNA Y uncovered the Resident and unfastened their brief, an uncovered, open wound was observed on the Resident's right hip. The area was directly over the bony prominence and approximately 2 inches by 2 inches in size. On Resident #82's back, along the bottom of prominently notable scapula (shoulder blade) near the spine, two dark purple/maroon colored, non-blanchable pressure areas were noted. The proximal wound was approximately the size of a nickel and the distal was slightly larger than a half dollar. During repositioning, Resident #82 began moaning and displaying non-verbal signs and symptoms of pain including wincing and facial grimacing. The staff proceeded to position the Resident on their right side to remove their brief and restore hygiene as Resident #82 had a bowel movement. When the Resident was turned on their side, a large, gaping pressure ulcer was observed on the Resident's sacrum. A second, large open pressure ulcer was present on the left buttocks/hip area. There were no dressings in place over either wound. A foul sour putrid odor immediately permeated the air when the pressure ulcers were exposed. The brief was saturated with thick yellow and red colored wound drainage. When queried regarding the drainage, CNA X stated, It's like pus. When asked, the staff indicated the wounds were supposed to be covered with a dressing and CNA Y notified the nurse. While waiting for the nurse, CNA X and CNA Y restored Resident #82's hygiene and observation of the pressure ulcers occurred. The left buttocks/hip pressure ulcer was open with tissue loss and active drainage. The wound bed was approximately 3 inches by 1 inch in size. The sacrum pressure ulcer had significant depth and was approximately the size of a softball in diameter. The wound edges were black with necrotic tissue present and the base was pink and white in color with an area of black, necrotic tissue noted at the 5 o'clock position. Observation of Resident #82's skin revealed a raised, fluid filled blister was observed on the medial aspect of the right foot. The area was irregularly shaped with a distinct, dark colored border and appeared to be approximately the size of a quarter. A second fluid filled blister was present along the medial aspect of the right great toe. At this time LPN Z entered the room with supplies to complete wound care and obtain wound measurements. LPN Z did not perform hand hygiene prior to beginning wound care. LPN Z rinsed Resident #82's sacral pressure ulcer with normal saline and wiped with gauze. LPN Z obtained wound measurement at this time at stated, It's 11 (centimeters- cm) by 5.5 (cm) x 2.4 (cm) deep. LPN Z did not perform hand hygiene and/or doff their gloves. LPN Z then proceeded to pack the wound bed with 4 X 4 gauze saturated in normal saline, cover the wound bed with a Maxord Ag dressing (wound dressing), and cover with an ABD pad. During the dressing application, Resident #82 was moaning and wincing. No treatment/dressing was completed on the open right buttocks/hip wound. LPN Z proceeded to place bordered gauze over the pressure injuries on the Resident's back. When asked about the areas, LPN Z indicated the areas were DTI pressure ulcers. Observation of Resident #82's skin on their lower extremities was completed at this time. A large wound approximately 5 inches long by 3 inches wide was present on Resident #82's right lateral malleolus (ankle). The wound did not have a dressing in place. The wound encompassed the entire lateral malleolus and extended above the ankle bone. The pressure ulcer contained two distinct open areas with visible, significant depth. The proximal end of the wound bed was black in color with white/yellow colored tissue at the distal end of the black tissue which progressed to the proximal open area. The base of the proximal open wound, directly over the ankle bone, was white and black in color with distinct necrotic tissue in the center and along the nine to eleven o'clock position. The tissue surrounding the wound was dark in color with irregular borders. When queried regarding the areas, CNA X and CNA Y indicated the pressure ulcer looked better than it did. With further inquiry, CNA X stated, I came in two weeks ago and the cath (indwelling urinary catheter to drain urine from the bladder) tubing was imbedded into (Resident #82's) ankle. CNA X stated, It was sore with pus. CNA Y revealed there had been an odor when the urinary catheter tubing was pulled out of the wound bed on Resident #82's ankle. LPN Z did not wash their hands but did don new gloves to apply a dressing to Resident #82's right lateral ankle. LPN Z did not cleanse the pressure ulcers prior to treatment. LPN Z applied Santyl ([MEDICATION(S)] wound treatment) to both open areas using the same Q-tip. LPN Z then applied an ABD pad and wrapped the Resident's ankle with Kerlix gauze dressing. Resident #82's toenails were noted to be untrimmed and thickened with jagged edges. The toenail on the fifth phalange (small toe) was digging into the Resident's skin. Upon request, LPN Z separated Resident #82's toenails. A foul odor was immediately noted which increased in intensity closer to the Resident's toes. An unknown black colored substance was present in-between each of the Resident's toes. When asked what the black was, LPN Z used a Q-tip between the toes and removed a large amount of an unknown malodorous black colored substance from between the Resident's toes. When asked what the substance was, LPN Z stated, Filth. A dark maroon/purple colored area was present on fifth phalange between the fourth and fifth phalanges. When asked, LPN Z revealed the area was an unstageable pressure ulcer. A dime sized open wound was observed on Resident #82's left lateral malleolus. The wound was open and approximately the size of a dime. When queried regarding Resident #82's signs and symptoms of pain during treatment and pain management, LPN Z revealed they were not aware CNA staff were going to be completing care to premedicate for pain and directed the CNA staff to notify them prior to completing care. With further inquiry, LPN Z revealed the Resident had not had anything available for pain until recently when they got it ordered. When asked why there were no dressings in place over the wounds, LPN Z was unable to provide an explanation. When asked how long the wounds had not had a dressing in place, the staff were unable to provide a response. CNA X and CNA Y did reveal this was the first time they had been in to provide care to the Resident during their shift. Resident #82 was repositioned on their back following treatment. When queried why the Resident was positioned on their back again, CNA X and CNA Y revealed the Resident did not have any positioning devices in their room. LPN Z confirmed and revealed they had attempted to obtained wedge positioning devices for the Resident previously but were informed none were available. No additional pillows for positioning were present in the Resident's room. When queried who checks and monitors the settings on alternating air mattresses in the facility, both CNAs revealed they don't check. LPN Z indicated they only make sure the bed is inflated. The settings on Resident #82's bed were reviewed with the staff at this time. When queried if Resident #82 weighed 350 lbs., all three staff revealed the Resident did not. When asked if the bed was supposed to be set at static, LPN Z stated, It (air mattress) ain't right. CNA X and CNA Y were unaware of the air mattress being able to be set to static for surface stability during care. CNA X then stated, It (mattress) was the same two weeks ago and indicated the air within the mattress did not move (alternating) when they had provided care to the Resident and CNA Y corroborated. When queried the air mattress was providing appropriate pressure reduction and redistribution to prevent and reduce pressure for Resident #82 at the current settings, LPN Z stated, No. LPN Z adjusted the air mattress settings at this time by clearing the alarm, deactivating the static setting, and decreasing the weight setting to 175 lbs. When queried why there was a container of [MEDICATION(S)] in the Resident's room if they are not receiving it as a treatment, LPN Z stated, I don't know. When queried regarding hand hygiene during wound care and separation of treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #82's EMR revealed the Resident weighed 147 lbs. on 1/6/22. Review of task documentation in Resident #82's EMR revealed the task, Bed - Pressure Relieving mattress to [TRUNCATED]

Based on interview and record review, the facility failed to provide pain medication timely for three residents (Resident #5, Resident #48, Resident #94) of three residents reviewed for pain, resulting in uncontrolled pain, calling 911 to go back to the hospital for pain control, and crying. Findings include. Resident #48: On 2/10/22, at 1:52 PM, Resident #48 was lying in their bed and complained that they went without pain medications for over twenty-four hours. Resident #48 offered that the pain was so bad they were sobbing and everyone she complained to would respond with statements like that's not my job; not my responsibility. On 2/14/22, at 11:57 AM, a record review of Resident #48's electronic medical record revealed an admission on 1/5/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #48 required assistance with all Activities of Daily Living and had intact cognition. On 2/14/22, at 4:25 PM, a record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no pain med offered on the 5th or the 6th and with the first dose not offered until 1/7/22 0942 (9:42 AM) On 2/14/222, at 4:30 PM, the Administrator was asked to provide a list of medications that was in the back up medication storage and all [MEDICATION(S)]/narcotic reconciliation forms for Resident #48. Resident #94: On 2/22/22, at 1:04 PM, During a phone conversation with Resident #94 regarding their short stay at the facility was conducted. Resident #94 complained that they were admitted for a wound infection and had constant pain in their foot. Resident #94 complained that their pain level was a constant 10 the whole time I was there and kept asking for pain medication but never received any. Resident #94 further complained that nobody came and assessed the wound to their foot which was the reason for the pain. Resident #94 further offered I had to call 911 to get out of there because the pain was so bad. A review of Resident #94's the electronic medical record revealed an admission on 12/3/2021 18:14 (6:18 PM) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of progress notes revealed the following: 12/3/2021 18:14 . Resident arrived to facility at around 5pm via ambulance. Vitals wnl (within normal limits), no c/o pain or discomfort at this time. (staff member) notified awaiting verification of medication. Will continue plan of care. 12/4/2021 21:17 . Resident asked this writer to use the phone at around 2000. About an hour later the ambulance came in the building to transport resident to the hospital. Resident states I called 911 to pick me up because I went to get out of here . Resident #5: On 2/14/22 at 1:52 PM, Resident #5 was observed lying in bed, this writer asked questions regarding her stay at the facility and Resident #5 explained their fulltime staff has resigned and she is not sure how the care will be affected. Resident #5 continued she has not been receiving her pain medications as ordered. Resident #5 expressed within the last month she has not received her [MEDICATION(S)] at least three times because it was unavailable at the facility, and they had to wait on pharmacy deliver it. She continued they did give her Tylenol but that was not effective, and her pain was not managed. Resident #5 reported she has arthritis, [CONDITION(S)] and vascular issues and her pain was at an 8 (on a scale from 1-10) on the days her [MEDICATION(S)] was not available. On 2/14/22 at 2:00 PM, a review was completed of Resident #5's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 is cognitively intact and able to make her needs know. Further review was completed of Resident #5's medical records and the following was revealed: Physician Order: [MEDICATION(S)] Tablet 5-325 MG (milligrams)- Give one tablet by mouth every 8 hours for pain. Care Plan: Focus: Pain in bilateral legs/generalized related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions: .Administer paint medications as ordered . MAR (Medication Administration Record): January MAR: There were three blanks in the MAR, which indicated the resident did not receive her [MEDICATION(S)]. o 1/14/22-8 AM dose o 1/31/22- 12 AM and 8 AM dose There were eleven entries with the code of 9 or 5 which directed this writer to look at the progress notes for more information. Progress Notes: Review was completed of the Medication Administration notes that correlated to the missed [MEDICATION(S)] doses in Resident #5's MAR. The overarching theme shown below is the medication was not available at the facility. 1/8/2022: - 4 PM: Medication administration note at 6:19 PM stated, not available. 1/11/2022: - 12 AM: Medication administration note at 1:02 AM stated, on order. - 8 AM: Medication administration note at 7:37 AM stated, waiting to be delivered. - 4 PM: There is no progress note related to this dose 1/12/2022 - 12 AM: Medication administration note at 2:53 AM stated, waiting on pharmacy drop in. - 4 PM: Medication administration note at 5:53 PM stated, in tonite's tote. 1/28/2022 - 12 AM: There is no progress note related to this dose 1/29/2022 - 12 AM: Medication administration note at 6:00 AM stated, waiting pharmacy to delivery. - 4 PM: Medication administration note at 10:13 PM stated, u able to get to capsa. 1/30/2022 - 12 AM: Medication administration note at 1:31 AM stated, on order. - 4 PM: Medication administration note at 7:42 PM stated, waiting on pharmacy deliver. It can be noted Resident #5 received her 8 AM dose of [MEDICATION(S)] on 1/30/22 but did not receive another dose until 1/31/22 at 4:00 PM. The resident went over 12 hours without receiving her scheduled pain medications. There was no documentation that facility/agency nurses contacted the physician to request other options. On 2/16/22 at approximately 2:15 PM, a review was completed of the facility's, Inventory Replenishment Report, dated 1/3/22. The inventory report is indicative of the medications available in the facility's back up machine. The nurses have access to the back up box to pull the required medication if it is not on their medication cart when needed. The medication that Resident #5 missed multiple doses of, was available in the back up machine: - [MEDICATION(S)]/APAP 5mg-325 mg Tab - [MEDICATION(S)]/APAP 7.5 mg-325 mg Tab - [MEDICATION(S)]/APAP 10 mg-325 mg Tab On 2/16/22 at 3:35 PM, an interview was conducted with the DON (Director of Nursing) regarding readily available medication in their back up machine. The DON explained they switched pharmacies recently, but they do have a backup machine in the facility. If a resident's medication is not on their cart they are able to go to the machine and request what medication is needed. The machine will alert them to contact the pharmacy and provide the required information. The nurse will then be provided with an authorization number to pull the medication from the machine. If a medication is not available, the pharmacy can drop-ship it the same or next day. The DON was not aware of the specific incident with Resident #5 but reported [MEDICATION(S)] is a readily available medication in their machine. The DON further explained many of the nurses (agency included) do not possess log-in credentials for the machine and may not be aware the facility has the back-up machine. The DON continued she is aware and working on the follow through with staff, ensuring they have the access, education on utilizing the machine and understanding they can always contact management to assist with resolving an issue. The DON reported if the medication had been ordered from pharmacy and would not arrive, they should have contacted the physician to request a different medication or place the medication on hold The DON expressed this all goes back to lack of education which they are working on. On 3/1/22 at 11:00 AM, a review was completed of the facility policy entitled, Pain Management, revised January 2020. The policy stated, To assess each resident for pain and maintain the resident as free of pain as possible .The physician will be notified of unrelieved or worsening pain .The licensed nurse will monitor the efficacy of the medication and notify the physician as needed.

This Citation Pertains to Intake Number MI 857 Based on observation, interview and record review, the facility failed to ensure pressure ulcers were assessed, monitored, wound care was provided and appropriate interventions were in place for two residents (Resident #21 and Resident #22) of three residents reviewed for pressure ulcers, resulting in 1) Resident #21 developing an unstageable facility-acquired pressure ulcer measuring 10.3 cm length x 6.0 cm width x 0 cm depth with 90% yellow and brown slough (fibrinous dead tissue) on the coccyx, that required hospitalization , surgical removal of dead tissue (debridement) and antibiotic treatment; 2) Resident #22 with two Stage 2 pressure ulcers on the right and left buttocks with surrounding Deep Tissue Injury (DTI) did not receive wound care as ordered, because the supplies were not available in the building, which could further lead to worsening of the wound. Findings Include: Resident #21: A review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #21 indicated an admission on 1/28/21 with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] revealed full cognitive abilities and the need for 2-person assistance with bed mobility, transfer, dressing, hygiene, bathing, and toileting. The resident was discharged on home on 2/18/21. A review of the progress notes revealed the following: A late note dated 2/16/21 at 1:39 PM, . Resident has right and left MASD. Right buttock is 3.1 cm length x 1.9 cm width x 0.1 cm depth, has scant serosanguinous drainage, no slough, no maceration, and no necrosis. The left buttock measures 0.4 cm x 0.8 cm x 0 cm. There is scant serosanguinous drainage, no slough, no maceration, and no necrosis . Resident has an unstageable pressure ulcer to coccyx. Site measures 10.3 cm x 6.0 cm x 0 cm. It is 90% yellow and brown slough . moderate amount of serosanguinous drainage . A Physician/NP note dated 2/16/21 at 12:15 PM, Due to patient's sarcopenia, debility he requires positioning of body that is not feasible in a regular bed. In frequent need of body positioning to alleviate pain and avoid body breakdown. Bed wedges and pillows have been unsuccessful . The resident's wounds on the buttocks and coccyx were not identified, measured, or treated until they were very large. The resident had documentation of resistance with repositioning due to discomfort and additional interventions were not initiated until the large wounds were observed. A review of the physician orders revealed: 2/15/21 and discontinued 2/16/21: Cleanse coccyx with normal saline, pat dry, apply 1:1 mix of z-guard and A&D, cover with border gauze. 2/15/21: Cleanse bilateral buttocks with normal saline, pat dry, apply 1;1 mix of z-guard and A&D, every night shift. 2/16/21: Cleanse coccyx with normal saline, pat dry, apply Santyl, cover with border foam, every night shift. 2/18/21: Daily Body Audit, every day shift. Woundsource: Assessing Wound Tissue and Drainage Types: Slough versus Purulence: [NAME] Haven MSN, GERO-BC, APRN, CWOCN-AP, dated February 2021, . Tissue Type: Slough, Slough is necrotic tissue that needs to be removed from the wound for healing to take place . necrotic tissue prevents or slows healing . An interview with Confidential Person GG on 5/27/21 at 10:46 AM, revealed, My husband had to be put in (the hospital) and then another nursing home. He had many sores. It's terrible. When he came home on February 18th, (2021) on a Thursday, I didn't know how bad it was. He had a home care nurse come in the next day. It was horrible. The hoecake nurse told me right away he needed to go to the hospital. He was in ICU for 5 days. When he was in the (facility) I couldn't check on him. He was full of sores. They did not tell me about it. He has had multiple surgeries on the sores and antibiotics. It is horrible. On 5/27/21 at 2:40 PM, and interview with the Director of Nursing (DON) provided, He went home. He was dependent with care. I know what his wounds looked like when he left here. Then they called the ambulance to take him to the hospital. She called here and I talked to her. She didn't feel like she could care for him at home. An interview with the Unit Manager F on 5/27/21 at 3:06 PM, He had a foot ulcer. He would refuse incontinence care and developed MASD (Moisture Associated Dermatitis; he started breaking down. We saw him on wound rounds. He would 'Ow, Ow, Ow, with movement. On 2/16/21 we saw he had an unstageable wound to the coccyx- 10.3 cm length x 6.0 cm width x 0 cm depth with 90% slough and a moderate amount of drainage. The wound was first observed by a nurse on 2/14/21. I'm surprised it didn't happen earlier. It progressed quick. We talked to the wife and explained to her about the wounds and treatments. He was discharge about 1:00 PM and she called and wanted to bring him back about 3:00 PM. There was some discussion about it. A review of the Admission/Re-Admission Evaluation (Nursing Assessment) dated 1/28/21 at 11:28 PM revealed, Clinical Evaluation Integumentary (Skin): Skin Integrity Issues Present: Yes; Current skin integrity Issues: [CONDITION(S)] catheter insertion wound right neck; Chest -[CONDITION(S)] catheter right upper chest; Right antecubital- blister right forearm; dry skin over majority of body; left toes- healed blister top of foot; left ankle inner-dried wound, open to air. A review of the Care Plans for Resident #21 provided: At risk for alteration in skin integrity related to generalized weakness . date initiated and created 1/28/21 and revision 3/2/21 (discontinued) with Interventions: Administer treatments as ordered (1/29/21); Barrier cream to peri area/buttocks as needed (1/29/21); Encourage to reposition as needed; use assistive devices as needed (1/28/21); Observe skin condition with ADL (activities of daily living) care daily, report abnormalities (1/29/21) Pressure redistributing device on bed/chair (1/28/21); Provide preventive skin care routinely and prn (1/28/21). Resident has unstageable pressure ulcer to coccyx . date initiated/created 2/17/21 with Interventions: Administer treatment per physician orders (2/17/21); Daily body audit (2/17/21); Incontinence management (2/17/21). Bilateral buttocks MASD, date created/initiated 2/17/21 with Interventions: Administer treatments per physician orders; Encourage and assist as needed to turn and reposition . Follow up care with physician as ordered; Report evidence of infection . all dated 2/17/21. Resident #22: A review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #22 was admitted to the facility on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/27/21 at 11:00 AM, Resident #22 was observed lying in bed watching TV. Upon interview, the resident said he had a sore and pointed to his buttocks. He said he was supposed to have a dressing change for the wound. On 5/27/21 at 1:00 PM, Nurse's F and FF were observed at the wound care cart on the back Central hall. Nurse FF said they did not have the wound ointment ordered Santyl (used for [MEDICATION(S)]/removal of dead tissue from the wound) for the wound on the resident's coccyx/buttocks area, We can't find it and it's not in the med room. The nurses were asked how often the dressing was ordered to be changed and Nurse FF said, Daily and we got a new order from the doctor, so we can change it. Nurse FF said she rounded weekly with the Wound Care Nurse and assisted her when she saw each resident's wound. On 5/27/21 at 1:05 PM, Nurse's F and FF entered the room and assisted the resident with bowel care in preparation of the dressing change. After Nurse FF completed the care tasks and rewashed her hands and changed into clean gloves, she removed the old dressing from the resident's coccyx and buttocks areas, and it was dated 5/25/21. The buttocks and coccyx areas were scaly, red, raw with 2 open areas, one on each right and left buttock. The entire area was large, but the 2 open areas were each small. Nurse F was asked again how often the dressing was to be changed and she said, Daily. She said the resident was supposed to have a wound ointment Santyl (used to remove dead tissue from the wound), but because they didn't have it they were going to cleanse the wound with normal saline and apply a boarder foam dressing one time and then the wound ointment would be in. The ointment was ordered on 5/25/21- two days prior and had not arrived. The dressing had not been changed on 5/26/21 as ordered and was not going to receive the ordered treatment on 5/27/21 either. A review of the physician orders indicated the following: 5/11/21 ordered and 5/25/21 discontinued: Cleanse left buttock with Normal Saline, pat dry, apply A&D, cover with border gauze. 5/25/21 ordered and 5/27/21 discontinued: Santyl Ointment, apply to left buttock topically daily. The right buttock had a new order on 5/25/21: Cleanse right buttock with Normal saline, pat dry, apply z-guard (ointment) with A&D, cover with border gauze, every day shift. A review of a progress note dated 5/25/21 at 2:27 PM revealed, Resident was seen on weekly wound rounds with wound NP (Nurse Practitioner). Resident has a left buttock Stage II pressure ulcer. The site measures 0.6 cm length x 0.5 cm width x 0.2 cm depth. There is scant serosanguinous drainage . 100 % slough (yellow fibrinous dead tissue) . The right buttock Stage II has a small amount of serosanguinous drainage. Site measures 1.5 cm x 0.1 cm x 0 cm . A wound note dated 5/19/21 at 1: 28 PM, provided . Resident has a left buttock Stage II pressure ulcer. The site measures 6.5 cm x 5.0 cm x 0.1 cm. There is scant serosanguinous drainage, no malodor, no necrosis, no slough. There are scattered areas of discoloration resembling a DTI (Deep tissue injury). Surrounding skin is dry and friable . The left buttock wound had developed the dead tissue/slough between 5/19/21 and 5/25/21. The National Pressure Injury Advisory Panel; February 13, 2020 NPIAP Staging for lightly pigmented skin . Stage 2 Pressure Injury . Granulation tissue, slough and eschar are not present . Stage 3 Pressure Injury: .Sough and/or eschar may be visible . If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury . A review of the Care Plans for Resident #22 provided: Coccyx shearing, at increased risk for breakdown, date initiated 4/13/21 and revised 5/14/21 with Interventions: Administer treatment per physician orders, date initiated 4/13/21. Resident has a Stage II pressure ulcer to the left buttock, date initiated 5/5/21 and revised 5/14/21 with Interventions: Administer treatment per physician orders (5/5/21); Daily body audit (5/5/21); Incontinence management (5/5/21). Resident has a Stage II pressure ulcer to the right buttock, date initiated 5/5/21 and revised 5/14/21 with Interventions: Administer treatment as ordered (5/5/21); Incontinence management (5/5/21). On 5/27/21 at 2:55 PM, the Director of Nursing (DON) was interviewed about the lack of necessary wound supplies to complete Resident #22's left buttock dressing to promote wound healing. The DON said the ointment had not been received, but the nurses had followed up on it today and it would be available by the next day. It would not be available until 3 days after it was ordered. Reviewed with the DON that the old dressing on the resident's wounds was dated 5/25/21- 2 days prior and she said, I heard about that. They should be changing the dressing as ordered. A review of the facility policy titled, Skin Practice Guide, dated 2013 provided, . International NPUAP (National Pressure Ulcer Advisory Panel) -EPUAP Pressure Ulcer Definition; A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or in combination with shear . Management Strategies: Moisture and Incontinence Management: Moist skin is more vulnerable to injury. Moisture may be the result of incontinence . Proper cleansing of the skin and application of protective skin products assist in protecting the skin . wound management also includes: wound documentation; dressing selection . Dressing selection is based upon: wound type; tissue type . treatment goals .Dressing changes are performed using non-sterile, clean techniques unless otherwise ordered by the attending physician . adhere to principles of infection control- separate clean and dirty . documentation- completion of the treatments are documented on the (TAR) immediately after being performed; dressing are dated and initialed .

This citation pertains to intake MI 9. Based on interview and record review, the facility failed to assess and monitor one resident (Resident #164) for signs and symptoms of a Urinary Tract Infection [MEDICAL CONDITION] who had a history of [REDACTED]. Findings Include: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment) dated 12/18, physician, nurses and social service notes dated 12/7/18 through 1/19/19 and admission assessment dated [DATE], revealed Resident #164 was an [AGE] year old, confused and unable to make her own healthcare decisions due to decreased cognitive status with a BIMS of 8 (cognitive evaluation, 10 to 15 being interviewable), dependent on staff for all Activities of Daily Living (ADL's) and admitted to the facility for rehabilitation services due to a fall at home. The resident's [DIAGNOSES REDACTED]. Review of the resident nursing notes, dated 12/13/18 through her discharge on 12/19/18, revealed no documentation of a complete nursing assessment for signs and symptoms of a UTI (temperature, complete vital signs, urine appearance, urine amount, burning or pain upon urination, blood in the urine, foul odor to urine, lower abdomen/back discomfort or pain and increased confusion). In addition, no complete documentation of monitoring the resident for UTI when put on an antibiotic (on 12/17/18) was found. Review of the resident's progress notes dated 12/13/18 through 12/19/18, are as follows: -12/13/18 at 3:10 a.m., Pt (patient) complained of burning while urinating. -12/15/18 at 2:05 p.m., Residents UA (urinary analysis, lab test for UTI) results obtained awaiting for cult (culture and sensitivity lab test for antibiotic) results. -12/16/18 at 11:19 a.m., awaiting for C & S (Culture & sensitivity lab test) results. -12/18/18 at 8:49 a.m., MD notified of UA results. Awaiting C & S. -12/18/18 at 9:27 a.m., Resident was started [MEDICATION NAME](antibiotic) yesterday (on 12/17/18) regarding UA results Review of the physician order [REDACTED]. Review of the hospital emergency room orders dated 12/20/18 (the day after the residents discharge from the facility on 12/19/18), stated cath (catheter) for UA (Urinary Analysis lab test for a UTI). The resident was discharged from the facility on 12/19/18. Review of the hospital Discharge Summary dated 1/4/19, stated She (Resident #164) did have a urinary tract infection (upon admission to the hospital). Review of the hospital Plan of Care dated 12/20/18, revealed the resident had received IV antibiotic [MEDICATION NAME]. Review of the hospital physician Consultation dated 12/21/18, stated Impression and Recommendations: Change in mental status. Likely metabolic [MEDICAL CONDITION] (a syndrome of overall [MEDICAL CONDITION]) given the fact that the patient has urinary tract infection. Review of the hospital physician Consultation dated 12/27/18, stated Diagnoses: [REDACTED]. At this time, the patient presents with a resolving [MEDICAL CONDITION] secondary to recent UTI. During an interview done on 1/9/19 at 3:15 p.m., Nurse RN N stated I didn't see any assessments for a UTI, most of that (facility nursing assessments for UTI) got lost in the wayside. During an interview done on 1/10/19 at 10:30 a.m., Charge Nurse, RN Y stated We (facility staff) should have done assessments for UTI. During an interview done on 1/10/19 at 1:43 p.m., Charge Nurse, LPN S stated It should be on alert charting which is anybody on antibiotics. UTI's and a change of condition should be on alert charting. It's hard when you bounce to a new section, you have to relay on the report. Report is not always good. During an interview done on 1/10/19 at 2:59 p.m., Charge Nurse, RN U stated I was not told she had a UTI (after lab returned and resident started on antibiotic Cipro), even in report no one told me, I was not informed. During an interview done on 1/10/19 at 3:30 p.m., the Director of Nursing (DON) stated they should have done assessments on her for UTI. During an interview done on 1/11/19 at 8:50 a.m., Physician V revealed she was not aware facility staff had not documented complete UTI assessments prior to putting the resident [MEDICATION NAME] been started (on 12/17/18). In Long Term Care with residents diagnosed with [REDACTED]. Assessment would include, changes in voiding patterns, painful urination, urgency to urinate, full vital signs monitored, increase in temperature, urine odor and appearance changes, blood in urine and discomfort/pain in lower abdomen/back area. [DIAGNOSES REDACTED].

This deficient practice relates to intake MI 736. Based on observation, interview and record review, the facility failed to prevent an avoidable fall for one sampled resident (#1) out of two sampled residents (#1, #3) reviewed for falls out of a total sample of four residents resulting in unexpected pain and injury due to a fall from a hospital bed. Findings include: Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE], according to her electronic medical record, for the following Diagnoses: [REDACTED]. The facility reported that, on 11/18/2015 at 8:00 PM, a certified nursing assistant (CNA) was changing Resident #1's shirt while Resident #1 was lying in bed. When the CNA rolled the resident away from the CNA, Resident #1 continued to roll and fell out of bed. Initially, there was no perceived injury. However, after Resident #1 was noted to have pain in her left arm and an x-ray on 12/1/2015 documented a fracture of the left humerus. On 2/9/2016 at 10:00 AM, a record review of Resident #1's Minimum Data Set, dated dated [DATE] was done. According to the documentation, Resident #1 was totally dependent on facility staff for all of her care including transferring from the bed to a geri-chair, dressing, bathing and feeding. On 2/9/2016 at 11:00 AM, a record review of a witness statement, signed by CNA E was done. CNA E documented I easily turned her away (from me), she was stiff and kept going. I tried to catch her. On 2/10/2016 at 3:05 PM, an observation of a re-enactment of Resident #1's fall was done in the presence of Unit Manager (UM) N and CNA E. UM N took the role of Resident #1 and CNA E demonstrated how the incident occurred. CNA E was the only person in the room when Resident #1 rolled out of bed onto the floor. The bed used in the demo was at waist height of CNA E not at the lowest level. CNA E had a drawsheet under UM Ns back and hips and was standing on UM N's left side. Initially, according to CNA E, CNA E first turned Resident #1 on her left side towards CNA E using the drawsheet to do so. Then, using the drawsheet, CNA E pulled Resident #1 into the center of the bed. When CNA E attempted to turn Resident #1 on her right side she just kept rolling out of bed. When CNA E was asked what she did next, CNA E said she went to get the nurse. CNA E was asked Did you leave the resident alone? CNA E stated she went into the doorway of Resident #1's room and called to the nurse who was nearby. CNA E was asked if Resident #1 hit her head on anything and CNA E said she did not see Resident #1 hit her head. She stated Resident #1 was lying facedown on the floor. On 2/11/2016, in an interview with Licensed Practical Nurse (LPN) M, she stated Resident #1 needed total care and was dependent on staff to dress and feed her. LPN M stated that, prior to the fall, Resident #1 was a one person assist but, after the fall, her care plan was upgraded to indicate she was now a two person assist. She also stated she thought Resident #1's fall was avoidable. On 2/11/2016, in an interview with LPNK, she stated Resident #1 was never left alone in her room but was usually in her Geri-chair at the nurse's station. LPN K stated Resident #1 was not able to put her hand out to stop herself from rolling out of bed if she was rolled away from a caregiver. She said Resident #1's fall was avoidable. On 2/11/2016, in an interview with CNA I, she stated Resident #1 was a total care patient who had to have everything done by the staff and was basically a vegetable. CNA I said the resident had no ability to stop rolling if she was rolled away from you. On 2/11/2016, in an interview with CNA J, she said Resident #1 was a total care resident who doesn't respond to anything and had to be fed. CNA J stated she never turned this resident using a draw sheet and only turned her towards herself for safety. CNA J said Resident #1 couldn't catch herself if she was turned away from the caregiver. ( )

This citation pertains to intake number MI 121 Based on interview and record review, the facility failed to ensure one (#501) of three residents reviewed for application of braces/splints from a total of three sampled residents had her specialized left leg brace on her leg and her wheelchair equipped with footrests resulting in the resident running over her own left foot resulting in a fracture of the left fifth metatarsal. Findings include: A complaint was submitted to the Department alleging that facility staff failed to ensure the Resident (#501) was wearing her leg brace, that was provided to her by the hospital, and that the footrests of her wheelchair were on the chair. During telephone contact with the complainant on 11/20/14 at 11:50 a.m. it was reported, "(Name of Resident) was initially admitted to the facility for rehabilitation due to a stroke and was in the dining room alone when she injured herself. This happened on July 2nd. (Name) had a left leg brace that was specially made for her while she was in the hospital. (Name) was suppose to have footrests on her wheelchair but they were not on. Most times, they were in her room laying on the floor." On 11/20/14 at 11:53 a.m., a telephone interview was conducted with Resident #501. Resident #501 reported, "I'm tired. I still have no use of my left hand...my left leg is really weak. On 7/02/14, they (staff) took us out of our rooms. I thought they were stripping the floors or something. They put us in this dining area near other residents. There was an Atrium in there. They left me in there by myself for so long and I started to get really cold so I tried to move myself over to the window to get some heat from the sun. That's when I injured my left foot...I ran over my foot with the wheel of my wheelchair...They didn't put the foot rest on my wheelchair and they didn't put my brace on my leg...I told a nurse what happened that day...I spoke with another nurse a few days later and she asked me if I had reported it. I didn't know the process and the first nurse never took a statement from me...I kept asking for pain pills...about a week later, they rushed me out to get a cast. I can hardly put pressure on it now." Interviews were conducted with the Director of Nursing (DON) on 11/20/14 at 9:30 a.m. and 12:20 p.m. Resident #501's closed clinical record and investigation of the injury were reviewed at this time. According to the face sheet, Resident #501 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed that Resident #501 had no cognitive impairments for decision making and required extensive physical assistance of staff with all activities of daily living including bed mobility, transfers, dressing hygiene, bathing and toileting. According to the Physical therapy evaluation, dated 6/26/14, Resident #501 had left sided weakness and "ataxic" gait--(a limp). There was no documentation of Resident #501's leg brace included in the Physical Therapy evaluation. The facility's investigation of the injury was reviewed with the DON on 11/20/14 at 12:20 p.m. The incident report, dated 7/06/14 at 1:43 p.m. indicated Resident #501 had bruising and swelling on top and on the outer side of her left foot. The attached investigation included a statement from RN "A" dated 7/11/14, that read as follows: "I was working on July 3rd and Resident #501 was my resident. The Physical Therapist Assistant (PTA) came up to me while I was passing meds and told me that Resident #501 backed over her left foot." A statement from the Physical Therapy Assistant was included with the investigation and the statement was as follows: "On July 3rd at about 10:00 a.m., I went to get the patient out of her room and she told me that she got her left foot caught under her wheelchair and she didn't realize that her foot was caught. She (Resident #501) got it out from under the wheel of the wheelchair and she said it hurt. It was slightly swollen but nothing to worry about except to report it to the nurse (RN "A")." Attempts to reach RN "A" were made on 11/20/14 at 11:00 a.m. and 12:30:pm were unsuccessful. On 11/20/14 at 2:48 p.m., during an interview, The Physical Therapist (PT) reported, "Resident #501 was admitted to the facility for physical therapy due to her stroke. She was non-weight bearing on the left lower extremity and could pivot with her right foot. Her (Resident #501) left foot should have been on a foot rest on her wheelchair. Her legs were not falling off of the foot rest so there was no need for guards. If the footrests was on the chair, there is no way she could have rolled over her foot." A follow-up interview was conducted with the PTA on 11/20/14 at 3:17 p.m. to determine whether the resident was admitted into the nursing facility with a brace for her left leg. During the interview, the PTA reported, "Resident #501 did have a brace. She came from the hospital with it. She was suppose to wear it while she was up in the wheelchair. It was an orthotic device that went inside your shoe to prevent foot drop." On 11/20/14 at 3:20 p.m., the DON reported, "Resident #501 had left sided weakness and needed her left foot placed on the foot rest. That should be a standard of practice. Resident #501 was able to propel herself with her right foot. There was no evidence that she refused to wear her brace or that she refused to have the wheelchair rest place on her wheelchair. The DON added, "(Name) Resident #501 came from the hospital with a brace (on her leg) due to her CVA (stroke). Foot rests should have been on her wheelchair especially if she had a brace on that foot. The nurses were signing off on it. They were responsible for making sure it was on as well as the CNAs (Certified Nursing Assist)." The DON was queried about the leg brace and reported it was ordered due to "foot drop" and the CNA's were responsible for application of the brace when the resident was provided care. A review of the care plan for Activities of Daily Living, dated 6/26/14 did not include the use of the leg brace and who was responsible for application of the brace. The care plan did not address application of footrests/pedals on the left side of the wheelchair until 7/22/14. Review of the clinical record revealed Nursing progress notes documented Resident #501 complained of left foot pain on 7/03/14 at 7:31 p.m., 7/04/14 at 11:30 p.m., 7/05/14 at 2:50 a.m., and 7/06/14 at 12:44 p.m. Resident #501 was administered: "Norco 5/325 mg (milligrams) every 8 hours as needed for pain." The next progress note entry, dated 7/06/14 at 1:16 p.m., described the following: "the resident reported "dull" pain and reported, "I did catch my foot under my wheelchair (w/c) last week..." An X-ray report dated 7/06/14 (no time) documented the following: "Acute, mildly displaced distal 5th metatarsal with mild displacement". The resident was sent to the emergency room and the discharge summary, dated 7/08/14, confirmed "Metatarsal fracture 5th, left". A policy and procedure for application of braces/orthotics was requested from the DON on 11/20/14 at 3:30 p.m. ; however was not provided.

Refer to Intake MI 728. Based on interview and closed record review, facility staff failed to meet professional standards of quality in completing pain assessments, failed to administer narcotic [MEDICATION NAME] per facility policy, and failed to notify the physician of changes in the condition of 1 (#501) of 3 sampled residents placing the residents at risk for a decline in condition. Findings include: In Creighton's "Law Every Nurse Should Know", 5th edition, the following is written. "In the American Nurses' Association's Standards of Nursing Practice, Standard I states: The collection of data about the health status of the client/patient is systematic and continuous. The data are accessible, communicated and recorded. Resident #501 was admitted to the facility on [DATE], per the Admitting Record. A Physician's Progress Note, dated 11/20/13, stated that Resident #501 had a history of [REDACTED]. The assessment indicated that the resident was alert but only oriented to himself. He was "moaning" and "shaking -cries out 'my toes, my toes'. Jerks arm when touched. Appears painful multiple areas." The nursing admission assessment for Resident #501 was completed on 11/19/13. No cognitive or memory problems were documented on admission. It was documented that the resident had no problem focusing attention or following what was being said, had no disorganized thinking, had no altered level of consciousness, had no psychomotor [MEDICAL CONDITION] (sluggishness, staring into space, moves slowly), and was able to make independent and accurate decisions. Resident #501's pain assessment was completed on 11/19/13. The pattern of pain (onset, duration, frequency, time of day, event causing pain) was marked by the nurse assessing the resident as "unable to be determined". Two locations of pain identified were the abdomen and groin. A numeric scale of 0-10, was identified as the resident's method to rate pain, however there were no numbers documenting the resident's pain, pain at best, pain goal, present pain, and pain at worst. Staff documented the following regarding Resident #501's cognitive status. (1) A physician's progress note for Resident #501, dated 11/26/13, documented the following. "Doesn't respond verbally most of the time. . . Still not very responsive/cooperative in therapy per therapist. Does not follow most commands. Alert. Oriented mainly to self." (2) On 11/27/13 a psychiatrist documented that Resident #501 was frail, mute, with hypersomnia (excessive sleepiness), and a poor appetite. (3) R.N. (registered nurse) "I", interviewed on 12/4/13 at 1:15 p.m., said Resident #501 had been lethargic since she first cared for him on admission (11/19/13), and he was difficult to wake up for medications or food R.N. "I" said she monitored Resident #501's pain using non-verbal indicators such as grimacing, guarding, and his degree of combativeness. The R.N. said the resident was not cognitively able to use the numerical indicator for assessing his pain. (4) Unit Manager "D" was interviewed about Resident #501's cognitive status on 12/3/13 at 3:25 p.m. She stated that Resident #501 knew who he was and sometimes where he was. He did not know the date or time when questioned. He was "very distracted" and had "problems concentrating". According to the MAR (Medication Administration Record) for November 2013, Resident #501 had physician orders [REDACTED]. [MEDICATION NAME] was administered for pain on 11/19/13, 11/20/13, 11/21/13, 11/24/13, 11/26/13, 11/27/13, 11/28/13, 11/30/13, and 12/1/13. On 11/21/13 there was a physician's orders [REDACTED]. Per the MAR for November, 2013, Resident #501 received a [MEDICATION NAME] on 11/21/13, 11/24/13, 11/27/13, and 11/30/13. Nurses documented a numeric pain level for each [MEDICATION NAME] dose administered. Nurses also documented on the MAR's a daily numerical indicator of pain on 11/27/13 - 11/30/13 and on 12/1/13 and 12/2/13. The documentation of a numerical pain indicator occurred despite the fact that nurses documented that the resident was confused on 11/19/13, 11/23/13, and 11/24/13 and lethargic on 11/25/13 and 11/27/13, according to nurses notes. On 12/1/13 and 12/2/13 nurses notes indicated that the resident was alert but non-verbal, however, the pain assessment on the MAR for 12/1/13 indicated that the resident rated his pain as a "5". In the nurses notes there was no description of "confused" or "lethargic". On 11/21/13 there was a physician's orders [REDACTED]. Per the MAR for November, 2013, Resident #501 received a [MEDICATION NAME] on 11/21/13, 11/24/13, 11/27/13, and 11/30/13. R.N. "I", interviewed on 12/4/13 at 1:15 p.m., said she monitored Resident #501's pain using non-verbal indicators such as grimacing, guarding, and his degree of combativeness. The R.N. said the resident was not cognitively able to use the numerical indicator for assessing his pain. The location of pain was documented only twice (generalized pain), in the 11/27/13 and 11/28/13 nurses notes. There were no descriptions of the patient's pain pattern (onset, duration, specific type of pain, specific event causing pain or what relieved pain). ( ) Standards of care is the level or degree of quality considered adequate by a given profession, according to Guido in "Legal and Ethical Issues in Nursing", 3rd edition. "Internal standards are those set by the role and education of the nurse or by individual institutions. These include the professional nurse's job description, education, and expertise as well as individual institution's policies and procedures." (p.64) On 11/21/13 there was a physician's orders [REDACTED]. Resident #501 received a [MEDICATION NAME] on 11/21/13, 11/24/13, 11/27/13, and 11/30/13. Licensed practical nurse (L.P.N.) "B" was interviewed by telephone on 12/4/13 at 12:45 p.m.. She said she changed the resident's [MEDICATION NAME] on 10/24/13 at 8:17 p.m. She said she found the resident's used patch on his left shoulder, removed the patch, and placed the new patch on his right shoulder. She said she folded the patch and placed it, without another nurse observing the destruction of a controlled substance, into the sharps container. A facility policy for Medication Disposal/Destruction, dated 6/16/2009, indicates that controlled substances must be destroyed in the presence of a registered nurse and a licensed professional. The policy states that single doses of medications for disposal can be placed in the sharp's container or flushed down the toilet. In an interview with DON (director of nursing) "A" on 12/4/13 at 2:30 p.m., the new facility policy says that [MEDICATION NAME] must be flushed down the toilet. Registered Nurse (R.N.) "I" was interviewed on 12/4/13 at 1:15 p.m. She said she placed a new patch on Resident #501 on 11/27/13 and 11/30/13. R.N. "I" said Resident #501 did not have the old [MEDICATION NAME] on his body on those dates when she went to change the patch. R.N. "I" said L.P.N. "K" went with her to change the patches on 11/27/13 and 11/30/13. L.P.N. "K" was interviewed by telephone on 12/4/13 at 4:30 p.m. He said he accompanied R.N. "I" to Resident #501's room on 11/27/13 and 11/30/13 to change the [MEDICATION NAME]. He said he did not see any patches on the resident on those dates and they assessed the entire back, chest, and shoulders. According to R.N. "I" a CNA (certified nursing assistant) had showered Resident #501 on 11/27/13 and 11/30/13 before she applied the new [MEDICATION NAME]. She said both CNA's stated there had been no patch on the resident when they were showered. CNA "J" was interviewed on 12/4/13 at 4:50 p.m. She stated she gave a shower to Resident #501 on 11/27/13 on the afternoon shift. She said she did not find a patch of any kind on the resident at the time of his shower. The CNA said she washed every part of his body. CNA "L" was interviewed by telephone on 12/5/13 at 12 p.m. He said he showered Resident #501 on 11/30/13 on the afternoon shift. He said he washed the resident from head to toe and did not find any patches on the resident. R.N. "I" said she documented removing the [MEDICATION NAME] from Resident #501 as though she had done so even though there had been no patch to remove. The R.N. said she had not documented anywhere in the medical record that she found the resident on 11/27/13 and 11/30/13 without a [MEDICATION NAME]. R.N. "I" said she did not report the missing [MEDICATION NAME]es to anyone. DON "A" was interviewed on 12/5/13 at 12:20 p.m. She said she was never informed about the missing patches. She said the patches were considered a missing narcotic and should have been reported so an investigation could have been done. The policy for Medication Disposal/Destruction, dated 6/26/09 states that wasted drugs to be destroyed by two licensed nurses employed by the nursing center applies to the disposal of unused doses wasted for any reason. According to the policy, the disposal is documented on the accountability record on the line representing that dose. ( ) In "Legal and Ethical Issues in Nursing, 3rd edition, by Guido (2001), it is written that a breach of duty (such as failed to notify the physician of a change in a patient's condition) is a deviation from the standard of professional care owed the patient. A breach of duty could be doing something that should not have been done or doing nothing when something should have been done. (p.82) On 11/29/13 at 8 a.m. Resident #501's [MEDICATION NAME] (antihypertensive) was held, according to the MAR, because the resident's blood pressure was too low, per parameters written by the physician (systolic blood pressure < 110). [MEDICATION NAME] (antihypertensive) was held at 5 p.m. on 11/29/13 because the resident's blood pressure was too low, per the MAR. On 11/30/13 at 8 a.m. Resident #501 had no blood pressure documented, but, according to the MAR, the resident refused his [MEDICATION NAME]. On 11/30/13 at 5 p.m. [MEDICATION NAME] was held due to a low blood pressure, per the MAR. On 12/1/13 Resident #501's 8 a.m. [MEDICATION NAME] and 5 p.m. [MEDICATION NAME] were held because of a low blood pressure, documented on the MAR. On 12/2/13 the resident's blood pressure in the nurses notes was low, and the [MEDICATION NAME] was not administered, per the MAR. There was no documentation that Resident #501's physician was notified when the antihypertensive medications were held. There were no neurologic or cardiovascular assessments documented in the nurses notes when a low blood pressure was documented. ( )

This citation refers to intake # MI 472. Based on observation, interviews and record reviews, the facility staff failed to respond to a call light for over 60 minutes for 1 (#117) out of 10 residents, from a total sample of 19 residents, when resident #117 had a large semi-solid bowel movement in her brief, which was not changed for over sixty minutes, resulting in feelings of embarrassment, anger and humiliation. Findings include: Resident #117 was an [AGE] year old female admitted to the facility on [DATE] for rehabilitation of a fractured right hip. Additional [DIAGNOSES REDACTED]. On 9/10/2012 at 1:30 PM, a record review of the Minimal Data Set ((MDS) dated [DATE] indicated Resident #117 scored 15 out of 15 point on the Brief Interview for Mental Status (BIMS) evaluation. A score of 15 on the BIMS indicated Resident #117 was cognitively (mentally) intact. In addition, Resident #117 was evaluated as frequently incontinent (unable to control her urine) of urine and always continent of her bowel movement. On 10/10/2012 at 1:30 PM, a record review of the nurse's notes indicated, on 10/9/2012 during the day shift, Resident #117 complained of constipation. Nursing staff administered ten milliliters of Milk of Magnesia and two Senna tablets during the day shift. Milk of Magnesia is a saline laxative used to stimulate the bowels resulting in a bowel movement. Senna is bowel stimulant that encourages the emptying of the bowels. At approximately 6:00 PM on 10/9/2012, Resident #117 turned on her call light as she needed to have a bowel movement and wanted to be assisted to the bathroom. When there was no response to the call light, Resident #117 had a bowel movement in her brief. The call light was answered at 7:10 PM and Resident #117 had her brief changed. During an observation on 10/10/2012 at 2:00 PM, Resident #117 was in physical therapy exercising her legs on a resistive pedal exerciser. Resident #117 was alert and smiling as she pedaled on the exerciser. Resident #117 was asked to confirm the allegation that her call light was on from 6:00 PM to approximately 7:10 PM on 10/9/2012 with no staff response to her call light during that time frame. Resident #117 verified the time frame was accurate and that she laid in her bowel movement for over an hour. Resident #117 said she had a bowel movement in her brief and the bowel movement filled her brief up to her waist. In addition, Resident #117 said she was "embarrassed" because she had two visitors in her room who witnessed her incontinence and the long time frame before there was a response to the call light. Resident #117 said there was not enough help on the afternoon shift and she always had to wait a long time for staff to answer her call light. Resident #117 said she did not want to get "the girls" working on the unit in trouble because they worked very hard. Resident #117 said she was scheduled to go home on 10/14/2012 and did not want the staff to be upset that she complained about the care she received in the facility. On 9/10/2012 at 1:30 PM, Staff Nurse #24 confronted the Surveyor regarding the allegation that Resident #117 was left in a soiled diaper for over an hour. Staff Nurse #24 denied the allegation and stated the longest amount of time that Resident #117 was in a soiled brief was thirty (30) minutes as there was an emergency on the unit where a 450 pound male fell and the entire staff working on the unit was involved in helping him up off the floor. On 10/11/2012 at 1:45 PM, Visitor #23 was interviewed by phone regarding the incontinent episode experienced by Resident #117. Visitor #23 said she and her mother came to visit Resident #117 at approximately 6:00 PM on 10/9/2012. Visitor #23 said she was in Resident #117's room until 7:10 PM when a certified Nursing Assistant (CNA) responded to Resident #117's call light. Resident #117 was embarrassed and said to Visitor #23 "I'm all sh***y in an angry tone of voice!" During the visit, between 6:00 PM to 7:10 PM, Visitor #23 walked out in the hall to look for help several times and saw three other call lights on but no staff were seen in the hall.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 441. BASED ON OBSERVATION, INTERVIEWS, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE DOOR ALARMS WERE FUNCTIONING AND PROVIDE SUPERVISION TO ENSURE THE SAFETY OF, ONE OF FOUR SAMPLED RESIDENTS (#104), FROM A TOTAL SAMPLE OF TEN RESIDENTS IDENTIFIED AT RISK FOR ELOPEMENT, RESULTING IN IMMEDIATE JEOPARDY WHEN RESIDENT #104 EXITED THE FACILITY ON 8/21/2012 AT 1:05 P.M., BY AN EXIT DOOR NEXT TO THE THERAPY GYM, AND WAS DISCOVERED OUTSIDE THE FACILITY IN THE PARKING LOT BY CERTIFIED NURSE AIDE (CNA) #5. FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #104 WAS A [AGE] year-OLD MAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE PHYSICAL THERAPY NOTE FROM THE HOSPITAL REFERRING RESIDENT #104 TO THE FACILITY, DATED 7/5/2012, RECOMMENDED "PATIENT WILL REQUIRE 24 HOUR SUPERVISION." THE MINIMUM DATA SETS ((MDS) dated [DATE], ASSESSED RESIDENT #104 AS MODERATELY TO SEVERELY COGNITIVELY IMPAIRED AND REQUIRING EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S). THE NURSING ADMISSION ASSESSMENT, DATED 7/9/2012 AT 2:29 P.M., ASSESSED RESIDENT #104 AS "COGNITIVELY IMPAIRED WITH MOBILITY, UNSTEADY IN GAIT." DOCUMENTATION INCLUDED APPLICATION OF A WANDERGUARD TO HIS PERSON. THE ELOPEMENT RISK CARE PLAN, INITIATED 8/7/2012, IDENTIFIED RESIDENT #104 AS AN ELOPEMENT RISK, AND INCLUDED AS HIS GOAL "WILL NOT LEAVE CENTER UNATTENDED." THE CARE PLAN SPECIFIED THE RESIDENT WAS TO UTILIZE PLACEMENT OF TWO WANDERGUARDS, ONE ON HIS ANKLE AND ONE ON HIS WHEELCHAIR. ACCORDING TO THE FACILITY INVESTIGATION REPORT DATED 8/28/2012 (UNTIMED), RESIDENT #104 WAS OBSERVED OUTSIDE THE FACILITY, AND IN THE PARKING LOT, ON 8/21/2012 AT 1:05 P.M., BY HOUSEKEEPER #5 AS SHE STOOD NEAR THE THERAPY ENTRANCE DOOR. THE RESIDENT WAS REPORTED TO HAVE SUSTAINED NO INJURY. DURING AN INTERVIEW ON 8/23/2012 AT 2:10 P.M., PHYSICAL THERAPIST (PT) #6 SAID SHE HAD PROVIDED THERAPY SERVICES TO RESIDENT #104 THE MORNING OF 8/21/2012, AND WAS AWARE HE HAD AT LEAST ONE WANDERGUARD PRESENT ON HIS ANKLE. SHE SAID THE RESIDENT, IN THE PRIOR WEEK, HAD "REPEATEDLY ASKED EVERYONE, AND ME, IF THIS DOOR, AN EXIT TO THE THERAPY GYM, WAS THE DOOR TO GET OUT. HE TOLD ME HE WANTED TO GO HOME." PT #6 SAID SHE WAS ON A COMPUTER AT 1:00 P.M. ON 8/21/2012 AND DID NOT HEAR ANY ALARMS SOUND AS RESIDENT #104 EXITED THE FACILITY. DURING AN INTERVIEW ON 8/23/2012 AT 2:20 P.M., HOUSEKEEPER #5 SAID, "I'M NOT SURE HOW HE (RESIDENT #104) GOT OUT. I SAW HIM OUT IN THE PARKING LOT THROUGH THE WINDOW ON THE EXIT DOOR, NEXT TO THE THERAPY GYM. HE HAD A WANDERGUARD ON HIS ANKLE. THERE WERE ABSOLUTELY NO ALARMS GOING OFF. I WENT OUT TO HIM. HE HAD CROSSED PAST OUR PARKING LOT, AND WAS STOPPED AT THE CURB LOOKING OUT AT AN OPEN AREA WITH WOODS. IT REALLY SCARED ME. HE WAS IN A SPACE BETWEEN TWO PARKED CARS. IT WAS DANGEROUS. HE COULD'VE BEEN HIT. HE WOULD'VE BEEN HARD TO SEE IF SOMEONE IN A CAR TURNED IN THAT SPACE; THEY MAY NOT HAVE SEEN HIM IN TIME NOT TO HIT HIM. I ASKED HIM HOW HE GOT OUT; HE DIDN'T ANSWER. I TOOK HIM BACK INTO THE BUILDING." DURING AN INTERVIEW ON 8/23/2012 AT 3:15 P.M., MAINTENANCE SUPERVISOR #7 SAID HE BELIEVED THE FACILITY'S ALARM SYSTEM WAS BREACHED BY USE OF A CODE, WHICH ALTERED THE SYSTEM'S RECOGNITION OF RESIDENT #104'S WANDERGUARD, AND FACILITATED THE RESIDENT'S ELOPEMENT FROM THE FACILITY WITH NO ALARM INITIATED. DURING A TELEPHONE INTERVIEW ON 8/23/2012 AT 5:30 P.M., MAINTENANCE TECHNICIAN #8 SAID HE BELIEVED THE ALARM SYSTEM WAS INTERRUPTED, AND THAT THE INTERRUPTION OF THE SYSTEM WOULD FACILITATE A RESIDENT WITH A WANDERGUARD GOING THROUGH A DOORWAY WITH NO ALARM SOUNDING. THE MAINTENANCE TECHNICIAN GAVE AS AN EXAMPLE, A SITUATION IN WHICH HE HAD WITNESSED A CNA ENTER A CODE IN A MASTER ALARM BOX TO A DOOR AT THE BACK OF THE FACILITY, USED BY STAFF TO ENTER THE BUILDING. THIS OBSERVATION, HE SAID, WAS MADE ON THE DAY BEFORE RESIDENT #104'S ELOPEMENT, AND THAT HE TOLD THE CNA NOT TO USE THE CODE NUMBER AGAIN. THE MAINTENANCE TECHNICIAN SAID ENTRY OF A CODE NUMBER INTO A MASTER ALARM SYSTEM BOX WAS KNOWN TO CONTROL THE MAGNETS THAT RELEASE THE DOOR, OPENING IT AND ALLOWING THE DOOR TO FREELY OPEN WITHOUT CAUSING THE DOOR TO ALARM. THE MAINTENANCE TECHNICIAN SAID HE DID NOT RE-PROGRAM THE MASTER ALARM SYSTEM BOXES AFTER OBSERVING THE CNA ENTERING A CODE NUMBER INTO THE MASTER ALARM BOX THE DAY BEFORE RESIDENT #104'S ELOPEMENT ON 8/21/2012. DURING AN INTERVIEW ON 8/28/2012 AT 3:30 P.M., CNA #25 SAID SHE AND OTHER STAFF MEMBERS, HAD ENTERED A CODE INTO THE MASTER ALARM SYSTEM BOXES, ROUTINELY SINCE JANUARY OF 2012, TO SILENCE THE ALARMS. THE CNA SAID SHE AND OTHER STAFF MEMBERS WERE AWARE THE CODE TO THE BOX WAS CHANGED OFTEN, BUT WAS CHANGED TO PREDICTABLE 3-DIGIT NUMBERS PRECEDED BY AN ASTERISK, WHICH WERE FREELY SHARED BY STAFF. SHE SAID STAFF WERE AWARE OF AN INSTANCE IN WHICH A RESIDENT ELOPED FROM THE FACILITY IN FEBRUARY 2012, HAVING KNOWN, AND ENTERED, THE CODE TO TURN OFF THE ALARM (SEE CMS 2567 DATED 3/6/2012). THE CNA SAID STAFF MEMBERS WOULD "FLASH" (USE FINGER GESTURES TO COMMUNICATE THE NUMBERS) THE NUMBERS TO EACH OTHER AS NEEDED. DURING AN INTERVIEW ON 8/29/2012 AT 9:50 A.M., UNSAMPLED RESIDENT #26 SAID HE HAD BEEN IN HIS MOTORIZED WHEELCHAIR ON 8/21/2012 AND "I SAW HIM (RESIDENT #104) OUT IN THE PARKING LOT; HE WAS IN BETWEEN TWO PARKED CARS. I SAW HIM, NO ONE WAS WITH HIM. I WAS ON THE SIDEWALK IN MY WHEELCHAIR; IT'S MOTORIZED. I WAS JUST OUTSIDE GOING AROUND IN MY WHEELCHAIR. I WAS RETURNING FROM THE SIDE AREA, NEAR THE THERAPY ENTRANCE, ROUNDING THAT CURVE IN THE SIDEWALK, AND HEADED IN THE DIRECTION TOWARD THE THERAPY DOOR. I SAW HIM (RESIDENT #104). THERE WERE NO ALARMS SOUNDING, NONE AT ALL. I KNOW WHAT THE ALARM SOUNDS LIKE, AND I WAS CLOSE ENOUGH TO THE DOOR THAT I WOULD'VE HEARD IT. THERE WAS NOBODY WITH HIM. THEN I SAW A HOUSEKEEPER RUN OUT TO HIM. HE MAY HAVE BEEN IN THE PARKING LOT WHEN I PASSED THAT AREA THE FIRST TIME. I WASN'T LOOKING IN THAT DIRECTION, YOU KNOW, WHERE HE WAS. I WAS LOOKING STRAIGHT AHEAD. I WAS OVER TO THE SIDE OF THE BUILDING A COUPLE OF MINUTES; MY WHEELCHAIR WAS RUNNING PRETTY SLOW, BEFORE I CAME BACK AROUND AND SAW HIM (RESIDENT #104) IN HIS WHEELCHAIR IN THE PARKING LOT. I DON'T KNOW HOW LONG HE'D BEEN OUT THERE. I DIDN'T SEE HIM AT LUNCH, BUT I DID SEE HIM AT BREAKFAST. THAT WAS THE LAST TIME UNTIL I SAW HIM OUTSIDE IN THE PARKING LOT. I DON'T KNOW HOW HE GOT OUT." DURING AN INTERVIEW ON 8/23/2012 AT 2:00 P.M., NURSING HOME ADMINISTRATOR (NHA) #1 SAID, "HE (RESIDENT #104) WAS OBSERVED OUTSIDE THE FACILITY BY A HOUSEKEEPER (#5) ON 8/21/2012 AT 1:05 P.M. WE BELIEVE HE WENT OUT OUR EXIT NEAREST TO THE THERAPY GYM. HE HAD A WANDERGARD ON. FACILITY DOORS, AND THE RESIDENT'S WANDERGUARD, WERE CHECKED AT 8:00 A.M. THAT DAY AND WERE FUNCTIONING. WE HAVEN'T BEEN ABLE TO DETERMINE HOW HE GOT OUT. IT WASN'T AN OBSERVED EXIT. WE DON'T HAVE SURVEILLANCE CAMERAS AT THE DOORS OR ANYWHERE IN OUR BUILDING. FROM A RE-ENACTMENT, WE BELIEVE HE WAS PROBABLY GONE NO LONGER THAN FIVE MINUTES." DURING A DOOR ALARM/WANDERGUARD ASSESSMENT OF THE FACILITY ON 8/23/2012 AT 1:35 P.M., THE SURVEYOR WAS ABLE TO FREELY OPEN A DOOR WITH A KEYPAD ALARM SYSTEM, LEADING FROM THE MAIN DINING ROOM INTO THE KITCHEN, WITHOUT BENEFIT OF AN ENTERED CODE. THIS DOOR WAS IDENTIFIED TO THE SURVEYOR, BY VISITORS AND AN UNSAMPLED RESIDENT, AS "ALWAYS OPEN." THE SURVEYOR PROCEEDED THROUGH THE DOORWAY, INTO THE KITCHEN, AND OUT ANOTHER KITCHEN DOOR THAT LEAD INTO A HALLWAY. THE SURVEYOR LEFT THE HALLWAY THROUGH AN OPEN DOOR OF THE LAUNDRY AREA, AND OUT OF THE FACILITY THROUGH AN UNLOCKED SCREEN DOOR. THE MAINTENANCE SUPERVISOR (#7), DIRECTOR OF NURSING #2, AND NURSING HOME ADMINISTRATOR #1 OBSERVED THE SURVEYOR AS SHE EXITED THE FACILITY, FREELY. DURING AN INTERVIEW ON 8/29/2012 AT 3:05 P.M., NURSING HOME ADMINISTRATOR #1 SAID, "WE WILL FIX THIS." ON 8/23/2012 AT 3:58 P.M., NURSING HOME ADMINISTRATOR #1 AND DON #2 WERE INFORMED OF THE IMMEDIATE JEOPARDY WHICH BEGAN ON 8/21/2012 AT 1:05 P.M., AND WAS IDENTIFIED ON 8/23/2012. THE IMMEDIATE JEOPARDY IS IDENTIFIED DUE TO THE FACILITY'S FAILURE TO ENSURE DOOR ALARMS WERE FUNCTIONING AND PROVIDE SUPERVISION TO ENSURE THE SAFETY OF RESIDENT (#104), AND 23 OTHER RESIDENTS WITH WANDERGUARDS AT RISK FOR ELOPEMENT, PLACING THEM AT HIGH RISK FOR HARM, INJURY, AND/OR DEATH. ON 8/27/2012, THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. CODE GREEN DRILL WAS CONDUCTED ON 8/21/2012 AT 1:40 P.M., AND ALL RESIDENTS WERE ACCOUNTED FOR. 2. DOOR SYSTEM FUNCTION WAS CHECKED ON 100% OF DOORS WHICH EXITED TO THE OUTSIDE WITH NO FUNCTIONAL CONCERNS IDENTIFIED ON 8/21/2012 AT 1:45 P.M. 3. ONE-TO-ONE SUPERVISION WAS IMPLEMENTED ON RESIDENT #104'S RETURN to the facility on [DATE] AT APPROXIMATELY 1:15 P.M., AND CONTINUED UNTIL THE RESIDENT'S DISCHARGE FROM THE FACILITY ON 8/24/2012. 4. ON 8/21/2012 RESIDENTS' CARE PLANS WERE REVIEWED AND NEW BEHAVIOR/ELOPEMENT RISK ASSESSMENT WAS COMPLETED. 5. ON 8/21/2012 AT 5:00 P.M., THE ALARM SYSTEM COMPANY REPRESENTATIVES CHECKED ALL DOORS THAT EXITED TO THE OUTSIDE OF THE FACILITY FOR PROPER FUNCTION 6. ON 8/23/2012 AT 12:30 P.M., THE MAINTENANCE TECHNICIAN WAS SUSPENDED PENDING THE OUTCOME OF THE INVESTIGATION. WHILE THE IMMEDIATE JEOPARDY (IJ) WAS REMOVED ON 8/23/2012, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND A SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED BY THE STATE AGENCY.

REFER TO INTAKE # MI 761 BASED ON OBSERVATION, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF ONE (RESIDENT #101) OF 7 SAMPLED RESIDENTS REVIEWED FOR ENVIRONMENTAL SAFETY AND ELOPEMENT RISK OUT OF A TOTAL OF 19 RESIDENTS WHO ARE IDENTIFIED AS ELOPEMENT RISKS, RESULTING IN IMMEDIATE JEOPARDY WHEN, ON 2/4/12 AT 12:40 P.M., RESIDENT #101 EXITED THE FACILITY VIA THE REHAB DOOR, CAUSING THE ALARM TO SOUND. RESIDENT #103 HEARD THE DOOR ALARM, KNEW THE ACCESS CODE FOR THE ALARM AND WENT TO THE DOOR AND SILENCED THE ALARM BY KEYING IN THE ACCESS CODE. RESIDENT #101 SUCCESSFULLY LEFT THE FACILITY AND WAS DISCOVERED OUTSIDE THE FACILITY ON THE SIDEWALK/PARKING LOT IN FRONT OF THE MAIN ENTRANCE BY LICENSED PRACTICAL NURSE (LPN) #4, WHO WAS LEAVING THE FACILITY VIA THE MAIN DOOR FOR LUNCH. FINDINGS INCLUDE: RESIDENT #101 IS A [AGE] year OLD MALE, WHO WAS admitted to the facility on [DATE] WITH A HISTORY OF DEVELOPMENTAL DISABILITY AND ALZHEIMER'S DEMENTIA IN ADDITION TO OTHER DIAGNOSES. NURSE'S ADMISSION NOTES, DATED 1/14/12, INDICATED, "PATIENT'S SISTER STATES THAT PATIENT HAS HISTORY OF WANDERING AND WAS INJURED SEVERELY THE LAST TIME WHICH PLACED HIM IN THE HOSPITAL WITH PNEUMOTHORAX." UPON ADMISSION ON 1/14/12, RESIDENT #101 WAS ASSESSED AS EXIT SEEKING, DUE TO HIS HISTORY OF WANDERING. A WANDERGUARD BRACELET WAS PUT IN PLACE ON 1/16/12, AND RESIDENT #101 WAS ON THE FACILITY'S CENTER WATCH (LIST OF RESIDENTS WHO ARE WANDERING/ELOPEMENT RISKS). RESIDENT #101'S PASSR (PREADMISSION SCREENING/ANNUAL RESIDENT REVIEW) EVALUATION, DATED 1/20/12, DOCUMENTED CURRENT [DIAGNOSES REDACTED].[REDACTED]. THE INCIDENT REPORT, DATED 2/4/12, DOCUMENTED THAT RESIDENT #101 HAD AN UNAUTHORIZED LEAVE OF THE FACILITY. RESIDENT #101 WAS OBSERVED ON THE SIDEWALK, ON FACILITY GROUNDS, SELF PROPELLING IN HIS OWN WHEELCHAIR TOWARDS THE MAIN ENTRANCE. HE WAS ASSISTED INTO THE FACILITY BY THE NURSE. ACCORDING TO THE TIMELINE OF EVENTS (FACILITY'S INVESTIGATION REPORT PAGE 2 OF 3) ON 2/4/12, AT 12:35 PM, NURSE AIDE #2 OBSERVED RESIDENT #101 EXITING THE MAIN DINING AREA. AT 12:38 PM, THE DOOR ALARM SYSTEM SOUNDED BUT STOPPED APPROXIMATELY 15 SECONDS LATER. AT 12:40 PM, RESIDENT #103 OBSERVED RESIDENT #101 SELF PROPELLING IN HIS WHEELCHAIR DOWN THE SIDEWALK IN FRONT OF THE FACILITY. RESIDENT #103 ENTERED THE CODE WHICH DISENGAGED THE ALARM. AT 12:40 PM, LPN #4 OBSERVED RESIDENT #101 OUTSIDE ON THE SIDEWALK GOING TOWARDS THE MAIN ENTRANCE AND ASSISTED HIM BACK INSIDE. LPN #4 WAS INTERVIEWED BY TELEPHONE ON 2/29/12 AT 2:30 PM. LPN #4 STATED THAT SHE RECOGNIZED RESIDENT #101 OUTSIDE WHEN SHE WAS LEAVING THE FACILITY FOR LUNCH. LPN #4 OBSERVED RESIDENT #101 WHEELING HIMSELF OUTSIDE THE FACILITY. HE DID NOT APPEAR TO BE IN DISTRESS. LPN #4 SAID THAT RESIDENT #101 "HAS MENTAL RETARDATION. HE CAN TALK BUT DOES NOT KNOW WHAT HE WAS DOING." LPN #4 RECALLED THAT SHE BROUGHT HIM BACK TO THE FACILITY AND THAT HE WAS UNHARMED. LPN #4 STATED THAT SHE HEARD THE EXIT DOOR ALARM GO OFF BUT DID NOT GO BY THE EXIT DOORS TO CHECK. SHE FURTHER EXPLAINED THAT THE ALARM WENT OFF BUT IT GOT SHUT OFF. LPN #4 STATED THAT SHE THOUGHT THAT A STAFF MEMBER MUST HAVE DISENGAGED THE ALARM. SHE DENIED KNOWLEDGE THAT A RESIDENT WOULD KNOW THE DOOR ALARM CODE. RESIDENT #103 IS [AGE] years OLD AND WAS admitted to the facility on [DATE] WITH HISTORY OF LATE EFFECT CVA (CEREBROVASCULAR ACCIDENT) AND APHASIA IN ADDITION TO OTHER DIAGNOSES. RESIDENT #103 WAS A SMOKER AND ON 8/9/11, RESIDENT #103 WAS EVALUATED AS BEING SAFE TO SMOKE INDEPENDENTLY OUTSIDE THE FACILITY. DURING AN INTERVIEW CONDUCTED ON 2/28/12 AT 1:06 PM, RESIDENT #103 WAS OBSERVED TO HAVE DIFFICULTY VERBALIZING, DUE TO HER MEDICAL HISTORY. RESIDENT #103 WAS ASKED TO DEMONSTRATE HOW SHE DEACTIVATED THE ALARM THAT DAY (2/4/12). RESIDENT #103 APPROACHED THE KEY PAD, ENTERED THE CODE WITHOUT DIFFICULTY AND SUCCESSFULLY OPENED THE DOOR WITHOUT ACTIVATING THE ALARM. SHE VERBALLY REPEATED THE CODE TO THE SURVEYOR. THE SURVEYOR VALIDATED WITH THE NURSE IN CHARGE THAT IT WAS THE CORRECT CODE . RESIDENT #101'S CLINICAL RECORD REVIEW REVEALED THAT ALTHOUGH HE WAS TO WEAR A WANDERGUARD STARTING ON 1/16/12, AND THE WANDERGUARD WAS CHECKED FOR FUNCTIONING PER FACILITY PROTOCOL, THE FACILITY HAD NOT INITIATED A CARE PLAN FOR WANDERING/PACING AND FOR ELOPEMENT BEHAVIOR FOR RESIDENT #101 UNTIL AFTER THE ELOPEMENT INCIDENT OCCURRED ON 2/4/12. ACCORDING TO THE FACILITY'S SUMMARY INVESTIGATION, DATED 2/4/12, RESIDENT #101 HAD THE WANDERGUARD BRACELET ON HIS ANKLE AFTER HIS ELOPEMENT ON 2/4/12 AND IT WAS FUNCTIONING WHEN tested . FAMILY MEMBER #6 WAS INTERVIEWED ON THE PHONE ON 2/29/12 AT 3:10 PM. FAMILY MEMBER #6 STATED, "UPON ADMISSION, I TOLD STAFF (NURSE) THAT MY BROTHER WANDERS AND HAD LEFT HOME WITHOUT MY KNOWLEDGE OF HIS WHEREABOUTS. HE IS DEVELOPMENTALLY DISABLED AND I WORRY ABOUT HIM NOT FINDING HIS WAY BACK HOME OR HURTING HIMSELF." FAMILY MEMBER #6 TOLD THE NURSE THAT RESIDENT #101 SEVERELY INJURED HIMSELF WHICH RESULTED IN hospitalization WITH PNEUMOTHORAX, RIB FRACTURES, LACERATIONS AND BRUISES. PREVIOUSLY, RESIDENT #101 HAD LIVED INDEPENDENTLY IN ASSISTED CARE UNTIL HE STARTED WANDERING FROM ROOM TO ROOM AND COULD NOT FIND HIS OWN ROOM. FAMILY MEMBER #6 RECALLED RESIDENT #101 TELLING HER, "I CAN'T FIND MY APARTMENT." IN AN INTERVIEW ON 2/28/12 AT 3:21 PM, NURSE AIDE #1 STATED THAT PRIOR TO THE ELOPEMENT INCIDENT ON 2/4/12, RESIDENT #103 WAS ABLE TO SMOKE OUTSIDE INDEPENDENTLY AND UNSUPERVISED. THE PROCEDURE INVOLVED RESIDENT #103 BEING GIVEN A CIGARETTE AND A LIGHTER BY THE NURSE IN CHARGE. RESIDENT #103 WOULD WHEEL HERSELF TO THE REHAB EXIT DOORS AND KEY IN THE EXIT ACCESS CODE. RESIDENT #103 HAD BEEN GIVEN THE DOOR ACCESS CODE SO SHE COULD SMOKE OUTSIDE WITHOUT STAFF PRESENT. NURSE AIDE #1 STATED THAT SHE BELIEVED THAT RESIDENT #103 TURNED THE ALARM OFF. THE NURSE IN CHARGE (LPN #5) WAS INTERVIEWED ON 2/28/12 AT 12:27 PM. LPN #5 STATED THAT RESIDENT #101 WAS HER RESPONSIBILITY THAT MORNING. RESIDENT #101 WAS ALERT AND ORIENTED, BUT WITH DEMENTIA AND WAS DEVELOPMENTALLY DISABLED. RESIDENT #101 HAD BEEN ASSESSED AS AN ELOPEMENT RISK UPON ADMISSION. LPN #5 admitted THAT SHE HEARD THE EXIT DOOR ALARM SOUND, BUT AFTER SHE WALKED APPROXIMATELY FIVE STEPS, THE ALARM STOPPED. LPN #5 SAID SHE DID NOT PROCEED ANY FURTHER BECAUSE SHE THOUGHT THAT A STAFF MEMBER OR VISITOR WHO KNEW THE CODE MAY HAVE STEPPED OUT. SHE CONTINUED WITH HER DUTIES AND DID NOT VERIFY THE CAUSE OF THE ALARM AND THE NEED TO CHECK IF A RESIDENT WAS MISSING OR HAD LEFT THE BUILDING. LPN #5 ALSO admitted THAT SHE WAS UNAWARE THAT RESIDENT #103 HAD THE ACCESS CODE TO THE DOOR ALARM. ON 3/1/12 AT 10:25 AM., THE ADMINISTRATOR AND THE DIRECTOR OF NURSING WERE INFORMED OF THE IMMEDIATE JEOPARDY WHICH BEGAN ON 2/4/12 AND WAS IDENTIFIED ON 2/28/12. THE IMMEDIATE JEOPARDY IS IDENTIFIED DUE TO THE FACILITY'S FAILURE TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF RESIDENT #101, WHO ELOPED FROM THE FACILITY ON 2/4/12 UNBEKNOWNST TO FACILITY STAFF; THE FACILITY'S FAILURE TO RESPOND APPROPRIATELY TO THE ACTIVATION OF AN EXIT DOOR ALARM AND THE FACILITY'S FAILURE TO PROTECT THE INTEGRITY OF THE DOOR ALARM ACCESS CODE. THESE DEFICIENT PRACTICES PLACE 19 RESIDENTS, WHO HAVE WANDERGUARD BRACELETS AND ARE IDENTIFIED AS BEING ON THE CENTER WATCH PROGRAM, AT HIGH RISK OF HARM, INJURY AND/OR DEATH. ON 3/1/12, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 2/4/12 AT 12:40 PM, RESIDENT #101 WAS RETURNED TO THE CENTER WITH NO EVIDENCE OF MOOD AND BEHAVIOR CHANGES OR PHYSICAL INJURY. 2. ONE-ON-ONE SUPERVISION FOR RESIDENT #101 WAS IMPLEMENTED UPON HIS RETURN to the facility on [DATE] AT 12:45 PM. 3. RESIDENT #101'S CARE PLAN WAS REVIEWED AND UPDATED ON 2/4/12. 4. RESIDENT #103 DOES NOT HAVE ACCESS TO THE DOOR CODE, EFFECTIVE 2/29/2012. 5. A QAA MEETING WAS HELD TO REVIEW THE INVESTIGATION PROGRESS AND DEVELOP ADDITIONAL RECOMMENDATIONS ON 2/6/12 AT 9:30 AM: ? 17 RESIDENTS SECURE CARE BRACELETS WERE VALIDATED FOR PLACEMENT AND FUNCTION ON 2/5/12. ? REVIEW OF CENTER WATCH BINDERS/BOARDS COMPLETED AND UPDATED AS NEEDED ON 2/5/12 AY 9:00 AM ? RESIDENTS IDENTIFIED AS EXIT SEEKERS RECEIVED COMPLETE REVIEW OF PLAN OF CARE AND UPDATED EXIT SEEKING ASSESSMENTS BETWEEN 2/4/12 AND 2/6/12. ? ALL RESIDENTS IN THE FACILITY WERE REASSESSED FOR EXIT SEEKING RISK. RISK ASSESSMENT WAS COMPLETED ON 2/7/12. PLAN OF CARE WERE REVIEWED/REVISED ON 2/7/12. 6. STAFF EDUCATION WAS INITIATED IN 2/4/12, ON DOOR ALARM RESPONSE AND CODE GREEN PROCESS. 13 EMPLOYEES WERE INSERVICED ON 2/4/12. TO DATE, 90% OF STAFF EDUCATION WAS COMPLETED. EMPLOYEES WHO HAVE NOT RECEIVED THE INSERVICE WILL NOT BE ALLOWED TO WORK UNTIL EDUCATION IS PROVIDED IN PERSON. 7. NEWLY admitted RESIDENTS WERE EVALUATED FOR ELOPEMENT RISK DURING ADMISSION EVALUATION. ANY IDENTIFIED RISK-REDUCING INTERVENTIONS ARE PUT INTO PLACE UPON ADMISSION. 8. THE EXTERIOR DOORS WILL CONTINUE TO BE LOCKED FOR ALL HOURS OF THE DAY WITH CODE ACCESS FOR EXITING THE FACILITY NOT PROVIDED TO RESIDENTS. DOOR CODE WILL BE ROUTINELY CHANGED TO ENSURE THE SAFETY OF THE RESIDENTS. 9. MISSING PATIENT PROCEDURE WAS REVIEWED ON 2/15/12 AND DEEMED APPROPRIATE. THE FACILITY WILL CONTINUE TO FOLLOW THE MISSING PATIENT PROCEDURE. 10. THE DIRECTOR OF NURSING AND ADMINISTRATOR ARE RESPONSIBLE FOR THE COMPLIANCE OF F-323. WHILE THE IMMEDIATE JEOPARDY (IJ) WAS REMOVED ON 2/29/12, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "PATTERN" AND A SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT AN IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED BY THE STATE AGENCY. ( )

REFER TO INTAKE MI 130. BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEWS, FACILITY STAFF FAILED TO PROVIDE ADEQUATE SUPERVISION AND FAILED TO PROPERLY SECURE THE SIDE RAILS OF A SHOWER BED FOR 1 (#503) OF 4 SAMPLED RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 7, RESULTING IN A FALL WITH A FRACTURED SHOULDER. FINDINGS INCLUDE: RESIDENT #503, [AGE] years OLD, WAS admitted to the facility on [DATE], PER THE ADMISSION RECORD. THIS ADMISSION FOLLOWED A hospitalization FOR STROKE, ALZHEIMER'S DISEASE, HYPERTENSION, CONGESTIVE HEART FAILURE, OSTEOPOROSIS, ARTHRITIS, AND DEPRESSION, ACCORDING TO A HOSPITAL HISTORY & PHYSICAL DATED 9/2/07. AN MDS (MINIMUM DATA SET) assessment dated [DATE] FOR RESIDENT #503 INDICATED THE RESIDENT HAD SEVERE COGNITIVE AND MEMORY DEFICITS. SHE REQUIRED TOTAL ASSISTANCE FOR ALL ACTIVITIES OF DAILY LIVING. AN OCCUPATIONAL THERAPY EVALUATION ON 10/3/11 FOR RESIDENT #503 DOCUMENTED APHASIA (INABILITY TO SPEAK), AN INABILITY TO FOLLOW COMMANDS, RIGIDITY IN THE LEFT UPPER EXTREMITY AND AN INABILITY TO USE THE LEFT UPPER EXTREMITY DUE TO STROKE. AN 11/22/07 OCCUPATIONAL THERAPY CONSULTATION NOTED THE RESIDENT HAD DECREASED SITTING BALANCE, DECREASED SITTING TOLERANCE, AND AN INABILITY TO MAINTAIN A SITTING POSITION UNSUPPORTED. ACCORDING TO A FACILITY INVESTIGATION REPORT, DATED 10/6/11, ON 10/1/11, RESIDENT #503 WAS BEING ASSISTED ON A SHOWER GURNEY BY CERTIFIED NURSING ASSISTANT (CNA) #7 WHEN THE SIDE RAIL GAVE WAY AND THE RESIDENT fell TO THE FLOOR. AN X-RAY ON 10/1/11 SHOWED A MILDLY DISPLACED ACUTE-TO-SUBACUTE FRACTURE OF THE DISTAL CLAVICLE (COLLAR BONE). ACCORDING TO THE DON (DIRECTOR OF NURSING) AND ADMINISTRATOR, INTERVIEWED 11/2/11 AT 10:30 A.M., CNA #7 HAD RESIDENT #503 ON THE SHOWER GURNEY AND TURNED THE RESIDENT ON HER SIDE, AWAY FROM HER (#7) TO FINISH DRYING HER BODY AND DRESS HER (#503), FOLLOWING THE SHOWER. THERE ARE TWO PINS ON EACH SIDE OF THE SHOWER GURNEY WHICH NEED TO BE IN PLACE TO HOLD THE SIDE RAIL UP. STAFF ARE RESPONSIBLE FOR MAKING SURE THE PINS ARE IN PLACE. AT LEAST ONE AND POSSIBLY BOTH PINS WERE MISSING ON THE SIDE TO WHICH THE RESIDENT WAS TURNED. THE SIDE RAIL GAVE WAY, AND THE RESIDENT fell TO THE FLOOR. CNA #7 WAS ALONE IN THE ROOM WITH RESIDENT #503. THE FACILITY'S INVESTIGATION INCLUDED TWO INTERVIEWS FROM 10/1/11 WITH CNA #7. THE STATEMENTS MADE BY CNA #7 WERE CONSISTENT WITH THE INFORMATION THAT WAS PROVIDED BY THE DON AND ADMINISTRATOR. HOWEVER, IN THE FIRST STATEMENT, CNA #7 SAID THAT WHEN SHE ROLLED RESIDENT #503 ONTO HER (#503) SIDE, "THE RAIL WAS UP ALREADY. I DIDN'T NOTICE THE PINS WERE MISSING." IN THE SECOND STATEMENT, CNA #7 STATED, "NO PINS WERE ON THAT SIDE OF THE RAIL. I KNEW IT WAS SUPPOSED TO BE FIXED A COUPLE OF WEEKS AGO. WHEN I SAW IT BACK IN THE SHOWER ROOM, I THOUGHT IT WAS FIXED." THE FACILITY HAD FOUR SHOWER GURNEYS. EQUIPMENT WAS CHECKED WITH THE DIRECTOR OF ENVIRONMENTAL SERVICES (EVS) ON 11/1/11 AT 3 P.M. ALL GURNEYS, INCLUDING #4, USED ON 10/1/11 BY CNA #7, WERE CLEAN, WITHOUT RUST OR CRACKS OR SIGNS OF DISREPAIR. THE EQUIPMENT, ACCORDING TO THE EVS DIRECTOR, WAS BOUGHT WITHIN THE LAST YEAR OR TWO. MAINTENANCE ON THE GURNEYS HAD NOT BEEN DOCUMENTED, BUT THE DIRECTOR SAID ALL THE GURNEYS WERE CHECKED THOROUGHLY EVERY 8 TO 15 WEEKS AND WHENEVER A REPORT FOR SERVICE REPAIR WAS RECEIVED. THE DIRECTOR OF EVS, INTERVIEWED ON 11/1/11 AT 2:45 P.M., SAID HE EXAMINED GURNEY #4 ON 11/3/11. THE GURNEY HAD BEEN TAKEN OUT OF SERVICE ON 11/1/11 AFTER THE INCIDENT. THE DIRECTOR OF EVS SAID HE REMEMBERED THAT AT LEAST ONE PIN WAS MISSING FROM THE SIDE RAIL ON GURNEY #4, AND POSSIBLY TWO PINS WERE MISSING. CNA #1 WAS INTERVIEWED ON 11/1/11 AT 12:45 P.M. SHE STATED THAT SHE HAD CARED FOR RESIDENT #503 IN THE PAST. THE CNA SAID THE RESIDENT WAS VERY STIFF, AND THAT SHE (#1) ALWAYS HAD ANOTHER STAFF MEMBER ASSIST HER (#1) WHEN PROVIDING CARE TO RESIDENT #503. CNA #1 SAID THE RESIDENT COULD NOT TURN TURN HERSELF OR HOLD THE POSITION ONCE SHE WAS TURNED. CNA #1 ALSO REPORTED THAT CNA #7 ASKED HER TO SAY SHE WAS IN THE ROOM AND HELPED WITH THE TRANSFER OF RESIDENT #503 ON 10/1/11. CNA #1 SAID SHE WAS IN THE DINING ROOM WHEN CNA #7 WAS PROVIDING CARE FOR RESIDENT #503. CNA #1 SAID SHE TOLD CNA #7 SHE (#1) COULD NOT "LIE ABOUT IT." ACCORDING TO THE DON AND ADMINISTRATOR, INTERVIEWED ON 11/2/11 AT 10:30 A.M., CNA #7'S INITIAL STATEMENT REGARDING THE 10/1/11 INCIDENT, STATED THAT SOMEONE FROM THE ASSISTED LIVING FACILITY "SPOTTED ME" DURING THE TRANSFER OF RESIDENT #503 FROM BED TO SHOWER GURNEY. HOWEVER, THE PERSON IDENTIFIED DID NOT ASSIST WITH THE TRANSFER, PER THE DON. UNSUCCESSFUL ATTEMPTS WERE MADE TO CONTACT CNA #7. CNA #7, ACCORDING TO PERSONNEL NOTICES, WAS TERMINATED ON 10/14/11 FOR FAILING TO FOLLOW PROTOCOL FOR POSITIONING A RESIDENT DURING CARE AND ATTEMPTING TO HAVE PEERS PROVIDE FALSE INFORMATION ABOUT CARE PROVIDED. TRANSFER OF RESIDENT #503 FROM THE BED TO THE SHOWER GURNEY USING A MECHANICAL LIFT WAS OBSERVED ON 11/2/11 AT 10:10 A.M. CNA #4 AND NURSE #5 TURNED THE RESIDENT FROM SIDE TO SIDE TO PLACE A SLING UNDER THE RESIDENT. THE RESIDENT WAS DIFFICULT TO TURN BECAUSE OF HER SIZE, AND HER BODY WAS STIFF. RESIDENT #503 WEIGHED 156.5 LBS ON 11/2/11 ACCORDING TO THE WEIGHT AND VITAL SIGNS REPORT. THE RESIDENT'S HEIGHT WAS 63", ACCORDING TO THE 9/10/07 WEIGHT AND VITAL SIGNS REPORT. THE RESIDENT COULD NOT MAINTAIN HER SIDE-LYING POSITION WITHOUT SUPPORT OF A PERSON OR OTHER POSITIONING DEVICES. THE RESIDENT WAS TURNED APPROPRIATELY. THE SHOWER GURNEY WAS LOCKED DURING THE TRANSFER. LOCKS FOR THE ONE SIDE RAIL WERE CHECKED TO MAKE SURE THE PINS WERE IN PLACE. THE OTHER SIDE RAIL WAS LOCKED IN PLACE AFTER THE RESIDENT WAS ON THE SHOWER GURNEY. ( )

This citation pertains to intake numbers MI 273. Based on observation, interview, and record review, the facility failed to provide the use of assistive devices for one of 2 residents that required the assistance of a mechanical device for transfers (Resident #101), from a total sample of 6 residents, when they failed to use a required mechanical device to transfer Resident #101, resulting in a fall and a fractured left ankle. Findings Include: Resident #101 According to the face sheet, Resident #101 was originally admitted to the facility on [DATE]. Per the "MDS" (Minimum Data Set), dated 2/23/11, Resident #101 was readmitted to the facility on [DATE], scored 12/15 (moderately impaired) on "Cognitive Patterns", had "Functional Limitation in Range of Motion" (difficulty or no movement) in one "Lower Extremity (leg), and needed "Extensive assistance" with transfers. Per a facility "5 Day Report", dated 6/03/11, "On 5/28/11...(Resident #101) stated she had a concern related to the transfer that occurred in the evening of 5/27/11. (Resident #101) stated that (nurse aide #19) dropped her (Resident #101) when transferring her the previous night...According to (nurse aide #19), on 5/27/11 transferred (Resident #101) from her wheel chair to her bed in the presence of (nurse aide #20). (Nurse aide #19) stated that she (nurse aide #19) used a gait belt when she was transferred her (Resident #101)...According to (nurse aide #20), she observed (nurse aide #19) transfer (Resident #101) from her wheel chair to her bed with a gait belt...(Nurse aide #20) stated that (Resident #101) said, 'you bent me over your leg' after she was transferred...(Resident #101) explained that her foot got twisted behind (nurse aide #19) somehow while she was being transferred...On 5/28/11 and x-ray (Resident #101) left ankle was completed and stated that their was a tibial fracture...returned from the hospital with a cast on her left leg and new orders for pain medication which were initiated..." In an interview, on 7/05/11 at 10:15 AM, Occupational Therapist #17 stated Resident #101 had been a Hoyer lift, had made slow progress in Therapy since 1/31/11, but had progressed enough that, "On 5/26/11, we (Therapy department) changed (Resident #101) to a Chorus (sit-to-stand mechanical lift)". Occupational Therapist #17 stated, "Everything was communicated to the supervisors. It was an exciting day!" Occupational Therapist #17 also stated, "A two assist (transfer) with a gait belt was not what was recommended". Per "Nurse's Notes", dated 5/27/11 at 10:00 PM, "...(Resident #101) complained of pain in LLE (left lower leg). (Resident #101) stated ankle was twisted during transfer..." Per Resident #101's "Nurse's Notes", dated 5/28/11 at 12:00 AM, "Crying, complaint of pain left ankle". Per an imaging report regarding Resident #101, dated 5/28/11, "Ankle Lt (left)... Impression: 1. Soft tissue swelling and non-displaced fracture of the distal tibia (ankle fracture), 2. Mild osteoarthritis, 3. Moderate (not excessive) osteoporosis". Per the "MDS" (Minimum Data Set), dated 5/29/11, Resident #101 scored 10/15 on "Cognitive Patterns" (indicating a decline from the "MDS" dated 2/23/11), had "Functional Limitation in Range of Motion" (difficulty or no movement) in two "Lower Extremities (both legs), and needed "Extensive assistance" with transfers. Per the "Patient Information Worksheet", dated 5/26/11 at 3:19 PM, regarding Resident #101, "Transfers and Mobility: Chorus lift...Brace on right leg on at all times..." In an interview, on 7/05/11, nurse aide #18 stated she had worked at the facility for [AGE] years and regularly provided cares for Resident #101. Nurse aide #18 stated, "A Chorus lift is a ...machine we use to help stand people...We have a 24 Hour Book where we can put notes. I put it in there (Resident #101's change from a Hoyer lift transfer to a Chorus lift transfer). I was present when Therapy made her a chorus lift...came back to work on Monday and found out her leg was injured. It (Resident #101's transfer status) went back to a Hoyer...I would not transfer her with a gait belt...have not seen anyone do that...(Resident #101) told me, 'two girls put me to bed and bumped my leg'. I was devastated. (Resident #101) had just been approved by Therapy for a Chorus. (Resident #101) was so excited. I feel this has put her (Resident #101) so far back mentally and physically...I told (nurse aide #19) (Resident #101) was a Chorus lift...I remember having a conversation with (nurse aide #19)". Per Resident #101's nursing care plan, (updated 6/07/11) "Focus: At risk for falls due to functional limitations, non-ambulatory ... Interventions: ...Resident is to transfer bed to chair using Hoyer lift at all times..." Per the "PIW (Patient Information Worksheet), dated 6/30/11 at 1:42 PM, regarding Resident #101, "Transfers and Mobility: Hoyer (full body mechanical lift) lift only..." In a telephone interview, on 7/07/11 at 2:19 PM, nurse aide #19 stated she was the nurse aide who transferred Resident #101 from her wheel chair to the bed on second shift, on the evening (exact time not recorded) of 5/27/11. Nurse aide #19 stated Resident #101 did not have a sling (full body sling used with a Hoyer/mechanical lift) under her, so she asked Resident #101 how they (nursing) were transferring her and Resident #101 told her (nurse aide #19) they 'stood her up'. Nurse aide #19 stated she then called nurse aide #20 into the room. Nurse aide #19 stated, "I pivoted her (Resident #101) into bed. She (Resident #101) said something. She cries so...I stayed there a second...(Nurse aide #20) went and got her "PIW (Patient Information Worksheet/(nurse aide care guide)". Nurse aide #19 stated, "When we looked, it said she was a Hoyer lift. Nurse aide #19 stated she did not realize that Resident #19 had been changed to a Chorus transfer by the Therapy department on 5/26/11". In an interview, on 7/05/11 at 4:40 PM, nurse aide #20 stated she observed nurse aide #19 pivot transfer Resident #101 from wheel chair to bed on the evening of 5/27/11. Nurse aide #20 stated, "She (Resident #101) hollered over and over, 'You (nurse aide #19) bent me over my leg!'". Nurse aide #20 stated the PIWs are kept behind the nurses' station and she had not looked at the PIW for Resident #101 prior to the transfer performed by nurse aide #19 on 5/27/11. On 7/05/11 at 9:40 AM, Resident #101 was observed lying in bed covered with a blanket. Resident #101 was well groomed and alert. Resident #101 stated, "I have a wound plus a broken leg. They dropped me. (Nurse aide # 19) broke it. She (nurse aide #19) wasn't using proper measures with me. They (unknown) told me they fired her last week and I saw her last week. They (they) tried to tell me it (the break in leg) was from arthritis...Someone (nurse aide #20) was helping her (nurse aide #19)...She (nurse aide #19) didn't use the little one (Chorus lift) that zips you in (to bed)...I'm so disappointed my leg is broken". ( and )

This citation pertains to intake number MI 758. Based on observations, interviews and records review, the facility failed to monitor, assess and provide pressure ulcer wound care for 1 of 20 sampled residents (#119) resulting a Stage IV pressure ulcer (a full thickness wound with extensive destruction exposing muscle or bone) requiring two admissions to a local hospital for surgical debridement (removal of dead tissue). Findings include: According to the Skin Practice Guide dated 07/08, "each center establishes a designated wound management team." The Guide stated pressure ulcers are to be evaluated weekly and the findings are to be documented on the PUSH Tool or Skin Alteration Record. The Guide stated patients with pressure ulcers are to have a head-toe skin evaluation completed daily and nursing documentation included the Treatment Administration Record (TAR). During an interview on 02-15-11 at 3:10pm, RN #3 stated the facility did not have a wound treatment nurse or wound team in place to monitor or treat pressure ulcers. RN #3 stated she informed the facility management that she was not experienced with wounds and skin ulcer care. RN #3 stated the wound training that she received from the facility was a staff member handing her a tape measure and telling her to "find an ass" and measure a wound. Resident #119: According to the face sheet, Resident #119 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Hospital Transfer Sheet dated 08-22-10 documented Resident #119 was being transferred to the facility and skin condition was "intact". During the investigation, the surveyor requested in writing for the facility provide a copy of the Admission Nursing Assessment performed upon Resident #119's admission to the facility and the facility did not provide the document. The MDS dated [DATE] documented Resident #119 had no memory problems, was able to make her own decisions, had no mood or behavior issues, required two person extensive assistance with bed mobility, totally dependant on two person staff assistance with transfers using a mechanical lift and was unable to walk. Resident #119 was continent (able to hold) of urine and bowel movement, had mild pain daily in an undisclosed location. Resident #119 did not have any pressure ulcers or other skin ulcers or wounds. Skin treatments implemented per the MDS was a pressure relieving device for bed and restorative nursing care was not initiated. The MDS documented Resident #119 expressed a preference to discharge from the facility and return to the community. The MDS identified areas needing further assessment and care planning including Pressure Ulcers. The RAP (Resident Assessment Protocol) dated 08-28-10 for documented Resident #119 was a risk for pressures ulcers being triggered by the need for extensive assistance and that a care plan will address the risk for pressure ulcers. The RAP documented "Staff frequently offer and provide assistance with mobility, transfers and toileting. Staff observe skin and perform body audits. The Skin Alteration record documented Resident #119 had a "Incontinence Excoriation" (rash caused by inability to hold urine or bowel movement). The assessment dated [DATE] documented the area was located in the mid left buttock and was dark pink, intact area measuring 1.7 cm x 1.6 cm. During an interview on 02-04-11 at 11:50am, Resident #119 stated her pressure sore started months ago as a painful blister from sitting to one side in her wheelchair. A Nurse's Note dated 11-14-10 documented Resident #119's treatment to left buttock was changed and a pressure relieving cushion was applied to wheelchair. Resident #119's Pressure Ulcer Healing Chart (PUSH) dated 11-04-10 documented a score placed on a wound taking into consideration size, drainage and tissue type. Scores ranged from 0 (no ulcer, drainage or tissue damage) to 17 (being the largest in size, heavy drainage and included dead tissue). Resident #119's PUSH score was (12) on 11-04-11 and (16) on 02-09-11. Resident #119's PUSH chart did not include the weekly documentation or assessment for the weeks of 12-09-10, 12-21-10, 12-28-10, 01-04-11, 01-28-11 or 02-04-11. The MDS dated [DATE] documented Resident #119 was a high risk for developing a pressure ulcer and Resident #119 did not have any current pressure ulcers. The MDS documented interventions in place including a pressure reducing device for bed, chair and turning and repositioning. A review of Resident #119's TAR dated 10/10 documented body audits were changed from weekly to daily on 10-27-10. There were no nurse initials documenting an audit was done 10-27-10 thru 10-31-10. The 11/10 TAR did not include nurse initials documenting a daily body audit on 11-01-10, 11-02-10, 11-04-10, 11-19-10, 11-22-10, 11-27-10, 11-28-10. The 12/10 TAR did not include nurse initials documenting daily body audits on 12-19-10, 12-24-10 or 12-30-10. The TAR dated 01/11 documented body audits were initialed as being performed 3 days out of the month. The TAR dated 02/11 did not include nurse initials documenting daily body audits on 02-01-11, 02-02-11, 02-04-11 or 02-06-11. According to the Hospital Consultation Sheet dated 01-04-11, Resident #119 developed a left gluteal pressure ulcer while a resident at the facility 3 months ago and the wound continued to worsen. The Consultation sheet documented Resident #119 had a Stage IV pressure sore filled with necrotic (dead) foul smelling tissue. According to Hospital Clinical Progress Chart dated 01-06-11, Resident #119 was admitted to the hospital for an "infected pressure ulcer on the left gluteal (buttock) wound". The Progress Chart documented Resident #119's pressure ulcer was surgically debrided and a heel relief wedge applied (to raise the heels off the bed to prevent pressure ulcers from forming on heels). Resident #119's readmission nursing assessment dated [DATE] documented Resident #119 returned from the hospital from recent surgery and was scored a low risk for pressure sores. The Physical Therapy Evaluation dated 01-12-11 documentation included Resident #119 would benefit from restorative care to maintain strength and quality of life. The Comprehensive History dated 01-24-11 documented Resident #119 had a second surgical wound debridement at the hospital on 01-21-11. The History documented Resident #119's pressure ulcer was "improving" and to continue with current wound care and debridements. Review of the Clinical Record revealed Resident #119's PUSH Score increased from (13) on 01-13-11 to (16) on 02-09-11. A Nurse's Note dated 01-25-11 at 6:30pm documented Resident #119's left outer ankle had a red area of 1 cm x 1 cm and a physician's orders [REDACTED]. During an interview on 02-04-11 at 11:50am, Resident #119 was crying stated she suffered from severe pain daily ever since the pressure ulcer developed months earlier. During an observation on 02-08-11 at 2:05 pm, Resident #119 has an air mattress on her bed set on medium and Resident #119 was using her left hand as a positioning tool off her left side and her heels were not raised up off the bed. The air mattress controller had an option for alternating pressures. During the observation, Resident #119 stated her mattress is hard and uncomfortable and the Surveyor felt the mattress and agree' d that the mattress is felt hard. Resident #119 stated the setting of Medium has not changed ever since the mattress was given to her months ago. Resident #119 stated that her physician recommended a "sand bed" for the promotion of healing pressure wounds but the facility told her they don't allow them due to their risk for residents falling out of them. Resident #119 stated she has been unable to use the toilet for a bowel movement since the pressure sore developed and now goes on a pad in her bed. Resident #119 stated prior to her admission to the facility she used to check her blood sugar on a daily basis and was concerned why the facility was not. Resident #119 stated although the facility should be checking her blood sugar, she would probably refuse a painful finger stick because of not wanting to suffer any more pain than she already has. Resident #119 was tearful throughout the interview. Resident #119 stated the facility does not use any type or level of wedging device or material to position her in bed. During an interview on 02-11-11 at 12:40pm, the RD (Registered Dietician) stated Resident #119 is a diabetic and the facility should be monitoring her blood sugar levels routinely. The RD stated abnormal blood sugar levels can delay wound healing. The Patient Information Worksheet (a guide to the most current, up to date information for providing patient care) dated 02-03-11 did not include any documented plan of care for the treatment of [REDACTED]. ( )