Every finding on record at Medilodge of Cass City

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act related to abuse for two residents (R2, R3) of eight residents reviewed for abuse. Resulting in the potential for the alleged abuse to continue to occur. Findings include: Resident #2 R2 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include vascular dementia, dysphagia, altered mental status and a history of substance abuse. R2 has a brief interview for mental status (BIMS) score of zero (0) indicating severe cognitive impairment. Resident #3 R3 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include dysphagia, major depressive disorder and mild cognitive impairment. R3 has a BIMS score of zero (0), indicating severe cognitive impairment. R3 is non-verbal and will nod to yes/no questions. On 8/4/26 at 11:30am, record review of a facility investigation revealed that on 07/12/26 at 5:15pm, a staff member observed R2 in the room of R3. R2 had one hand on the outside of the brief of R2 and the other hand was under the shirt of R3 on her chest. The staff member immediately separated the two residents, redirected R2 back to his room and notified the nurse in charge that shift. After completing the investigation, the facility determined that there were negative outcomes and that due to the cognitive impairment of each resident, they could not prove willful intent on behalf of R3 and therefore could not substantiate the abuse. Record review of the MI-FRI incident form revealed that the incident was reported to the state agency on 7/20/26. On 8/4/26 at 12:22pm, an interview was conducted with Certified Nursing Assistant (CNA) J. CNA J was the staff member that witnessed the incident between R2 and R3. CNA J was asked to describe the incident he witnessed. CNA J stated that the incident occurred on 7/12/26 at 5:15pm. CNA J stated, I stepped off the hall for a quick break. When I came back, I was headed to answer the call light before R3's room, when I passed by R2's room I noticed he wasn't in there, then I went down to R2's room and observed R3 in there. CNA J stated that R2 has been going in and out of other rooms a lot, so we try to keep an eye on him to redirect him if need be. CNA J stated that R2 had been outside of R3's room earlier in the shift, but the nurse was able to redirect him back to his room. CNA J asked what he saw when observed R2 in the room of R3. CNA J stated that R2 had one hand on the brief of R2 and he had his other hand under her shirt on the general breast area. CNA J stated, I separated them and took him back to his room and then I told my nurse. CNA J' was asked if prior to this incident had he ever witnessed R2 physically touching any residents. CNA J stated no, I had not witnessed it until this time. CNA J was asked if R2 had his genitalia exposed. CNA J stated that his genitalia were not exposed.On 8/4/26 at 12:41pm, an interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked why they didn't report the incident on the day it occurred. The NHA stated, I was notified on that day, and I didn't believe there was any willful intent based on their cognition levels. The NHA stated, the police came out on 7/20/26, due to this now being an Adult Protective Services (APS) case. The NHA stated that even though there was a lack of willful intent, now with the police being involved we decided as a facility to report in good faith on 7/20/26. The NHA was asked what the facility did after reporting. The NHA stated we did a full investigation and based on the cognition levels we could not substantiate willful intent or abuse. We then moved R3 to another hall. The NHA was asked if R2 had gone in R3's room prior. The NHA stated, no, not this resident. The NHA was asked if there had been prior incidents with R2 and other residents, The NHA stated, that yes, there was a prior incident, but it was cleared through investigation. The NHA asked what the facility policy is for reporting allegations of abuse. The NHA stated, the policy is that we follow the critical pathway to see if there is willful intent, pain or mental anguish. The NHA was asked what they do after you follow that pathway. The NHA stated, we would determine if it was reportable or not, we still do med reviews, labs, and urinalysis, to see if it is reportable or not. On 8/4/26 at 12:57pm, an interview was conducted with Social Worker (SW) A. SW A was asked if R2 has any prior behaviors of being sexually inappropriate. SW A stated that it varies; he has had some behaviors in the past where he would be masturbating or have his genitals exposed. SW A' was asked if R2 had any inappropriate behaviors with other residents. SW A stated that R2 used to hold hands with another resident, it was hand holding and that was it. SW A was asked what their involvement is in the reporting process. SW A stated, I do the interviews with residents and follow up with the involved residents. SW A was asked if there were any issues with R2 since that day. SW A stated no, none that I am aware of. SW A was asked if a staff member witnesses one resident touching another resident in a private area should that be reported to the state. SW A stated that yes, it should be reported immediately and then we would investigate to determine if it was abuse or not. SW A stated that she was on vacation at the time of the incident and was not aware of it until 7/23/26 when she returned to the facility.On 8/4/26 at 1:57pm, an interview was conducted with Licensed Practical Nurse (LPN) L. LPN L was working on the day of the incident. LPN L was asked if prior to the incident had R2 had any interaction with R3. LPN L stated no, there was no interaction that day with those two or anything prior I know of. LPN L was asked what they did after the two residents were separated. LPN L stated they questioned R2 about the incident and he denied any wrongdoing, denied that he was involved and didn't know what I was talking about. LPN L stated they notified the family, physician and the NHA. LPN L was asked if they thought this incident should have been reported to the state at the time of the incident. LPN L stated yes, any allegation of abuse should be reported. LPN L was asked if R2 has had any behaviors since then. LPN L stated no, not that I am aware of.Review of the policy titled, Abuse, Neglect and Exploitation, revealed: VII. Reporting/ResponseA. The facility will have written procedures that include:Reporting of alleged violations to the administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes.a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, or

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of the premise's plumbing. Findings include: On 08/26/2025 at approximately 1:00-1:30PM during the environmental tour with the Director of Maintenance D observed drain line to water softener sitting inside drain located in B hall. 08/26/2025 at approximately 1:00-1:30PM conducted interview with Director of Maintenance D on flushing water lines, he stated that the boiler is flushed, and it's done every month. On 08/26/2025 at approximately 1:00-2:00PM record review of legionella results showed legionella positive in C utility room, result was 0.8 CFU/mL on 3/14/25. When water was retested, legionella test results was negative on 5/15/25 for C utility hall. On 08/27/2025 at approximately 8:30-9:00AM during the housekeeping tour with the Housekeeping Manager E, observed a box with supplies stacked inside the basin of the utility sink in the janitor's closet between C and D hallways. When questioned on how often the utility sink is used, the Housekeeping Manager E stated housekeeping does not use this utility sink. On 08/27/2025 at 9:00-9:25AM observed the utility sink leaking from the atmospheric vacuum breaker in the janitor's closet located between C and D hallways. Conducted an interview with the Senior Maintenance Director F on the usage of the utility sink, and he claimed that housekeeping comes in and flushes the sink weekly. But when the surveyor mentioned the Housekeeping Manager E stated that this sink was not being used by housekeeping, he then claimed the Director of Maintenance D flushes it weekly. On 08/27/2025 at 9:00-9:25AM conducted interview with Director of Maintenance D and Senior Maintenance Director F on the utility sink located between C and D hallways. When asked about the usage of the utility sink, Director of Maintenance D answered that it's not in use and there was confusion on who flushes the sink weekly. The Senior Maintenance Director F stated that it is flushed weekly, but that there are no records on flushing. On 08/27/2025 10:47 AM observed a drinking fountain between A and B hallways. The water fountain would not turn on. Conducted interview with the Nursing Home Administrator on when the drinking fountain was shut off, and she stated she wasn't sure, but it's shut off due to an ongoing construction project. According to the 2008 Cross Connections Manual on water softeners, Typical water softener installations may pose a public health threat mainly due to the waste discharge piping being terminated in a floor drain or sewage piping system thereby creating a submerged inlet cross connection. According to Controlling Legionella in Potable Water Systems from the Centers of Disease Control and Prevention dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow. and Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures regularly as needed to maintain water quality parameters within control limits. Record review of the facility's Water Management Program, it states Flush low-flow pipe runs, dead end legs and infrequently used fixtures weekly.

Based on interview and record review the facility failed to develop a comprehensive care plan for one resident (R31) of 16 residents reviewed for comprehensive care plans, resulting in the absence of a diabetic management care plan and the potential for unmet care needs. Findings include:R31 is [AGE] years old and admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, dementia, history of falling and delusional disorders. On 08/27/25 at 9:00AM, record review of the comprehensive minimum data set (MDS) dated [DATE], revealed that R31 had a diagnosis of diabetes mellitus. On 08/27/25 at 10:30AM, record review revealed an order for Lyumjev (Insulin) 2 units, subcutaneous prior to meals, hold if blood sugar (BS) is less than 120, call physician if more than 300, it is dated 10/17/24. On 08/27/25 at 10:33AM, record review of care plans revealed there was no care plan present for diabetic care of R31. On 08/28/2025 at 10:19AM, an interview was conducted with the Director of Nursing (DON). The DON was asked if R31 should have a care plan in place for diabetic management. The DON replied, yes, R31 should have one in the record. The DON stated, I'm not sure why there isn't one in the record, I will put it in right now. Review of the policy titled, Comprehensive Care Plans, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment (minimum data set). Policy Explanation and Compliance Guidelines: 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care assessment area triggered by the MDS will be considered in developing a plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.

Based on observation, interview and record review, the facility failed to ensure that dialysis communication forms were completed and included pre-dialysis and post-dialysis assessments and accurate identification of the dialysis access site for one resident (Resident #5) of 1 resident reviewed for dialysis services, resulting in the potential for a decline in condition and the inability for a prompt response to care needs.Findings include: Dialysis Resident #5 On 8/26/2025 at 9:33 AM, Resident #5 was observed in his room sitting in a wheelchair. He said he was getting ready to leave for dialysis. He said he goes on Tuesday, Thursday, and Saturday and leaves the facility about 9:00 AM. The resident showed his dialysis access site on his right chest. The dressing over the site was dated 8/20/25 and he said they would change it at the dialysis center. A record review of the Face sheet and electronic medical record, indicated Resident #5 was admitted to the facility on [DATE] with diagnoses: Diabetes, end stage kidney disease, dependence on renal dialysis, heart failure, COPD, post-polio syndrome, weakness, depression, and hypertension. The resident had a Brief Interview for Mental Status/BIMS score of 15/15 revealing full cognitive ability. The resident needed some assistance with care. A review of the physician orders for Resident #5 provided the following: Dialysis Tuesday, Thursday, Saturday, dated 7/23/2025; Monitor AV (arteriovenous) shunt site every shift for signs & symptoms of Infection/bleeding, dated 7/23/2025; Monitor new AV fistula site to left upper arm for bleeding, increased edema, or signs and symptoms of infection. Notify physician of changes, dated 8/18/2025. A review of Dialysis Communication Record for Resident #5 dated 8/26/2025 indicated the resident's dialysis access site was the Right chest CVC (central venous catheter). The physician orders identified an AV shunt, AV fistula in the left upper arm and the Communication record revealed right chest. There was a discrepancy with identifying the location of the dialysis access site. The nurses needed to the precise location to aid in assessing the resident for complications and adverse effects. Further review of the Dialysis Communication Records for Resident #5 indicated there were 2 assessment sections to be completed by the nurse. The first Pre dialysis section was for the facility to complete prior to the resident leaving for dialysis. The resident would take the form to the dialysis center and they would complete the 2nd section Dialysis and send the form back to the facility with the resident. Three of the 13 Dialysis Communication Record forms reviewed were missing assessment information such as vital signs, weights and on 8/12/2025 the facility assessment section was blank. There was nothing written for Vital signs: Blood pressure, pulse, respirations, temperature or weight, dialysis access site, pain or any problems. Further review of the 8/12/2025 Dialysis Communication Record for Resident #5, although blank on the top facility assessment section, the 2nd section completed by the Dialysis center revealed the following, Patient became unresponsive for < 1 minute d/t (due to) hypotension (low blood pressure); quickly returned baseline after intermittent fluid bolus. The resident had very low blood pressure and was administered IV fluids to elevate his blood pressure. A review of a progress note dated 8/12/2025 at 5:22 PM, Notes provided by dialysis while resident in care of dialysis center staff states resident experienced a brief unresponsive episode lasting less than 1 minute. States he quickly recovered following a few fluid boluses. Resident had not mentioned this.A review of the Care Plans for Resident #5 identified the following: (Resident #5) is at risk for infection related to dialysis port, initiated on 7/23/2025 and revised 7/31/2025, with Interventions including: Observe dialysis access site and report to Physician/NP/PA signs /symptoms bleeding or signs of infection: redness, swelling, local warmth, tenderness, date initiated 7/23/2025; Observe vital signs as indicated, date initiated 7/23/2025. The Care Plan did not provide a location of the dialysis port. On 8/28/2025 at 12:20 PM, during an interview with the Director of Nursing/DON, the resident's Dialysis Communication Record for 8/12/2025 was reviewed. The DON said the nurses should have completed the assessment information. Reviewed there was a discrepancy between the orders and Care Plan for location of the dialysis access site. The DON was asked how the nurses would assess the resident if they did not correctly have this information, she said it would be fixed. A review of a facility policy titled, Care Planning Special Needs- Dialysis, date implemented 10/30/2020 and reviewed/revised 12/28/2023 provided, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving dialysis. Comprehensive care plans will be developed. The care plan will reflect the coordination between the facility and the dialysis provider. Interventions will include, but not limited to: a. Documentation and monitoring of complications; b. Pre- and post-weights; c. Assessing, observing, and documenting care of access sites. f. Vital signs; g. Provision of medications on dialysis treatment days, such as which medications are: 1. Administered during dialysis; 2. Held prior to dialysis; 3. Given prior to dialysis; 4. Administered by dialysis staff. Nursing staff will provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day. The care plan will be reviewed routinely and as needed for effectiveness and revised as needed.

Based on interview and record review, the facility failed follow physician-ordered medication administration parameters for two residents (R31, R49) of five residents reviewed for unnecessary medications, resulting in medications being administered outside of parameters. Findings include: Resident #49: A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #49 revealed an admission to the facility on 5/21/2024 with diagnoses: Diabetes, Heart failure, Cardiac pacemaker, history of repeated falls, COPD, high blood pressure, Dementia, weakness, hypothyroidism, depression, anxiety, peripheral vascular disease, arthritis and pain. The resident has a memory problem with a Brief Interview for Mental Status/BIMS score of 3/15 and needs assistance with care. A review of the physician orders for Resident #49 identified the following: Metoprolol Tartrate Oral Tablet: Give 50 mg by mouth two times a day for CHF (congestive heart failure), Hold dose if: SBP (systolic blood pressure/top number) <110 or heart rate less than 60,” start date 7/19/2025. A review of the Medication Administration Record/MAR for August 2025 indicated Metoprolol was administered 3 times to Resident #49 when his heart rate was lower than 60: on 8/11/2025 at 8:00 AM with heart rate of 59; 8/15/2025 at 8:00 AM with heart rate of 59 and 8/27/2025 with heart rate of 58. A physician order for Hydralazine HCl tablet 10 mg: Give 1 tablet by mouth three times a day for hypertension related to Essential (primary) hypertension, Hold if SBP is less than 120 mmhg,” start date 4/30/2025. A review of the Medication Administration Record/MAR for August 2025 indicated Hydralazine was administered on 8/18/2025 at 10:00 PM with a blood pressure of 118/58. A review of the progress notes for Resident #49 indicated there were no notes addressing the low blood pressures or heart rates or why the medications were not held as ordered. Although, on 2 of the dates the resident's pulse or blood pressure was low, the resident was yelling out “Help me” 8/18/2025 and yelling out for care 8/15/2025. A review of the Care Plans for Resident #49 identified the following: “(Resident #49) has an impaired cardiovascular status related to coronary artery disease, hypertension, CHF, Hyperlipidemia, (Pace Maker),” date initiated 6/28/2024 and revised 8/22/2024 with Interventions including: “Medications as ordered; observe for side effects and report to Physician/NP/PA,” date initiated 6/28/2024; “Observe vital signs as needed,” date initiated 6/28/2024. On 8/28/2025 at 12:25 PM, during an interview with the Director of Nursing/DON, the August 2025 MAR for Resident #49 was reviewed, the cardiac medication parameters to hold were not consistently followed. It was reviewed with the DON the progress notes did not explain why the medications were not held. The DON said the nurses should have followed the orders. Resident #31: R31 is [AGE] years old and admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, dementia, history of falling and delusional disorder. On 08/27/25 at 9:00AM, record review of the comprehensive minimum data set (MDS) dated [DATE], revealed that R31 had a diagnosis of diabetes mellitus. On 08/27/2025 at 10:11AM, a review was completed of monthly medication regimen reviews performed by the pharmacy. It was revealed that on 10/12/24 there was a recommendation by the pharmacy to clarify blood sugar hold levels for an insulin order. This recommendation was completed on 10/17/24. On 08/27/25 at 10:30AM, record review revealed an order for Lyumjev (Insulin) 2 units, subcutaneous prior to meals, hold if blood sugar (BS) is less than 120, call physician if more than 300, it is dated 10/17/24. On 08/27/25 at 10:35AM, record review of the medication administration records from April 2025, May 2025, June 2025, July 2025 and August 2025 for the Lyumjev revealed that the insulin had been given outside of parameters on multiple dates: 4/11/25: BS of 109, administered 4/12/25: BS of 114, administered 4/21/25: BS of 117, administered 5/3/25: BS of 112, administered 5/3/25: BS of 117, administered 5/12/25: BS of 117, administered 5/19/25: BS of 114, administered 5/27/25: BS of 95, administered 6/3/25: BS of 107, administered 6/8/25: BS of 115, administered 6/22/25: BS of 114, administered 7/2/25: BS of 102, administered 7/26/25: BS of 100, administered 7/26/25: BS of 118, administered 8/11/25: BS of 112, administered On 08/28/2025 at 10:19AM, an interview was conducted with the Director of Nursing (DON). The DON was asked if the nursing staff should be administering insulin outside of the parameters or holding it. The DON stated the nurses should be holding it and not administering it. The only time they should ever administer insulin outside of parameters is if the physician was notified and told them it was ok to give it. Review of the policy titled, Medication Administration, revealed: Policy: Medications are administered by licensed nurses, or other stuff 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. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observation, interview and record review, the facility failed to ensure a comprehensive bowel elimination care plan, ensure documented assessments and changes for a colostomy (an opening in the abdomen through which stool from the colon can be discharged into a bag) for one resident (Resident #38) of one resident reviewed for colostomy (ostomy), resulting in a lack of overall documentation of the colostomy care with the likelihood of signs and symptoms of complications going unnoticed. Findings include: On 8/27/2025, at 8:15 AM, CNA A offered that when the ostomy bag needs changed, they let the nurses know and the nurses change it. On 8/27/2025, at 9:30 AM, a record review of Resident #38's electronic medical record revealed an admission on [DATE] with diagnoses that included Mild Intellectual Disabilities, Alzheimer's disease and Dementia. Resident #38 required assistance with all Activities of Daily Living. According to the most recent accepted quarterly Minimal Data set assessment revealed the resident had severely impaired cognition. A review of the care plan (the resident) has an alteration in elimination GI related to need for a Colostomy Date Initiated: 01/17/2025 . Goal Resident will have no signs of skin breakdown or irritation around stoma through the next review . Resident will have reduced complications related to their ostomy through the next review. Date Initiated: 01/17/2025 . Interventions . assist resident with colostomy care as needed. Date Initiated: 01/17/2025 Observe skin integrity at the stoma site and report signs of irritation, redness and/or rashes to Physician Date Initiated: 01/17/2025 Treatment to stoma site as ordered . Empty colostomy bag as needed . Observe stoma site for complications when colostomy appliance is changed . A review of the TREATMENT ADMINISTRATION RECORD 8/1/2025 - 8/31/2025 revealed colostomy- to be changed @ skin when coming off. As needed for bowel movement -Start Date- 08/17/2025 There was no documented colostomy changes. A review of the TREATMENT ADMINISTRATION RECORD for both July and June 2025 revealed no order to change the colostomy or order to assess the skin, stoma and stool consistency. A review of the physician orders revealed colostomy-to be changed @ skin when coming off. As needed for bowel movement . Start Date 8/17/2025 . A review of the following skin assessments and corresponding progress notes revealed Skin Assessment for the days of 8/24/20205 8/17/2025 8/10/2025 8/3/2025 . There were no documented assessments of the stoma, surrounding skin and stool consistency and/or color. On 8/27/2025, at 11:58 AM, the Director of Nursing (DON) was asked regarding Resident #38's ostomy care and how often it should be completed and the DON stated, every 7 days and prn (as needed). The DON was alerted there was no documentation of colostomy assessments and ostomy care every 7 days. The DON offered, they would look into and follow up. On 8/27/2025, at 1:34 PM, an observation of Resident #38's colostomy was conducted with Unit Manager (UM) B Resident #38 offered, the nurse changed it last night. The ostomy bag has liquid brown stool with the name [NAME]. The stoma appeared to be red in color and was unable to be completely visualized. UM B was asked where the nurses document the assessment of the stoma, surrounding skin and the changes of the ostomy appliance and UM B did not answer. A further review of Resident #38's electronic medical revealed a new physician order Order Date: 8/27/2025 . Change bag and flange every day shift every 7 day(s) for ostomy AND as needed. On 8/28/2025, at 11:18 AM, an observation along with Nurse C of the colostomy supplies for Resident #38 revealed a box of [NAME] appliances and a box of colostomy bags. There were no other colostomy supplies such as: stoma wipes, adhesive remover wipes, stoma powder /paste or deodorizer. Nurse C was asked if that was all the supplies and Nurse C stated, yes. According to National Institute of Health, A nurse assessing a colostomy should evaluate the stoma color and appearance, peristomal skin for irritation or breakdown, the pouching system for leaks, the ostomy output for consistency and abnormal changes, and the patient for symptoms like pain . A review of the facility provided Ostomy Care . Policy revealed it is the policy of this facility to ensure that resident who require colostomy . services receive care consistent with professional standards of practice . The frequency of pouch changes and the products required for changing ostomy devices will be noted on the resident's person-centered care plan .

Based on observation, interview and record review, the facility failed to ensure appropriate measures were in place, assessed for effectiveness and the resident was monitored to prevent constipation for one resident (Resident #56) of 1 resident reviewed for constipation, resulting in Resident #56 experiencing discomfort, restlessness and adverse reactions after not having a bowel movement for 8 days. Findings include: Change of Condition Resident #56 A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #56 was initially admitted to the facility on [DATE], 4/4/2022 and readmitted on [DATE] with diagnoses: Heart disease, Epilepsy, dysphasia, Multiple sclerosis, neuromuscular dysfunction of the bladder, high blood pressure, muscle weakness, depression, constipation and acute bladder inflammation with bleeding (8/24/2025). The MDS assessment dated [DATE] revealed the resident had a memory problem and needed assistance with care. On 8/26/2025 at 11:03 AM, Resident #56 was observed lying in bed, he rubbed his abdomen and stated, Can't go and shook his head back and forth No. Resident #56 continued to rub his abdomen, and it appeared distended. Certified Nurse Aide G entered the room and talked to the resident he nodded his head and attempted to answer her questions. She said he had not been feeling well. Certified Nurse Aide G said he had been like that recently. While in the resident's room an X-ray technician arrived and said he was there to perform an X-ray of the resident's abdomen. A review of the Tasks documentation in the electronic medical record/emr for Bowel Elimination Description for 7/29/2025 to 8/26/2025. The documentation indicated Resident #56 had several long stretches with no Bowel movement/BM: On 8/7/2025 to 8/13/2025 the resident had no BM for 5 days and a small BM on 2 days (8/7/2025 and 8/12/2025). On 8/18/2025 to 8/25/2025 the resident had no BM for 8 days. A record review of the physician orders and Medication Administration Record/MAR indicated Resident #56 was receiving Hospice care and the resident had an order for daily Fleets enemas beginning 7/15/2025 to 8/13/2025 and 8/19/2025 to 8/26/2025. The resident had also received an enema on 8/14/2025 and 8/17/2025. There was an order for one Dulcolax suppository as needed for constipation dated 5/13/2025, but there was no documentation it was given in August 2025. A new order dated 8/26/2025 said to give 2 Dulcolax suppositories that day and it was documented as given (The resident had 2 large bowel movements after receiving the 2 suppositories). There was an order for Milk of Magnesia every 72 hours as needed for Constipation if no bowel movement for 3 days. It was provided once on 8/21/2025. A record review of the 8/26/2025 abdominal X-ray results for Resident #56 identified an ileus pattern and could not rule out an obstruction. Further review of the progress notes identified the following: 8/9/2025 at 8:00 AM, an encounter notes, Nurse reports pt (patient) has recent report of ileus type pattern of bowel, has been receiving nightly enemas. Pt is now on day 3 of no BM. Treatment: give MOM (Milk of Magnesia) and an enema or Dulcolax suppository. 8/12/2025 at 8:24 AM, a Nurses Note, Resident going on day 5 with out a BM. 8/13/2025 at 8:00 AM, a Provider Progress Note, . Patient has been bloated and has not passed bowel movement for the last 3-4 days. Upon examination, patient's abdomen is distended and he has active bowel sounds. 8/24/2025 at 5:33 PM, a Nurses Note, Resident declining, has not had a bowel movement in 7 days even with enemas. There was no prior documentation that the resident had not had a bowel movement day 4 through day 6. 8/26/2025 at 9:35 AM, a Nurses Note, Resident 8 day. Abdomen rigid and distended. ON 8/27/2025 at 9:59 AM, interviewed Certified Nurse Aide/CNA G in the resident's room, she said Resident #56 had a large bowel movement yesterday (8/26/2025) on days and afternoons after he had a suppository. The CNA was asked if the staff documented if a resident ha a bowel movement or not and she said they did. The CNA was asked what the staff do if the resident had not had a bowel movement for several days, and she said they would tell the nurse. On 8/27/2025 at 10:10 AM, Nurse H was interviewed she said she had cared for Resident #56 the day before on 8/26/2025 and that day 8/27/2025. Nurse H was asked if Resident #56 had constipation and she stated, He was on our bowel list for not having a BM for 8 days. The Nurse said she had been off for several days and when she came back she was notified he was on day 8. She said she contacted the provider, and they ordered an abdominal X-ray on 8/26/2025. Nurse H was asked if the facility had a protocol for addressing a resident's constipation and she stated, After day 3 they get MOM, but Hospice may have gotten rid of that, then a suppository day 4 and an enema day 5. She said the instructions were on the Bowel list that the nurses receive each morning. She said Resident #56 was day 8 and should have received a suppository on day 4. She said for some residents' dietary would provide the residents with a bran mixture in the morning. A review of the Bowel Watch List dated 8/27/2025 indicated each hallway was listed with each resident. Beside each resident's name was a number for how many days without a BM. The majority had 0 next to their names, but one resident on another hall was noted with a 6, indicating 6 days without a BM. The list provided: L1- Monitor (no BM for 1 day); L2 Monitor/dietary will provide a bran muffin (no BM for 2 days); L3- 30 ml of MOM given on day shift (no BM for 3 days); L4- Dulcolax suppository on the night of identification no BM for 4 days); L5- Fleet enema on the night of identification (no BM for 5 days); L6- Call physician morning of identification (no BM for 6 days). Document interventions next to each resident when complete & initial. A review of the Care Plans for Resident #56 identified the following: (Resident #56) has episodes of bowel incontinence related to dementia, generalized weakness, impaired mobility, physical limitations, has supra-pubic cath in place, dated initiated 10/20/2023 and revised 10/27/2025 with Interventions including: (Resident #56) has a history of constipation, initiated power pudding along with PO (by mouth) medication to assist with irregularity, date initiated 2/26/2024; Administer medications as ordered, date initiated 10/20/2023. The interventions had not been updated since 2/26/2024. The residents' constipation had worsened.On 8/28/2025 at 10:30 AM, during an interview with the Director of Nursing/DON, she was asked about the facility bowel protocol. She said the dayshift nurses each received the bowel list in the morning to notify them if a resident had not had a bowel movement. She said the bowel protocol was also on the document and the nurses were to follow it. The DON was asked about Resident #56 being on the list on 8/26/2025 with no BM for 8 days and per the Medication Administration Record/MAR for August 2025 he did not receive MOM or a Dulcolax suppository until 8/26/2025, when he received 2 Dulcolax suppositories, per a new physician order. Reviewed the resident also had another long stretch of no BM August 7-13th. She said the residents had a history of constipation, but the nurses should follow the Bowel protocol. The DON was asked about the Bowel protocol as it waits until the resident has not had a bowel movement for 6 days prior to contacting the provider. Discussed the resident was supposed to receive an enema daily, but it was not working, and the nurses did not address the issue with the provider until the 8th day with no BM. She said they would have to work on that.

Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures for labeling, storage, and disposition of medications and medical supplies in three (A, B, and C Hall) of four medication carts, one of one medication room, and one closet containing medications and medical supplies resulting in open and undated medications, medications and medical supplies being stored in an unlocked closet, and the likelihood for unauthorized access to medications and medical supplies, and Residents to receive expired medications with altered potency and efficacy. Findings include: A tour of the C-Hall medication cart was completed with Licensed Practical Nurse (LPN) L on 8/28/24 at 12:50 PM. The following items were present in the medication cart: - Trelegy Ellipta (prescription inhaler used to treat chronic obstructive pulmonary disease and asthma) 100 mcg (micrograms)/62.5 mcg/25 mcg for Resident #18. The medication was dated as Opened 7/5/24 and included the instructions, Discard 6 weeks after opening. When queried when the medication should be discarded and the instructions on the medication, LPN L reviewed the instructions and confirmed the medication should have been disposed in August. - Open and undated Ipratropium Bromide 0.5 mg (milligram)/Albuterol Sulfate 3 mg/3 mL (milliliter) (DouNeb Treatment) Inhalation Solution foil pack for Resident #18. The package included the instructions to discard the medication within seven days of opening the foil package. When queried, LPN L reviewed the medication information and verbalized they were unaware the medication was supposed to be discarded if not used within seven days of opening. - Open and undated Trelegy Ellipta 100 mcg/62.5 mcg/25 mcg for Resident #5. - Open and undated DouNeb 0.5 mg/3 mg in 3 mL Inhalation Solution foil pack for Resident #5. - Open and undated DouNeb 0.5 mg/3 mg in 3 mL Inhalation Solution foil pack for Resident #366. - Twenty-one DouNeb 5 mg/3 mg in 3 mL Inhalation Solution vials, opened and dated 7/1/24 for Resident #50. When asked, LPN L verbalized the medication was expired as it had been open longer than seven days and would need to be discarded. - Four containers of Budesonide 1 mg/2 mL nebulizer inhalation solution for Resident #50. The medication information specified, Discard 2 weeks after opening. - Open and undated blood glucose test strips container. When queried regarding the opened and undated medications, LPN L confirmed the medications should have been dated when opened but did not provide further explanation. A tour of the B-Hall medication cart was completed on 8/28/24 at 2:54 PM with LPN E. An Arnuity Ellipta 50 mcg inhaler for Resident #37 was present in the cart. The medication was dated as opened, 7/11/24 and the instructions on the medication label specified, Discard 6 weeks after opening. When queried regarding the medication, LPN E verbalized the medication was expired and should have been disposed. On 8/28/24 at 4:02 PM, a tour of the A-Hall Medication Cart was completed with LPN G. The following items were present in the medication cart: - Two opened and undated Budesonide 1 mg/2 mL inhalation container vials for Resident # 54. When queried, LPN G verbalized the medication should have been dated when opened. - Tresiba FlexTouch (insulin degludec, long-acting insulin) Pen for Resident #2. The insulin pen was labeled as opened on 6/20/24 and expired on 8/15/24. When queried, LPN G confirmed the medication was expired. With further inquiry, LPN G was unable to provide an explanation related to the reason the medication had not been discarded when expired. On 8/28/24 at 4:21 PM, a tour of the Medication Room was completed with LPN G. A medication refrigerator was present in the medication room. The refrigerator had a freezer which had a significant build up, over one inch, of ice. When queried regarding the amount of ice and build up in the medication refrigerator, LPN G confirmed the build up but did not provide an explanation. LPN G was queried regarding the facility procedure related to defrosting and cleaning the refrigerator/freezer, LPN G revealed they did not know. Eight vials of Ativan (medication used to induce sedation and to treat anxiety and seizures) 2 mg/mL for intravenous IV) and intramuscular (IM) injection for Resident #3. The medication label stated, Discard after 12/1/23. When queried why the medication had not been discarded, LPN G was unable to provide an explanation. A green box was present in the medication room. When queried regarding the box, LPN G verbalized it was back-up medications supplied by the pharmacy. The following expired medications were noted: - Epinephrine 0.3 mg Auto-Injector Pen (medication used to treat emergency allergic reactions); Expired: 12/23 - Two vials of Narcan 0.4 mg/mL (used to reverse opioid overdose); Expired: 3/1/24 - Two Gvoke HypoPen 1 mg per 0.2 mL (used to treat low blood sugar) injection pens; Expired: 2/24. On 8/29/24 at 8:00 AM, an observation of the Linen Closet on the A-Hall of the facility was completed. The closet was unlocked and accessible to residents, visitors, and staff. The Linen Closet contained medications, wound care supplies, and other medical procedure supplies and no linens. Initial items observed in the Linen Closet included: - Arthritis cream 3-ounce (oz) tube - Lidocaine 4% cream tube - Hydrocortisone 1% Cream tube - Three Zinc Oxide Cream 15 oz - Two boxes of Medihoney (wound care gel) 0.53 oz packets - Two 2 Suture Removal kits containing scissors - Two Staple Removal kits - Multiple containers of Dimethicone skin protectant cream From 8:00 AM to 8:57 AM, multiple staff and residents were observed passing the unlocked Linen Closet containing medications and medical supplies. On 8/29/24 at 8:57 AM, an interview and tour of the A-Hall Linen Closet was completed with LPN G. When queried what the unlocked Linen Closet was used for, LPN G replied, Overstock for locked supplies. When queried why it was not locked if it contained overstock of locked supplies, LPN G was unable to provide an explanation. At 9:03 AM on 8/29/24, Supply Staff M approached LPN G and this Surveyor at the Linen Closet. Staff M revealed they use the closet to store overstock supplies. When queried regarding the closet being unlocked and the medications and medical supplies being accessible to all residents, visitors, and staff, Staff M did not provide an explanation. Staff M was asked if they had a list of all the items contained in the Linen Closet and replied they did. A copy of the list of items contained in the Linen Closet was requested. Review of Item List provided by Staff M of the medications and medical supplies stored in the unlocked Linen Closet revealed multiple different wound care dressings, including dressing impregnated with medications as well as the following medications: - Bacitracin Zinc (antibiotic ointment) - Dermafungal cream (antifungal cream) - Iodosorb gel (antimicrobial wound gel) - Dermaphor Skin Ointment - Solosite (hydrogel) wound care treatment - Triple Antibiotic Ointment - Biofreeze (topical pain relief medication) - Triad (hydrophilic) wound paste - Tucks (used for hemorrhoid pain relief) - Icy Hot (topical pain relief medication) - BenGay (pain relief cream) - Aspercreme (topical pain relief cream) - Dermaseptin ointment (barrier skin protectant) - Antifungal powder - Cornstarch powder - Dakins Solution (diluted bleach solution for wounds) - Iodine solution (topical wound care antiseptic) - Normal Saline solution - Saline Wound Cleanser - Voltaren gel (topical pain relief medication) An interview was completed with the Director of Nursing (DON) on 8/29/24 at 10:47 AM. When queried regarding the undated and opened medications/medical supplies and expired medications observed in the medication carts, the DON indicated they were aware and would address. When queried regarding the unlocked Linen Closet containing medications and medical supplies, the DON confirmed the closet should be locked. Review of facility policy/procedure entitled, Medication Storage (Reviewed/Revised: 1/30/24) revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . All drugs and biological's will be stored in locked compartments under proper temperature controls . 7. Unused Medications: The pharmacy and all medications rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels .

Based on observation, interview and record review, the facility failed to implement and operationalize processes and procedures to ensure pharmacological oversight of controlled and narcotic medications, including accurate electronic order entry, monitoring and accountability of receipt, dispensing, administration, and disposal in two of three medication carts and one of medication rooms reviewed. This deficiency resulted in expired medications as well as inaccurate controlled and narcotic medication reconciliation for five residents (Resident #3, Resident #11, Resident #31, Resident #50, and Resident #503) and the likelihood for additional medication errors, inappropriate medication use and administration, and diversion which has the potential to affect all 68 residents residing in the facility. Findings include: A tour and narcotic medication reconciliation/count of the C-Hall medication cart was completed with Licensed Practical Nurse (LPN) L on 8/28/24 at 12:50 PM. The following items were identified during the narcotic medication reconciliation/count: - Vimpat (controlled substance medication used for treatment of seizures) 10 mg (milligram)/milliliter (mL) for Resident #11. On the paper Control Substance Record for the medication, the last administered dose dated 8/28/24 at 8:00 (AM) had a line drawn through it but did not have error written. LPN L was asked if the medication was administered and revealed a different nurse was working the cart at that time. When queried regarding the time through the administration documentation, LPN L confirmed the documentation was unclear but was unable to provide further explanation. - Ativan (controlled substance medication commonly used to treat anxiety) 0.5 milligrams (mg) for Resident #39. The paper Control Substance Record for the medication specified the last administered dose was on 8/27/24 at 9:00 PM and there should be seven pills remaining in the Resident's medication blister pack. There were six pills in the blister pack. When queried regarding the discrepancy between the number of pills present in the blister pack and the number which should be present per the Control Substance Record, LPN L indicated the prior nurse may not have signed the medication out on the Control Substance Record when they administered it. A review of Resident #39's electronic Medication Administration Record (eMAR) revealed the medication was documented as administered on 8/28/24 in the morning. When queried if controlled/narcotic medications are supposed to be documented on the eMAR and the Control Substance Record at the time of administration, LPN L confirmed they are. - A Control Substance Record for Ativan 0.5 mg; quantity 30 tablets was present for Resident #50. The Ativan was not in the medication cart. When queried where Resident #50's Ativan was, LPN L went through all the controlled substance medications in the cart and stated it was not there. Resident #50 had separate Control Substance Sheet for Ativan 0.5 mg in the narcotic medication book on the medication cart. This sheet specified 30 tablets were received and 18 were left in the blister pack which accurately reconciled with the number of tablets remaining in the blister pack. The prescription information on the blister pack detailed the order was written on 8/6/24 for 58 tablets and filled on 8/7/24. - A blister pack of Xanax (controlled medication used to treat anxiety) was present in the medication cart labeled for administration to Resident #50. There was no corresponding paper Control Substance Record for this medication. When queried why there was a medication in the cart without a Control Substance Record, LPN L revealed each controlled medication should have a form but was unable to location and/or explain where the form was. The Director of Nursing (DON) was requested at this time. On 8/28/24 at 1:42 PM, the DON arrived at the medication cart. When queried regarding Resident #50 having a Control Substance Record for Ativan 0.5 mg tablets and the medication not being in the medication cart, the DON went through the medications and confirmed it was not there. When queried why Resident #50 had a blister pack of Xanax in the drawer without a Control Substance Record, the DON confirmed the medication was present with a paper Control Substance Record. The DON indicated they were unable to provide an explanation at this time but would look into it. When queried regarding expectations related to nursing staff documentation of controlled substance medication administration, the DON revealed nursing staff have to sign the medication out on the Control Substance Record, update the count, and on the eMAR. The DON was then shown the discrepancies between the Control Substance Record and blister pack for Resident #39's Ativan 0.5 mg tablets. The DON confirmed the discrepancy. The DON was then shown Resident #11's Control Substance Record for Vimpat. When queried regarding the line drawn through the written medication administration documentation meant, the DON verified the administration appeared to have been crossed out. When asked if nursing staff are supposed to write error when crossing out an administration, the DON confirmed they are. On 8/28/24 at 1:50 PM, the Assistant Director of Nursing (ADON) entered the conference room. The ADON brought Resident #39's Control Substance Record form with them and stated, I didn't sign out the Ativan. The ADON proceeded to sign and document administration of Ativan from the morning on Resident #39's Control Substance Record form. When queried if controlled medications are supposed to be signed out on the paper form and counted at the time of administration to the Resident, the ADON verbalized they are. When asked why they did not count/sign out the medication when it was administered, the ADON revealed they were busy and forgot. When queried if they had signed Resident #11's Control Substance Form for Vimpat on 8/28/24 at 8:00 (AM), the ADON confirmed they had. The ADON was then asked about the line drawn through the medication administration documentation and verbalized they administered the medication. No further explanation was provided. An interview was completed with the DON on 8/28/24 at 2:36 PM. The DON provided documentation from the pharmacy specifying 58 Xanax tablets had been sent to the facility for Resident #50 on 6/14/24. The DON stated, The Doctor ordered Xanax, not Ativan per the pharmacy. When queried if they were saying the Resident was not supposed to be getting Ativan because Xanax was ordered, the DON reiterated pharmacy told them that the Doctor ordered Xanax. When asked why Ativan was still in the drawer, if Resident #50 was not supposed to be receiving it, and why there was a blister pack of Xanax in the medication cart with no Control Substance Record form. The DON replied, Not sure. A review of Resident #50 Health Care Provider Orders and eMAR was completed with the DON at this time. Resident #50 had an active order for, Ativan Oral Tablet 0.5 mg . 1 tablet by mouth two times a day for anxiety . (Start Date: 6/19/24). The eMAR revealed the medication was documented as administered twice a day for the month of August 2024. When queried if Resident #50 was supposed to be receiving Ativan and not Xanax, the DON stated, Yes. The DON was queried again regarding the location of the blister back of 30 Ativan tablets not in the medication cart and was unable to provide an explanation. A tour and narcotic medication reconciliation/count of the B-Hall medication cart was completed with LPN E on 8/28/24 at 2:54 PM. During the narcotic medication reconciliation/count, a discrepancy was identified in Resident #31's Xanax 0.5 mg count. The Control Substance Record detailed the Resident should have 30 tablets in the blister medication pack. There were only 29 tablets present in the blister medication pack. When queried regarding the discrepancy, LPN E revealed they must have forgotten to sign the medication out on the Control Substance Record when they administered it. On 8/28/24 at 3:35 PM, the facility Administrator was observed going through the C-Hall medication cart with LPN L. When asked, the Administrator verbalized they were looking for the missing narcotic medication blister pack for Resident #50. During a tour of the Medication Room on 8/28/24 at 4:21 PM with LPN G, eight vials of Ativan 2 mg/mL for intravenous (IV) and intramuscular (IM) injection for Resident #3 were present in the refrigerator. The medication was contained in a box which was able to be removed. The medication label stated, Discard after 12/1/23. When queried why the medication had not been discarded, LPN G was unable to provide an explanation. Resident #3 resided on the C-Hall of the facility and a Control Substance Record for the medication was not present in the narcotic count book on the medication cart. When queried if the Control Substance Record for the medication was in the medication room, LPN G revealed it was not. A follow-up interview was completed with the DON on 8/29/24 at 10:47 AM. When queried regarding Resident #50's missing Ativan, the DON revealed they believed staff had utilized the Control Substance Form for Xanax when Ativan was administered. The DON provided a completed Control Substance Record for Xanax 0.25 mg for Resident #50. The form detailed 28 tablets of Xanax 0.25 mg was received by the facility on 6/14/24. When asked to clarify if they were saying nursing staff administered Ativan and documented it on the controlled substance form for Xanax, the DON confirmed. When queried why the staff would do that when it was the wrong medication and the Resident does not have an order for Xanax, the DON was unable to provide an explanation. When queried what happened to the Xanax that was delivered, the DON indicated they would need to look into it. The DON then provided a pharmacy delivery manifest detailing 58 tablets of Ativan 0.5 mg was delivered to the facility by the pharmacy on 8/7/24. A review of the dates documented on the Control Substance Forms for both the Ativan and Xanax revealed overlap in dates. When asked, the DON was unable to explain. The DON stated there were 28 missing doses of Ativan. When asked if they were able to locate the medication and clear documentation of administration and narcotic reconciliation, the DON confirmed they were not. An interview was completed with Physician Q on 8/29/24 at 2:50 PM. When queried if they were aware of the facility not being able to account for all of Resident #50's Ativan and a lack of clear narcotic medication reconciliation/documentation, Physician Q replied they were not. Resident #50's Control Substance Forms for Ativan and Xanax were reviewed with Physician Q. After review, Physician Q stated, Think need to tighten documentation. Definitely a concern. On 8/29/24 at 3:00 PM, the DON provided two blister backs of Xanax 0.25 mg containing a total of 58 tablets and labeled for administration to Resident #50. The pharmacy label and prescription number matched the prior Control Substance Form provided showing documentation of the medication. The DON stated, I think they (nursing staff) document on that sheet (pointed to controlled form for Xanax) because the Xanax blister packs are full. When queried why the documentation dates on the Control Substance Forms for the Xanax and Ativan overlapped, the DON was unable to explain. When queried regarding the importance of controlled medication reconciliation, the DON verified concerns. The DON was asked if staff count and reconcile controlled/narcotic medication counts each shift and stated they do. When asked how there a blister pack of Ativan could be missing and/or how staff could document the incorrect medication and it not be identified during reconciliation, the DON was unable to provide an explanation. During medication pass observation on 8/29/24 at 2:07 PM for Resident #503 with LPN E, the nurse was observed removing Oxycodone (narcotic medication for severe pain) IR (Immediate Release) 10 mg tablet for administration to the Resident while the eMAR specified the Resident was supposed to receive Oxycodone HCL (Hydrochloride) 10 mg. LPN E was stopped prior to administration of the medication. A review of Resident #503's narcotic/controlled medications was completed, and LPN E verbalized Resident #503 only had Oxycodone IR 10 mg available. A review of the Resident's controlled substance blister pack medications revealed the Resident had received 10 doses of Oxycodone IR 10 mg when the ordered medication was Oxycodone HCL 10 mg from 8/27/24 to 8/29/24. LPN E indicated they would speak to the Physician and obtain the correct medication for administration. At 3:33 PM on 8/29/24, LPN E entered the Conference Room and stated, Oxy (Oxycodone) IR order is haunted. LPN E proceeded to demonstrate that whenever Oxycodone HCL or Oxycodone IR was ordered, the Electronic Medical Record (EMR) automatically changed the medication order to Oxycodone HCL. When queried, LPN E revealed they called the pharmacy who confirmed the problem with order and said they would look into it. When queried how no one had noticed and/or identified the concern previously, an explanation was not provided. Review of facility policy/procedure entitled, Controlled Substance Administration & Accountability (Reviewed/Revised: 10/26/23) revealed, 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 . will have safeguards in place in order to prevent loss, diversion . 3. Controlled substances must be counted upon delivery. The nurse receiving the delivery, along with the person delivering the medication order, must count the controlled substances together . 4. If the count is correct, a control count sheet which accompanies the medication will be placed in the controlled substances binder for the designated medication cart . The control count record should contain: a. Name . b. Name and strength of the drug; c. Quantity received; d. Number on hand . k. Signature of person receiving medication; and l. Signature of nurse administering medications . 11. Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together . must document and report any discrepancies .

Based on observation and record review, the facility failed to perform hand hygiene and ensure proper Personal Protection Equipment (PPE) (gown, gloves) for one resident (Resident #19), resulting in the likelihood of contamination during wound care and incontinence care and the spread of infection. Findings include: Resident #19: On 8/27/24, at 3:30 PM, a review of Resident #19's electronic medical record revealed an admission on 8/01/2024 with diagnoses that included laceration of the cerebellum with loss of consciousness, impaired gastrointestinal status requiring enteral feeding and subdural hemorrhage. Resident #19 required extensive assistance and had severely impaired cognition. A review of Physicians orders revealed an order for . Enhanced barrier precautions . Active Start Date 8/1/2024 . On 8/29/24, at 10:01 AM, an observation along with CNA P and CNA O of Resident #19's skin who required incontinence care. CNA O assisted with incontinence care with gloved hands. With the same gloved hands, CNA O entered their pocket and pulled out a roll of clear garbage bags for use. Nurse G entered Resident #19's room and donned gloves without performing hand hygiene. Nurse G then donned a gown with their gloved hands. Nurse G set up wound care supplies and with the assistance of CNA O and CNA P positioned the resident. Nurse G removed the old dressing cleansed the area with the same gloves. Nurse G then applied the new dressing on Resident #19's wound on their coccyx area with no change of the dirty gloves and hand hygiene. 37668

This Citation pertains to Intake Numbers MI00134661 and MI00142794. Based on observation, interview and record review, the facility failed to provide a functional call light in a timely manner for two residents (Resident #9, Resident #30), resulting in delayed staff response to the residents' needs and feelings of frustration and worry. Findings include: Resident #9: On 8/27/24, at 11:23 AM, Resident #9 was resting in bed. There was an approximate 4-inch by 6-inch hole in the wall where the call device was once housed. Resident #9 stated it had been broken for about 4 days and that they were given a handheld bell to ring for help. Resident #9 rang the bell as loud as they could for 10 seconds. No staff came. Resident #9 offered that they ring it but often wait for long periods of time as much as an hour. The television (TV) in the room was audibly loud. The roommate (Resident #30) was resting with their eyes closed and the only remote to the TV was on their nightstand. Resident #9 rang the handheld bell again for 15 seconds with no staff response. On 8/27/24, at 11:29 AM, There were two staff members seen in the hallway near Resident #9's room. They were asked if they heard a ring from the handheld bell and both offered, No. On 8/27/24, at 11:34 AM, Resident #9 rang the handheld bell for 30 seconds long with no staff response. Resident #9 offered they keep working the bell as the staff don't hear it. Resident #9 was asked if they had chest pain or had trouble breathing what would happen if the staff didn't respond to the bell and Resident #9 offered, I'd probably die. At 11:36 AM, Resident #9 rang the bell for 35 seconds this time. Two staff members walked by the doorway and did not enter the room. On 8/27/24, at 11:40 AM, CNA N entered Resident #9's room for assistance. CNA N was asked if that was the first time they had heard the handheld bell ringing and CNA N offered, yes. CNA N was asked if they knew how long the call light had been broken and CNA N offered, at least a couple days. Resident #9 further offered that they ring the handheld bell, wait for 15 minutes and if nobody answers they ring it again. Resident #30: On 8/27/24, at 4:34 PM, a record review along with the Administrator of the last weeks list of maintenance fixes was conducted. The call light for Resident #9's room was not on the list. The Administrator was asked if there had any report of broken call lights and the Administrator stated, just (Resident #30's) and that he had pulled it out of the wall that morning. On 8/27/24, at 4:40 PM, an observation of Resident #9 and 30's broken call light was conducted along with the Administrator. Resident #30 was now awake. Resident #30 was asked how long their call light had been broken and Resident #30 stated, about two days. The Administrator responded that it was reported that it was broken that day. The Administrator was alerted that both Resident #9 and 30 along with a staff member offered that the call light had been broken for two days and the Administrator offered well they have bells. The Administrator was alerted that Resident #9 rang the handheld bell on three separate measured times before staff responded. On 8/27/24, at 4:50 PM, The Administrator offered that the Maintenance lead was replacing the call light in Resident #9 and Resident #30's rooms. On 8/28/14, at 11:00 AM, a record review of both Resident #9 and Resident #30's electronic medical records revealed both residents were cognitively intact. On 8/28/24, at 8:50 AM, an observation of the call light in Resident #9 and 30's room revealed a functioning replaced call light where the empty hole was.

Based on observation, interview and record review, the facility failed to ensure the provision of hygiene and daily care for two residents (Resident #28, and Resident #48) of four residents reviewed, resulting in unkept and long toenails, foul odors, and exposed, visible stool on the bedside commode in Resident #48's room. Findings include: Resident #28: On 8/28/24 at 9:27 AM, Resident #28 was observed in their room. The Resident was in bed, positioned on their back with their toothbrush in place on the overbed table in front of the Resident. Upon entering the room, the room temperature was immediately noted to be uncomfortably hot and humid. A fan was present in the room, but there was not an air conditioning unit in the window. An uncovered, pink colored bedpan was observed sitting on top of the garbage can next to the Resident's bed. An interview was completed at this time. When queried regarding the level of assistance they need for transfers and ambulating, Resident #28 revealed staff transfer them using a mechanical lift. A wheelchair was observed in the room. When queried if they are able to brush their teeth in the bathroom when sitting in their wheelchair, Resident #28 revealed they never use the bathroom because it stinks. Upon request, this surveyor entered the bathroom attached to the Resident's room. Upon opening the bathroom door, a foul and pungent, overwhelming odor was immediately noted which permeated into the room. The bathroom was contained a toilet and sink and was shared with another resident room. Upon exiting the bathroom, Resident #28 requested the door be shut. When queried, Resident #28 verbalized the bathroom always sticks horribly and they cannot stand the smell. Resident #28 revealed they were unsure of the reason for the odor. At 9:34 AM on 8/28/24, Certified Nursing Assistant (CNA) A entered Resident #28's room to remove the Resident's toothbrush. While they were in the room, CNA A was asked if they noticed the odor in the bathroom. CNA A confirmed the pungency of odor and stated, It's urine. CNA A revealed they take Resident #28's toiletry items to a sink in a different room to clean them because the odor in the bathroom is so strong and it bothers Resident #28. When queried why the odor was present, CNA A indicated the resident in the adjoining room is incontinent at times. No further explanation was provided. Review of Resident #28's Electronic Medical Record (EMR) revealed the Resident was admitted to the facility on [DATE] with diagnoses which included heart failure, respiratory failure, depression, and weakness with bilateral foot drop (inability to raise the front part of the foot and the toes point away from the head). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, displayed no behaviors, and required maximum to total assistance to complete Activities of Daily Living (ADL) with the exception of eating and oral hygiene. On 8/29/24 at 9:10 AM, Resident #28 was observed in their room. The Resident was in bed, positioned on their back and the Director of Nursing (DON) was in the room. The DON was observed entering the Resident's bathroom and the pungent odor was immediately noted and became stronger closer to the bathroom. When queried regarding the odor, the DON revealed they did not think it was strong. When asked, Resident #28 revealed they were able to smell it from their bed. No further explanation was provided by the DON. Resident #48: On 8/27/24 at 2:38 PM, Resident #48 was observed sitting in a recliner in their room. There was no bed in the room. A bedside commode was sitting approximately four feet from the recliner and was visible from the hallway of the facility. The smell of feces was present in the room. The bedside commode was uncovered, and a dried brown colored substance was on the seat of the commode. Stool was present in the commode bucket. An interview was completed at this time. When queried if they or their roommate utilized the commode, Resident #48 indicated it was their commode and revealed they are incontinent and wear a brief. Resident #48 stated, I only use my commode when I overfill my brief and they (staff) have to change everything. Record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, falls, gout, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required maximum to total assistance to complete ADL's with the exception of set-up/clean-up assistance with eating and oral hygiene. On 8/29/24 at 9:50 AM, Resident #48 was observed sitting in the recliner in their room. The brown substance and stool remained on the uncovered bedside commode. An interview was completed with Certified Nursing Assistant (CNA) D on 8/29/24 at 9:56 AM. When queried regarding the commode in Resident #48's room, CNA D confirmed Resident #48 used the bedside commode on occasion. CNA D was asked if they were assigned to provide care to Resident #48 and confirmed they were. When asked if they had been in the Resident's room today, CNA D revealed they had. When queried regarding the substance and bowel movement in/on the bedside commode, CNA D indicated they would go look. CNA D entered Resident #48's room and exited. When asked if they saw the commode, CNA D replied, Yeah, I'm going to go clean it. CNA D was asked what the substance was and replied, Poop. When queried regarding the bedside commode being in the same condition when observed on 8/27/24 at 2:38 PM. CNA D was unable to provide an explanation. Review of facility policy/procedure entitled, Activities of Daily Living (ADL) (Reviewed: 12/23) revealed, 3. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good . grooming, and personal and oral hygiene .

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5% when three medication errors were observed from a total of 25 opportunities for three residents (Resident #56, Resident #501, and Resident #503) of five residents reviewed. This deficient practice resulted in a medication error rate of 12% and the potential for the risk of adverse medication effects and decreased medication efficacy. Findings include: Resident #56: On 8/28/24 at 12:45 PM, medication pass observation for Resident #56 was completed with Unit Manager Licensed Practical Nurse (LPN) L. LPN L prepared Valporic Acid (Depakote- used to treat seizures and as a mood stabilizer) oral solution (liquid) 250 milligram (mg)/5 milliliter (mL) for administration to the Resident. The ordered dose was 20 mL (1000 mg). LPN L was observed holding the medication cup in their hand and while dispensing the liquid Valporic Acid into the cup. LPN L then set the medication cup on the top of the medication cart. LPN L did not confirm the accuracy of the amount of the medication on a flat surface. The amount of Valporic Acid in the medication cup, while on the flat surface, was 22 mL (1100 mg). Prior to administering the Valporic Acid, LPN L was asked to stop. When queried how much Valporic Acid Resident #56 was supposed to receive per Health Care Provider (HCP) order, LPN L revealed 20 mL. LPN L was then asked to confirm the amount of Valporic Acid in the medication cup with it placed on a flat surface. LPN L confirmed the medication in the medication cup was 22 mL. LPN L was asked why they did not dispense the medication into the medication cup with the cup placed on a flat surface for accuracy, an explanation was not provided. Resident #501: A medication observation was completed on 8/29/24 at 1:30 for Resident # 501 with LPN G. LPN had reconstituted Aztreonam (antibiotic) 1 gram (g) for Intramuscular (IM) injection with 1 mL of sterile water. When queried why they reconstituted the medication with 1 mL of sterile water, LPN G replied, One gram is 1 mL. LPN G was stopped and asked to review the medication package insert for medication reconstitution instruction prior to administration. The package insert for Aztreonam specified the antibiotic was to be reconstituted with 3 mL of sterile water for administration. With further inquiry, LPN G revealed they were unaware that reconstitution instructions were included on the medication inserts. When queried if they had provided care to the Resident previously, LPN G confirmed they had. LPN G then revealed they had administered the medication previously but did not reconstitute the medications prior to administering it. When asked who reconstituted the medication, LPN G replied, (LPN E). No explanation was provided when queried why they did not reconstitute the medication themselves prior to administration. Resident #503: A medication pass observation was completed on 8/29/24 at 2:07 PM for Resident #503 with LPN E. LPN E was observed removing Oxycodone (narcotic medication for severe pain) IR (Immediate Release) 10 mg tablet for administration to the Resident. The Resident's Medication Administration Record (MAR) specified the Resident was supposed to receive Oxycodone HCL (Hydrochloride) 10 mg. LPN E was stopped prior to administering the medication. When queried if the Resident was supposed to receive Oxycodone HCL 10 mg or Oxycodone IR 10 mg, LPN E reviewed the HCP order and MAR and confirmed the order was for Oxycodone HCL 10 mg and they were going to administer Oxycodone IR 10 mg. LPN E proceeded to go through the narcotic/controlled medications and verbalized Resident #503 only had Oxycodone IR 10 mg available. A review of the Resident's controlled substance blister pack medications revealed the Resident had received 10 doses of Oxycodone IR 10 mg when the ordered medication was Oxycodone HCL 10 mg from 8/27/24 to 8/29/24. A policy/procedure related to medication administration was requested from the facility Administrator on 8/28/24 at 3:32 PM but not received by the conclusion of the survey.

Based on observation, interview and record review, the facility failed to store and care plan Continuous Positive Airway Pressure (CPAP) masks appropriately, administer oxygen per physicians' orders and provide appropriate water for the CPAP machine for three residents (Resident #22, Resident #23, Resident #67) of three residents reviewed for Oxygen/CPAP use, resulting in the likelihood of infection and abnormal oxygen levels. Findings include: Resident #22: On 8/27/24, at 8:38 AM, Resident #22's CPAP mask was face down uncovered resting on their nightstand. On 8/27/24, at 3:15 PM, a record review of Resident #22's electronic medical record revealed an admission on 07/29/2024 with diagnoses that included Obstructive Sleep Apnea, Diabetes Mellitus and Traumatic Subdural Hemorrhage. A review of the Physician orders revealed CPAP 14/5 Rate . at bedtime . Start Date 7/30/2024 . A review of the care plan revealed no care plan for the CPAP machine and need. Resident #67: On 8/27/24, at 8:38 AM, Resident #67's CPAP mask was resting face down uncovered on their nightstand. On 8/28/24, at 8:31 AM. Resident #67 was in their wheelchair. Their CPAP mask was covered and stored on their nightstand. There was 1 gallon of purified water with a small amount missing. There was 1 gallon of distilled water with a small amount missing. Resident #67 was asked why they had the two different types of water and what did they use it for, and Resident #67 offered that the facility provided the purified water but couldn't use it in their CPAP machine because it had minerals in it. Resident #67 further offered that their wife brought in the distilled water the evening before. 37668 Resident #23: On 8/27/24 at 4:27 PM, Resident #23 was observed in their room. The Resident was in bed, positioned on their back with their eyes closed. Nasal Cannula (NC) oxygen administration tubing was laying on the Resident's chest and not in their nose. The oxygen concentrator was on. Record review revealed Resident #23 was most recently admitted to the facility on [DATE] with diagnoses which included respiratory failure, pulmonary fibrosis (scarred and damaged lung tissue), heart failure, falls, dementia, and Alzheimer's disease. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required maximum to total assistance to complete all ADL's with the exception of eating. The MDS further detailed the Resident received oxygen therapy. Review of Resident #23's Health Care Provider orders in the Electronic Medical Record (EMR) revealed the order, Oxygen: Run @ [2]L (liters)/Min via NC . Continuous to keep Oxygen saturation above 90% every day and night shift . Review of Resident #23's EMR revealed a care plan entitled, (Resident #23) has an impaired pulmonary/respiratory status related to pulmonary fibrosis (Initiated: 10/20/23; Revised: 10/30/23). The care plan included the intervention, Oxygen as ordered 2L NC continues (Initiated: 10/20/23; Revised: 10/30/23). On 8/29/24 at 9:50 AM, Resident #23 was observed in their room in bed. The Resident was positioned on their back with their eyes were closed. Resident #23 was receiving oxygen via NC at 1.5 L/minute. An interview was completed with Licensed Practical Nurse (LPN) L on 8/29/24 at 10:04 AM. When queried regarding Resident #23's oxygen therapy, LPN L verbalized the Resident was receiving oxygen at 2L/minute continuously. When queried regarding the Resident's oxygen administration rate currently being set at 1.5L/min, LPN L stated, Okay, I will go fix it. LPN L proceeded to go Resident #23's room and return to the nurses' station. When queried, LPN L confirmed they corrected the Resident's oxygen flow delivery rate. No further explanation was provided. Review of facility provided policy/procedure entitled, Oxygen Administration (Reviewed/Revised: 10/26/23) revealed, Policy . 1. Oxygen is administered under orders of a physician .

Based on observation, interview and record review, the facility failed to ensure positioning and follow care-planned interventions during enteral feeding for two residents (Resident #19, Resident #50) of two residents reviewed for enteral feeding assistance, resulting in the likelihood of aspiration and/or enteral tube malfunction. Findings include: Resident #19: On 8/27/24, at 10:51 AM, Resident #19 was resting in bed scooted down slightly sideways in their bed which was approximately 20 degrees. Their tube feeding was not hooked up. They did not have on an abdominal binder. On 8/27/24, at 12:01 PM, Resident #19 was in the same position in their bed. Their tube feeding was hooked up and running. They did not have on an abdominal binder. On 8/27/24, at 3:30 PM, a review of Resident #19's electronic medical record revealed an admission on 8/01/2024 with diagnoses that included laceration of the cerebellum with loss of consciousness, impaired gastrointestinal status requiring enteral feeding and subdural hemorrhage. Resident #19 required extensive assistance and had severely impaired cognition. A review of the care plans revealed the following interventions: ABD (abdominal) binder on at all times Date Initiated: 08/14/2024 Keep head at 30 degrees at all times during tube feeding and for 30 min post feeding completion. Date Initiated: 08/21/2024 On 8/28/24, at 8:35 AM, Resident #19 was sitting in their wheelchair. They had on an abdominal binder. On 8/28/24, at 4:00 PM, Resident #19 was resting in their bed scooted down in the bend of the bed with their head nearly flat with their tube feeding hooked up and infusing. On 8/28/24, at 4:12 PM, Resident #19 was in the same position. Two staff members entered the room and assisted the resident with repositioning in their bed. Nurse E provided that the resident often needs repositioning. On 8/29/24, at 4:06 PM, Resident #19 was resting in their bed scooted down to the bend in the bed with their head nearly flat with an approximate elevated degree of 15. 37668 Resident #50: On 8/27/24 at 4:19 PM, an observation occurred of Resident #50 in their room. The Resident was in bed, positioned on their back with their head elevated between approximately 20 and 25 degrees. Jevity 1.5 CAL enteral feeding solution at 70 milliliters (mL) per hour with a 200 mL flush every two hours was infusing via pump. An orange magnet device to measure the degree of elevation of the head of bed was present on Resident #50's bed. The measurement device stated the head of Resident #50's bed was elevated 24 degrees. Resident #50 was covered with a blanket from the chest down. Both of their hands and wrists appeared contracted with their hands bend inwards towards their inner arm and their fingers at different angles. When spoke to, Resident #50 made eye contact but did not provide meaningful verbal responses and made non-intelligible sounds. Resident #50 had a moist sounding cough, and their breathing was audible and moist sounding. Record review Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included respiratory failure, gastrostomy (feeding tube), cognitive communication deficit, and [NAME] encephalopathy (life threatening acute neurological condition characterized by loss of muscle coordination and balance, eye twitching/spasms, and confusion). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood, had impaired Range of Motion (ROM) in both their upper and lower extremities, and was totally dependent upon staff for completion of Activities of Daily Living (ADL).

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure a thorough investigation, accurate documentation, and implementation of meaningful interventions for fall prevention for two residents (Resident #16 and Resident #23) of two residents reviewed for falls, resulting in a lack of accurate Minimum Data Set (MDS) documentation, comprehensive analysis of falls, a lack of updated and meaningful interventions to prevent falls, and the likelihood of unnecessary pain and injury. Findings include: Resident #16: On 08/28/24 at 9:01 AM, Resident #16 was not in their room. Resident #16's bed was observed to have bilateral, half-length side rails in place. The side rails were very loose and moved several inches with pressure. At 10:37 AM on 8/28/24, Resident #16 was not in their room. Record review revealed Resident #16 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included [NAME] encephalopathy (life threatening acute neurological condition characterized by loss of muscle coordination and balance, eye twitching/spasms, and confusion), weakness, Transient Ischemic Attack (TIA- mini stroke), schizoaffective disorder, bipolar disorder, weakness, and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to substantial assistance for transferring, dressing, and toileting. The MDS detailed the Resident had no falls. Review of the facility provided CMS-802 Resident Matrix Form revealed Resident #16 did not have any falls at the facility. Review of Resident #16's Electronic Medical Record (EMR) revealed the following documentation: - 3/28/24 at 8:35 AM: Nurses' Notes . Patient reported to therapy . had a fall in bathroom and got themselves up . no injuries noted . - 3/28/24 at 9:13 AM: Fall- Initial . Date of Fall: 3/28/24 . Most Recent O2 sats . 100.0 (%). Date: 3/23/24 at 9:42 . Most Recent Blood Pressure . 122/70 . Date: 3/26/24 at 9:47 PM . What was resident doing prior to the fall? Self-reported fall. Last seen by nurse wheeling in hall back to bedroom after eating breakfast New intervention(s) implemented post-fall . Patient educated on call bell use and need to wait for assistance . - 3/28/24: Health Care Provider Telehealth - Asynchronous . Patient self-reported a fall in bathroom to therapy, denied fall when asked by this nurse. No injuries noted per nursing . - 3/29/24: Health Care Provider Progress Notes . Acute . Patient is observed in wheelchair . reports self-transferred in the bathroom because everyone was busy and (they) had to go. Patient denies injury or hitting head . Repeated falls: No injury . - 4/29/24 at 10:24 PM: Nurses' Notes . Resident observed on floor lying on right side facing bathroom door with no injury's noted at this time. Resident stated 'I fell asleep and fell out of chair because I'm tired' . - 4/29/24 at 10:28 PM: Fall- Initial . Date of Fall: 4/29/24 . Last time toileted prior to fall: 8:00 PM . What was Resident doing prior to fall? In wheelchair sleeping . New Intervention implemented post-fall . Describe change in footwear: Need gripper socks on at all time . - 4/29/24: Health Care Provider Telehealth - Asynchronous . Notified resident was observed on the floor. No injury . - 4/30/24: Progress Notes . Visit Type: Acute . Fall . seen for F/U after a fall last night. (Resident #16) started leaning forward and landed on the floor face first . Unspecified fall, initial encounter: No Obvious Post-Fall Injury. Will have Psych Review Meds . - 7/7/24: Telehealth - Asynchronous (Provider Note) . Unwitnessed fall this morning . was found on the floor by the aid (Certified Nursing Assistant [CNA]) and was not sure how long had been on the floor. (Resident #16) had urinated on self. Neurochecks initiated . is on Plavix (antiplatelet medication used to prevent blood clots) and unsure if hit head. (Blood Pressure) 87/52 (hypotensive - low). Left shoulder pain 7/10 after was back in bed, but moving back to bed was in quite a bit of pain. STAT x-ray ordered of Left shoulder . - 7/8/24 at 4:53 AM: Fall- Initial . Date of Fall: 7/7/24 . Most Recent Blood Pressure . 126/76 (mmHg) Date: 7/8/24 at 12:25 AM . Describe new physician orders: X-ray of Left Forearm & Shoulder . Last time resident was toileted prior to fall: 7/7/24 at 6:00 AM . What was resident doing prior to the fall? .was getting ready for breakfast . Does the resident have new complaint of pain? No . New intervention(s) implemented post-fall . Staff to assist resident with AM care . Additional comments: No change in mentation with no new injuries noted. No c/o pain or discomfort. Call light within reach . - 7/9/24: Health Care Provider Progress Notes . Visit Type: Acute . Fall Several Days Prior . seen for F/U (follow up) after a fall recently. Pt started leaning forward and landed on the floor face first . Unspecified fall, initial encounter: No Obvious Post-Fall Injury. Cont. Fall Precautions . On 8/29/24 at 9:54 AM, Resident #16 was observed in their wheelchair in the hallway of the facility. The Resident's right arm was positioned on an additional padded rest on the wheelchair, and they were using their legs to propel themselves towards their room. The Resident was slid down in their wheelchair with their bottom not positioned at the back of the wheelchair. When asked questions, Resident #16 murmured but did not provide a clear response. Review of Resident #16's facility provided Incident and Accident (I and A) forms revealed the following: - 3/28/24 at 9:04 AM: Unwitnessed Fall . Resident's Room . Therapy notified this nurse patient self-reported a fall in bathroom. Stated . got themselves up but did not tell nurse or CNA . Patient denies unwitnessed fall to this nurse . Root Cause: Self transfer to bathroom in room and didn't use call light. Educated to use call light and wait for assistance. Resident had shoes on . Predisposing Environmental Factors . None . Predisposing Physiological Factors . Recent change in Medications/New Medications . Gait Imbalance . Predisposing Situational Factors . Ambulating without Assist . - 4/29/24 at 10:00 PM: Observed on Floor . Resident's Room . Nurse observed Resident on floor lying on right side facing bathroom door . Resident stated was sleeping in chair . Was this incident witnessed: Y . Root Cause: Resident fell asleep in wheelchair and fell forward out of wheelchair. Intervention: Sleep diary has been initiated, psych services to review medications . Predisposing Environmental Factors . None . Predisposing Physiological Factors . None . Predisposing Situational Factors . None . Statements: (Licensed Practical Nurse [LPN] I) I was called to resident room and observed resident lying on the floor . - 7/7/24 at 7:45 AM: Unwitnessed Fall . Resident's Room . Aide came and got nurse stating that she could not open residents door due to them laying in front of it. Went in through the bathroom, resident laying on left shoulder/side, wheelchair behind them and side table against the wall by the door, resident stated ' .was trying to pick something off the floor and fell , did not hit head, shoulder 7/10 pain, didn't know how long was on the floor, did have incontinent episode' . resident own person asked if wanted to be sent out or get x-ray in house. Resident stated that wanted to stay in room. Stat x-ray ordered . Resident getting up for the morning, got in wheelchair and went to bedside table by door. Went to pick something off the floor and leaned to far forward and fell . Landed on left shoulder/side, couldn't get up or reach call light . Immediate Action Taken . provider ordered xray as resident c/o (complain of) pain . Root Cause: Resident has deficits in balance, vision, and has impulsive behaviors. Intervention: Xray on left shoulder, educated resident to use call light for assistance before attempting task, use their reacher when trying to obtain items out of reach. Resident continues on therapy . Predisposing Environmental Factors . Poor lighting . Predisposing Physiological Factors . Gait Imbalance . Predisposing Situational Factors . None . Statements: (LPN E) . Resident was inside door when . arrived to room with CNA . did not want to go to hospital to be CT scanned . (CNA F) . (Went) to check on resident . normally up early. I tried opening the door and couldn't. I saw the resident legs, went though the bathroom, (Resident #16) was laying on the floor . Review of pain documentation in Resident #16's EMR on 7/7/24 revealed the Resident's pain level was 8 out of 10 at 7:51 AM and 7 out of 10 at 2:48 PM. Review of Resident #16's care plans revealed a care plan entitled, (Resident #16) is at risk for falls/injury related to decreased strength and endurance, generalized weakness, history of falls (Initiated and Revised: 8/9/23). The care plan included the interventions: - (Resident #16) educated to use call light and wait for assistance, staff to offer toileting with every face-to-face interaction (Initiated: 3/28/24; Revised: 4/12/24) - Encourage resident to use call light and wait for assistance and use of grabber (Initiated: 7/7/24) - Encourage/educate (Resident #16) to use call light (Initiated: 8/9/23; Revised: 4/3/24) - Frequent reminders not to ambulate without assist (Initiated: 8/23/23) - MD medication review, psych medication review, labs, sleep diary initiated (Initiated: 4/30/24) - Bed enablers to help promote bed mobility and promote independence (Initiated and Revised: 8/9/23) - Encourage (Resident #16) to wear glasses; assist with applying as needed (Initiated and Revised: 8/9/23) - Ensure (Resident) room is free from accident hazards . (Initiated and Revised: 8/9/23) - Place call light within reach (Initiated: 8/9/23) Another care plan entitled, (Resident #16) has an ADL self-care performance deficit related to history of TIA, weakness (Initiated and Revised: 8/9/23) in their EMR. This care plan included the interventions: - Toileting: 2 person assist (Initiated: 8/9/23; Revised: 7/12/24) - Transfers: 2 person assist (Initiated: 8/9/23; Revised: 7/10/24) - Encourage to use call light when assistance is needed (Initiated and Revised: 8/9/23) Resident #16 did not have a care plan and/or intervention in place related to gripper socks and/or non-slip footwear. Resident #23: On 8/27/24 at 4:27 PM, Resident #23 was observed in their room. The Resident was in bed, positioned on their back with their eyes closed. A wheelchair with leg rests in place was positioned next to the Resident's bed. Resident #23's room was noted to be the last room at the end of the hallway and the furthest from the nurses' station. On 8/28/24 at 9:00 AM, Resident #23 was observed sitting in their wheelchair in their room. The Resident's legs were positioned on the wheelchair leg rests and an overbed table was in place in front of them. The wheelchair was facing away from the door, toward the room divider curtain. Resident #23's call light was not within their reach. While in a resident room across the hall on 8/28/24 at 9:09 AM, a Resident was heard yelling for help. Upon approaching Resident #23's room, the Resident was observed laying on the floor between the bed and the wheelchair. The Resident's head was on the floor, towards wall with the room door and away from the room divider curtain. The wheelchair was in the same place as prior observation at 9:00 AM and the bilateral footrests remained in place. The call light was not visualized. Record review revealed Resident #23 was most recently admitted to the facility on [DATE] with diagnoses which included respiratory failure, heart failure, falls, dementia, and Alzheimer's disease. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required maximum to total assistance to complete all ADL's with the exception of eating. The MDS further revealed Resident #23 had one fall with injury since their prior MDS assessment. Review of the facility provided CMS-802 Resident Matrix Form detailed Resident #23 was receiving Hospice services and did not have any falls at the facility. Review of Resident #23's EMR revealed the following documentation: - 10/13/23 at 10:24 PM: Nurses' Notes . Resident lying on left hip with left hand supporting Resident up and Head facing towards the window . - 10/13/23 at 11:20 PM: Fall- Initial . Date of Fall: 10/13/23 . Most Recent Blood Pressure . Date: 10/5/23 at 7:54 AM . Last time resident was toileted prior to fall: 10/13/23 at 7:00 PM . What was resident doing prior to fall? Lying in bed . New intervention implemented . Reminder to use call light before getting up . - 10/17/23 at 3:36 AM: Fall- Initial . Date of Fall: 10/17/23 . Last time . toileted . 2:00 AM . New intervention (s) implemented post fall . environmental modification . WC to be placed next to bed for easier access . - 10/17/23: Health Care Provider Progress Notes . Acute visit for fall out of bed . Patient was attempting to self-transfer from bed to the wheelchair when fell on to the floor. Nursing staff Assisted into the wheelchair. No obvious injury . Recurrent falls . - 4/11/24 at 3:08 AM: Nurses' Notes . This writer heard yelling and went down the hall and observed Resident lying on back on the floor next to bed. When this writer ask what was trying to do, stated, 'I'm trying to get to my wife.' . - 4/11/24 at 3:17 AM: Fall- Initial . Date of Fall: 4/11/24 . Most Recent Blood Pressure . 111/64 Date: 4/5/24 1:45 PM . What was resident doing prior to fall? Lying in bed . Injury . Skin tear to left elbow . New intervention implemented post-fall . Bed height adjustment . - 8/28/24 at 11:27 AM: Was called to residents room. Resident was noted next to bed on the floor between bed and wheelchair. Head towards foot of bed and feet towards head of bed. Resident stated just wanted back into bed and didn't make it. Resident assessed no injuries noted . New intervention applied don't leave resident alone in room in wheelchair . - 8/28/24 at 11:31 AM: Fall - Initial . Date of Fall: 8/28/24 . Most Recent Blood Pressure . Date: 7/15/24 at 10:41 AM . Last time . toileted . 8/28/24 at 9:00 AM . What was resident doing prior to the fall? Sitting in wheelchair eating breakfast . New Intervention implemented post-fall . not to be left in the room while in wheelchair Review of I and A forms for Resident #23 revealed the following: - 10/13/23 at 10:08 PM: Un-witnessed Fall . Resident's Room . Resident lying on left hip with left hand supporting Resident up and head facing towards the window . Root Cause: Self transfer to wheelchair. Intervention: If resident awake . assist to nurses' station for closer observation . Predisposing Environmental Factors . None . Predisposing Physiological Factors . Incontinent . Predisposing Situational Factors . None . Statements . (RN I) . Resident had been resting quietly all night . does attempt to self-transfer . - 10/17/23 at 3:00 AM: Un-witnessed Fall . Resident's Room . (Resident #23) yelling help, upon entering room observed pt (patient) sitting on buttocks leaning against bed, with feet out in from of them. WC (wheelchair) unlocked at pt's feet. Resident Description: Getting in my chair . Root Cause: Resident impulsive and attempted self-transfer to wheelchair. Resident lacks safety awareness. Intervention: Continue assisting resident to nurses' station for closer observation if awake during night along with collaboration with hospice for further intervention . Predisposing Environmental Factors . None . Predisposing Physiological Factors . Confused . Predisposing Situational Factors . Ambulating without Assist . Statement . Spoke with charge nurse . stated resident was last toileted at 12:38 AM . - 4/11/24 at 2:51 AM: Unwitnessed Fall . Resident's Room . Resident in room yelling for help at 2:30 AM when this writer went into room. Resident was observed on floor next to bed lying on back . Root Cause: Confusion, resident looking for wife d/t (due to) advanced vascular dementia. Intervention: Will initiate perimeter mattress . Bed in lowest position . Injury . Skin Tear . Left elbow . Predisposing Environmental Factors . None . Predisposing Physiological Factors . Impaired Memory . Predisposing Situational Factors . None . Statements . (CNA J) . I heard resident calling for help, when I entered room . was lying on the floor on left side beside bed . - 8/28/24 at 9:16 AM: Observed on Floor . Was called to resident's room. Resident was noted next to bed on the floor between bed and wheelchair. Head toward foot of bed and feet towards head of bed . Resident stated they just wanted back to bed . Predisposing Environmental Factors . None . Predisposing Physiological Factors . Impaired Memory . Predisposing Situational Factors . None . Statements . (CNA K) . Resident was sitting in wheelchair eating breakfast, half hour prior to fall . Review of Resident #23's EMR revealed a care plan entitled, (Resident #23) is at risk for falls/injury related to Alzheimer's dystonia, poor eyesight (Initiated: 10/20/23; Revised: 10/30/23). The care plan included the interventions: - Bed in lowest position while in bed (Initiated: 4/11/24) - Do not leave resident up in wheelchair alone in room (Initiated: 8/28/24) - (Resident #23) is impulsive and continue to self-transfer (Initiated: 10/30/23; Revised: 4/12/24) - Perimeter mattress in place to assist with bed boundaries (Initiated: 4/17/24) - When (Resident #23) is awake, assist to nurses' station for closer observation collaborate with hospice for any further intervention (Initiated: 10/30/23; Revised: 4/12/24) - Place call light within reach (Initiated: 10/20/23) On 8/29/24 at 9:50 AM, Resident #23 was observed in their room in bed. The Resident's eyes were closed. An interview and review of Resident falls was completed with the Director of Nursing (DON) on 8/29/24 at 4:26 PM. When queried regarding Resident #16's fall on 3/28/24, the DON indicated they were unsure if the Resident had actually fell . When queried regarding the intervention implemented following the fall, the DON specified the Resident was educated to use their call light. The DON was then queried regarding the meaningfulness of the intervention, as the same intervention was in place and initiated on 8/3/23, the DON reviewed the Resident's care plan and confirmed the intervention was already in place. When asked if the Resident's call light was on, due to documentation indicating the Resident self-transferred to the bathroom because everyone was busy, the DON revealed they did not know. The DON was then asked what intervention was implemented following the residents fall on 4/29/24. After reviewing the Resident's EMR and fall documentation, the DON stated, Gripper socks. When queried where the intervention on the Resident's care plan, the DON reviewed the care plan and confirmed Resident #16 did not have an intervention in place related to non-slip footwear and/or gripper socks. When asked why the intervention was not added, an explanation was not provided. When queried what footwear Resident #16 had in place when they fell and if their call light was in reach, the DON reviewed the documentation and revealed they did not know because it was not documented. When queried regarding the interventions implemented following Resident #16's fall on 7/7/24, the DON reviewed the EMR and indicated they were educated to use their call light and grabber. When asked if the Resident already had a grabber, the DON revealed they did. When queried regarding the meaningfulness of implementing the same intervention already on the care plan, the DON verbalized understanding. The DON was then asked why the post fall assessment was not completed until 7/8/24 and indicated nursing staff may have forgotten. When queried regarding contractionary documentation related to pain in the EMR, the DON was unable to provide an explanation. When queried regarding the location of the call light and the last time the Resident was visualized by staff for each fall, the DON revealed they did not know if the information was not included on the fall documentation. When queried if Resident #23 was a high fall risk, the DON confirmed they were. When queried why a Resident who is at risk for falls and confused was in the last room of the hall, furthest from the nurses' station, the DON did not provide an explanation but revealed they understood. When queried regarding the fall on 8/28/24, the DON indicated the Resident was eating and then attempted to self-transfer to bed. When queried if the Resident's call light was in reach when they were in their chair, the DON reiterated they did not know if it was not included in the fall documentation. The DON was informed of observations prior to the fall and asked why the call light was not in reach but was unable to provide an explanation. When queried if the Resident had tripped over the wheelchair leg rests, the DON revealed they did not know but indicated it was possible. The DON was then asked why the leg rests were not removed but did not provide an explanation. When queried why the Resident was left alone in their room when their care plan included an intervention to assist to the nurses' station for closer observation when awake, no further explanation was provided. When queried regarding interventions implemented for previous falls and analysis completed to identify the cause of the falls, the DON verbalized they understood the need for additional documentation and analysis to implement meaningful interventions. Review of facility policy/procedure entitled, Fall Prevention Program (Reviewed/Revised: 10/26/23) revealed, Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls . 5. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive care plan. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 6. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report . e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury.

Based on observation, interview and record review the facility failed to prevent the development of three (one Stage IV and two unstageable) pressure ulcers for one resident (Resident #31), resulting in, Resident #31 developing a right ankle unstageable wound, a left ankle unstageable wound and a Stage IV coccyx wound and delayed wound healing. Findings include: Resident #31: On 8/27/2024 at 10:55 AM, Resident #31 was observed sitting in the wheelchair after staff had completed morning cares. The resident was asked if she had any wounds on her body and she pointed to her coccyx area and stated it was painful. On 8/27/2024 at approximately 1:00 PM, a review was completed of Resident #31's medical record and it revealed she was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Diabetes, Dementia, Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of left ankle and Pressure Ulcer of right ankle, Schizophrenia, Anxiety and Major Depressive Disorder. Further review revealed the following: Care Plan: .Currently has stage 4 to coccyx and unstageable to bilateral ankles . Bed Mobility: 1 person assistance r/t (related to) hip fx (hip fracture). Dressing: 1 person assist .Personal Hygiene: 1 person assist for set up . .Roho cushion in wheelchair to assist with weight distribution . initiated on 1/22/2024 January 13, 2024, Readmission Assessment: .Left ankle (outer) brown dry scab .Coccyx redness .resident c/o (complains of) painful heels, soft boots applied . Progress Notes: 1/13/2024 at 15:37: .Resident readmitted to facility s/p (status post) right hip fracture surgery, right hip without redness/drainage s/s of infection with 17 staples intact, open to air, hip precautions in place. Advised by hospital resident is 2 assist transfer to wheelchair. Resident c/o bilateral heels painful, upon assessment heels red blanchable, soft with intact skin. Foley removed upon admission to facility, staff advised to monitor voiding . 1/23/2024 at 00:00: .seen today after discovery of a pressure wound measuring 6 cm x 4 cm x 2.5 cm .Patient is up in her wheelchair primarily. She requires assistance with her ADL's. On assessment patient is in her bed on her left side. She currently denies pain related to the area. Recommending patient be place on a turn schedule. Limited time up in wheelchair to prevent worsening of the wound . 1/24/2024 at 13:48: . was called to resident room r/t (related to) discoloration to bottom. resident noted to have two small open area and dark purple 2 cm width line a crossed buttocks with top layer of skin sloughing off. No drainage noted at this time .staff educated on the importance of resident being placed back in bed between meals and side to side repositioning . 4/5/2024 at 00:00: .seen today for reports of bilateral pressure wounds to her outer ankles. Once observed in her bed, she is laying on her right side with soft boots in use. Despite boots there is still pressure to the areas .and believed to be the cause of the wounds . 7/15/2024 at 14:41: .Wound nurse continues to evaluate wounds weekly with measurements and pictures, wounds continue to heal slowly . 8/9/2024 at 11:41: .Wound nurse continues to assess wound weekly with pictures and measurements, wounds slowly healing, changes being made as needed . On 8/29/2024 at 9:40 AM, an interview was conducted with ADON (Assistant Director of Nursing)/Wound care Nurse regarding Resident #31's three facility acquired wounds. The ADON stated the coccyx wound developed first on 1/22/2024 shortly after her return from the hospital. When asked if it was present upon readmission the ADON stated it was not as she completed the admission skin check of Resident #31. Upon further discussion it was stated the resident was not able to reposition herself in bed and was frequently in her wheelchair. The ADON was asked if the wound developed from not being turned/repositioned and being in her wheelchair for long periods. The ADON reported those are both plausible explanations. The ADON stated Resident #31 additionally has a facility-acquired wound on her bilateral outer ankles that were discovered on 3/18/2024. The resident wore soft heel boots while in bed and was most comfortable laying in a fetal position in bed. Both wounds are on the ankle bone and most likely caused from the boot rubbing against her skin. The ADON reported all three wounds have not resolved but are showing signs of improvement. Further review was completed of Resident #31's facility-acquired wounds: Coccyx: 1/22/2024: 6.82 cm x 4 cm x 2.45 cm. In house acquired pressure. Small open areas noted deep purple line noted sloughing of first layer of skin no drainage noted. 1/30/2024: 5.25 cm x 4.3 cm x 2.24 cm .Resident noted to have slough throughout wound no drainage at this time . 2/5/2024: 8.36 cm x 6.22 cm x 2.85 cm . Resident noted to have slough throughout wound no drainage at this time . 3/5/2024: 11.36 cm x 6.26 cm x 3.22 cm .light sanguineous/bloody exudate, 70% granulation and 30% slough .Wound noted to have decrease in slough wound has a depth now of 1 cm with granulation starting to show . 4/2/2024: 4.34 cm x 3 x 1.62 cm x 4 cm (deepest point). Moderate sanguineous/bloody exudate, 10% granulation and 90% slough .Wound bed slough noted to be more of a light gray in color. With pink granulation tissue to outer edge of wound. 4/10/2024: 21.96 cm x 7.54 cm x 4.05 cm x 3.5 (deepest point). Light sanguineous/bloody exudate, 90% granulation and 10% slough. Resident had debridement to her unstageable pressure wound to coccyx's wound and is not classified as a stage 4. Light drainage noted at this time and no s/s of infection resident continues on IV and oral antibiotics for wound infection. 5/13/2024: 14.12 cm x 6.06 cm x 3.42 cm x 3.5 cm (deepest point). Moderate sanguineous/bloody exudate, 100% granulation. Wound bed had pink granulation tissue some slough notes in spots, depth continues to be 3 cm moderate amount of drainage noted in wound vac at this time. 5/29/2024: 15.76 cm x 6.21 cm x 3.75 cm x 3 cm (deepest point). Moderate sanguineous/bloody exudate, 100% granulation. Wound bed had pink granulation tissue dept continued to be 3 cm moderate amount of drainage noted in wound vac at this time. 6/10/2024: 14.61 cm x 5.66 cm x 3.84 cm x 2.5 cm (deepest point). Moderate sanguineous/bloody exudate, 100% granulation. Wound bed had pink granulation tissue depth continues to be 3 cm moderate amount of drainage noted in wound vac at this time. 6/24/2024: 9.69 cm x 4.67 cm x 2.71 cm x 2.5 cm. No sanguineous/bloody exudate, 70% granulation. Wound bed has become a lighter pink color with some nice red granulation. Continue to have moderate drainage no s/s of infection. 7/8/2024: 7.85 cm x 4.23 cm x 2.61 cm x 2 cm (deepest point). Light serous exudate, 100% granulation. Wound bed noted to be getting dry and light white coloring to outer edge of wound bed. 7/30/2024: 8.08 cm x 4.24 cm x 2.46 cm x 2 cm. Moderate sanguineous/bloody exudate, 100% granulation. Wound bed noted to be getting beefy red granulation .Outside of wound bed noted to be white and soft drainage is moderate . 8/27/2024: 13.16 cm x 4.8 cm x 4.03 cm x 2 cm. Moderate sanguineous/bloody exudate, 100% granulation. Wound bed continues to have granulation tissue noted little yellow slough noted to wound bed. Moderate drainage no s/s of infections diameter wound continue to get smaller. Top left side of wound dark purple area noted, and bottom left has some dark purples noted . Left Lateral Ankle: 3/18/2024: 1.22 cm x 1.46 cm x 1 .While doing her tx (treatment) noted drainage to left ankle. Slough noted in center of wound with serosanguineous drainage. Peri wound noted to be deep purple in color . 4/2/2024: 2.58 cm x 2.24 cm x 1.5 cm . While doing her tx (treatment) noted drainage to left ankle. Slough noted in center of wound with serosanguineous drainage . Right Lateral Ankle: 3/18/2024: 1.22 cm x 1.46 cm x 1.2 cm. 100% slough .Slough noted to center of wound with serousangous drainage. Peri wound noted to be deep purple in color . 4/2/2024: 3.03 cm x 2.45 cm x 1.78 cm. 100% eschar. Education provided to staff on proper repositioning. Wound bed noted to have eschar present . Review was completed of the facility policy entitled, Pressure Injury Prevention and Management, reviewed 3/20/2024. The policy stated, This facility is continued to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .evidence based interventions for prevention will be implemented for all residents who are assessed as at risk or who have a pressure injury present .i. Redistribute pressure .iii. Provide appropriate, pressure-redistributing, support surfaces .

Based on interview and record review, the facility failed to ensure dignified and respectful treatment for one resident (Resident #28) of two residents reviewed, resulting in staff speaking to Resident #28 in an undignified and belittling manner and the resident's verbalization of feelings of frustration and discontentment. Findings include: Resident #28: On 8/28/24 at 9:27 AM, Resident #28 was observed in their room. The Resident was in bed, positioned on their back. Upon entering the room, the room temperature was immediately noted to be uncomfortably hot and humid. A fan was present in the room, but an air conditioning unit was not present in the window. An interview was completed at this time. When queried how they were treated by facility staff, Resident #28 replied that some staff don't give good care. Resident #28 was asked what they meant and stated, (They) act like it is a burden to provide care and assist them. Resident #28 verbalized frustration and indicated they would prefer to be able to do things for themselves, but they are in the facility because they need help. When asked if there are specific staff who make them feel that they are a burden, Resident #28 stated, (Certified Nursing Assistant)[CNA C]. With further inquiry, Resident #28 revealed CNA C asks them, What do you want? when they come in the room in a rude tone. Resident #28 stated, I asked (CNA C) to put me to bed and revealed they waited over an hour and CNA C never returned. Resident #28 then stated, (CNA C) always rolls their eyes when they ask for something. Resident #28 revealed they asked CNA C why they did not like them one day and CNA C told them that it's hot in here (room) and they need to hurry up. When queried if they thought the room was hot, Resident #28 verbalized they were and indicated they had no air conditioning. When queried if they want air conditioning (AC), Resident #28 verbalized they did and stated, (facility staff) said can't put a window AC in the room and they can't open the window because it leaks. When asked about the window leaking, Resident #28 revealed the facility staff informed them they were unable to put a window AC in because there was a problem with the roof which caused the window to leak. Resident #28 was then asked if they had spoke to anyone at the facility about CAN's C, Resident #28 verbalized they had and stated, I've had reports written. Review of Resident #28's Electronic Medical Record (EMR) revealed the Resident was admitted to the facility on [DATE] with diagnoses which included heart failure, respiratory failure, depression, and weakness with bilateral foot drop (inability to raise the front part of the foot and the toes point away from the head). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, displayed no behaviors, and required maximum to total assistance to complete Activities of Daily Living (ADL) with the exception of eating and oral hygiene. Resident #28's concern/Incident and Accident (I and A) forms were requested from the facility Administrator on 8/28/24 at 3:32 PM. An interview was conducted with CNA C on 8/28/24 at 2:49 PM. When queried if they had provided care to Resident #28 at the facility, CNA C confirmed they had. CNA C was asked what shift they worked and revealed they usually worked day and afternoon shift but had also previously worked night shift. When queried if they had any negative interactions with Resident #28, CNA C initially stated, No. CNA C then stated, The one day (Resident #28) said, I take it you don't like me. I said no. I'm just trying to hurry up and get you done because I am dying in here it is so hot. When asked how Resident #28 responded, CNA C indicated they did not recall. CNA C verbalized there is no air conditioning in the Resident's room, and they had an oxygen concentrator which makes the room even hotter when the door is closed. When queried if they ask Resident #28 what they want when they enter their room, CNA C did not respond. No concern/I and A forms for Resident #28 were received by the conclusion of the survey. Review of facility provided policy/procedure entitled, Resident Rights (Revised: 10/30/23) revealed, 11. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents.

Based on observation, interview and record review the facility failed to implement infection control practices related to COVID-19 (COVID) for four residents (#2, #3, #4, #5) of 5 residents sampled resulting in missing Transmission Based Precaution (TBP) orders for residents positive with COVID, missing COVID positive care plans, missing trash cans for contaminated personal protective equipment (PPE), lack of PPE outside of the rooms and the potential for spreading COVID in the facility. Findings include: On 02/28/24 at 10:00 AM, observation revealed one large trash can outside of room B5/#2 for the whole hallway and missing trash cans outside of resident rooms (B7/#3, B9/#4, B13/#5) on transmission based precautions (TBP) for COVID. Observation revealed signs on the room doors that indicated anyone entering should wear gloves, a gown, a mask and a face shield. On 02/28/24 at 10:05 AM, RN 'A' was interviewed about the lack of trash cans outside of the rooms and where would you place wrappers that PPE came in and they stated that you would just take the one trash can outside of room B5 and take it down the hall to the other rooms where it was needed. On 02/28/24 at 10:10 AM, the housekeeping supervisor was interviewed about the lack of trash cans outside the rooms for PPE, they stated that every room with TBP should have a trash can outside of it for PPE and that there are usually trash cans outside of the room. When asked about where to place contaminated PPE due to having small trash cans in the rooms. Housekeeping supervisor stated that you would remove your PPE in the room, place it in the trash can, bag it up and bring it out to the one trash can in the hallway. On 02/28/24 at 10:20 AM, a housekeeper was observed standing in the doorway of a COVID positive residents room, they were wearing gloves, a gown, and a mask, but missing a face shield/goggles. The housekeeper was observed reaching back out into the hallway to the housekeeping cart and grabbing items off it. The housekeeper was asked if they had already been performing cleaning services in the room (therefore wearing contaminated PPE now) before reaching back out into the hallway for more cleaning items. Housekeeper 'A' responded that yes they had already been in the room cleaning before reaching back out for items on the cart. On 02/28/24 at 1:00 PM, observation revealed that there were no face shields/goggles available to staff or visitors outside of rooms B5, B7 and B13. On 02/28/24 at 2:00 PM, record review of resident electronic health records (EHR) revealed that an order for TBP was missing for four residents (#2, #3, #4, #5) with COVID. Record review revealed that COVID care plans were missing for two residents (#3, #4) with COVID. Review of Resident #2's EHR revealed they were [AGE] years old and admitted to the facility on [DATE] with diagnoses of hip fracture, diabetes, schizophrenia and dementia. Resident #2 became COVID positive on 02/22/24, an order for TBP was not present on initial record review on 02/28/24. Review of Resident #3's EHR revealed they were [AGE] years old and admitted to the facility on [DATE] with diagnoses of urinary tract infection, myocardial infarction, heart disease, hypertension (high blood pressure) and kidney failure. Resident #3 became COVID positive on 02/25/24, an order for TBP and a care plan for COVID were not present on initial record review on 02/28/24. Review of Resident #4's EHR revealed they were [AGE] years old and admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), respiratory failure, asthma, anxiety and depression. Resident #4 became COVID positive on 02/25/24, an order for TBP and a care plan for COVID were not present on initial record review on 02/28/24. Review of Resident #5's EHR revealed they were [AGE] years old and admitted to the facility on [DATE] with diagnoses of asthma, respiratory syncytial virus (RSV) respiratory failure and atrial fibrillation. Resident #5 became COVID positive on 02/20/24, an order for TBP was not present on initial record review on 02/28/24. On 02/28/24 at 2:45 PM, the director of nursing (DON) was asked if residents who are COVID positive should have an order for TBP and they stated, yes those residents should have an order. The DON was also asked how many residents in the building were COVID positive and they said ten residents. The DON was asked if they have any staff that were out sick with COVID and they stated there were nine staff members that were COVID positive. The DON stated that the residents and staff were identified as COVID positive anywhere from 02/20/24 to 02/28/24. On 2/28/2024 at 9:15 AM, upon entrance to the facility a sign was posted on the outside entry door indicating there were cases of Covid-19 identified in the facility and a face mask was required to be worn when in the building. On 2/28/2024 at 11:30 AM, during an attempt to enter Resident #3's room, it was observed that Personal Protective Equipment (PPE) was hanging on a holder on the resident's door. There was a sign on the door that indicated a protective isolation gown, gloves, an N 95 mask and a Face shield was required to enter the room. The N 95 mask was to be donned (put on) after removing the Face mask. There was no trash receptacle outside the resident room to throw away the soiled Face mask. There were no Face shields in the PPE holder. On 2/28/2024 at 2:40 PM, a staff member was observed outside Resident #3's room. The staff member was donning a gown, gloves and an N 95 mask. A covered trash receptacle had been placed outside the room. There were no Face Shields. The facility Administrator was observed in the hallway and was asked if the Face shields were required, and she said they were. Reviewed with her there were no Face shields in 3 of the 4 PPE door holders. She said staff could wear a Face shield or goggles. One PPE holder had one pair of goggles. The Administrator left the hallway and returned with 4 face shields and said they were in a storage area outside of the hallway. The 4 Face shields were not sufficient to ensure there was adequate PPE to care for the residents for an entire shift and there was no area for the staff to clean and sanitize the Face shields to re-wear them. On 2/28/2024 at 3:15 PM, during an interview with the Director of Nursing/DON, she provided a copy of an Inservice/training sign in sheet for the staff dated 2/28/2024 related to donning (putting on) and doffing (taking off) PPE. Reviewed with the DON that there was not an adequate amount of PPE readily available at the resident's doorway to ensure staff were wearing the Face shields/goggles. She said she would address it. CDC: Centers for Disease Control and Prevention, 6/3/2020 Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19: Before caring for patients with confirmed or suspected COVID-19, healthcare personnel (HCP) must: Receive comprehensive training on when and what PPE is necessary .PPP must be donned correctly before entering the patient area . PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas . PPE must be removed slowly and deliberately in a sequence that prevents self-contamination . Preferred PPE: N 95 or higher respirator, Face shield or goggles, One pair of clean, non-sterile gloves, Isolation gown . 49944

This Citation Pertains to Intake Number MI00142937. Based on observation, interview and record review, the facility failed to justify the use of a PRN/as needed antianxiety medication and document rationale for prolonged PRN use for one resident (#1), resulting in the potential for unnecessary medications and adverse effects. Findings Include: A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #1 revealed an admission into the facility on [DATE] with diagnoses: Schizophrenia, heart failure, hypertension, Systemic Lupus (an autoimmune disorder), anxiety, depression, pathological dislocation of left hip (present on admission), and hypothyroidism. The MDS assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11/15 revealing moderate cognitive loss. The resident needed some assistance with all care and was unable to walk. An interview with the Assistant Director of Nursing/ADON A on 2/28/2024 at 9:54 AM, revealed Resident #1 had several falls at the facility: 1/3/2024, 1/21/2024, and 1/24/2024. The resident was admitted with a dislocated Left hip and had a history of falling at home prior to admission. He had previously had several surgical repairs of the Left hip and per the ADON he was not a surgical candidate to have the dislocation repaired. On 2/28/2024 at 10:57 AM, Confidential Person F was interviewed. The Confidential Person said Resident #1 had a history of falling, with several surgical repairs. She said the Left hip became dislocated after that and the surgeon said the resident would no longer be a candidate for surgery. She said the resident had pain in the Left hip and would often become restless from the pain. She said that is one of the reasons he would try to get up on his own. On 2/28/2024 at 1:00 PM, a record review of the physician orders for Resident #1 indicated he had an order for the following: Clonazepam (an anti-anxiety medication also called Klonopin) oral tablet 0.5 mg: Give 1 tablet by mouth every 12 hours as needed for anxiety, Start Date 10/3/2023. A record review of the Medication Administration Record (MAR) for February 2024 on 2/28/2024 at 2:07 PM, revealed Clonazepam oral tablet 0.5 mg: Give 1 tablet by mouth every 12 hours as needed for anxiety, start date 10/3/2023. During the month of February 2024, the resident received the dose of Clonazepam 11 times. Further review of the physician orders for Resident #1 revealed the as needed order for Clonazepam had not been discontinued, restarted or adjusted. The as needed order had remained since 10/3/2023. A review of the Monthly Pharmacy reviews for Resident #1 indicated there was no mention of the as needed Clonazepam order. A review of the provider assessments and notes for the resident revealed the following: 11/8/2023 a psych provider note/assessment with a review of the resident's psychotropic medication orders, but no mention of the Clonazepam order. 10/11/2024 a psych provider note/assessment- a New admission eval . seen for management of psychotropic medications. admitted [DATE] . history of schizophrenia . Current psychotropic medications: . Klonopin (Clonazepam) 0.5 mg BID (twice a day) PRN (as needed) 14 days . The provider note indicated the resident was receiving the medication for 14 days as needed. Upon further review of the resident's notes and assessments, the PRN/as needed Clonazepam (Klonopin) was not mentioned. Further review of the Medication Administration Record and Treatment Administration Record for February 2024 did not identify monitoring for side effects of the Clonazepam medication. A review of the Care Plans for Resident #1 identified the following: (Resident #1) is at risk for fall/injury . Date initiated 10/3/2023 and revised 10/9/2023. A review of the interventions identified no mention of the resident receiving psychotropic medications or to monitor for side effects that could affect his judgement and balance that could predispose him to a fall. (Resident #1) has an impaired mood/psychiatric status related to dx (diagnosis) schizophrenia . date initiated 10/3/2023 and updated 2/7/2024. A review of the interventions identified no mention of as needed/prn anti-anxiety medications. (Resident #1) takes psychotropic/mood stabilizer medication as evidenced by antianxiety use, antipsychotic use, mood stabilizer use, date initiated 10/3/2023 and revised 10/6/2023. The interventions do not address the as needed/prn use for longer than 14 days of Clonazepam/Klonopin an anti-anxiety medication. On 2/28/2024 at 3:00 PM, interviewed the Director of Nursing/DON related to Resident #1 receiving As needed/PRN Clonazepam since 10/3/2024. Reviewed with her the 10/11/2023 psych eval said the medication was PRN for 14 days, but no one else addressed it. She said she was looking into it. Also reviewed the Pharmacist's monthly medication regimen reviews did not mention the Clonazepam was being given PRN since 10/3/2023. The DON said she was checking on that. A review of the facility policy titled, Medications-PRN, date implemented 10/10/2020 and reviewed/revised 1/30/2024 provided, . 'PRN medication' refers to a medication that is taken as needed for a specific situation. It is not provided routinely, and requires assessment for need and effectiveness . Recurrent use of or repeated requests for PRN medications may indicate the need to reevaluate the situation, including the current medication regimen . PRN orders for psychotropic drugs are limited to 14 days . If the prescriber believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

This Citation Pertains to Intake MI 179. Based on observation, interview and record review, the facility failed to ensure that policies and procedures were implemented to ensure assessment and interventions for pressure ulcer (wounds caused by pressure) prevention were implemented, per professional standards of practice, for three residents (Resident #701, Resident #707, and Resident #709) of six residents reviewed. This deficient practice resulted in the lack of monitoring of alternating air mattress (pressure reduction mattress) settings and resulted in the following: 1) Resident #701's pressure ulcer worsening, hospitalization , and a potential contribution to death, 2) Resident #707 developing Deep Tissue Injury (DTI) pressure ulcers (unknown depth), and 3) Resident #709 developing a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer, with the likelihood for infection, pressure ulcer development and/or worsening, and a decline in overall health. Findings include: Resident #701: Review of intake documentation dated 8/19/21 detailed, On 07/15/21 (Resident #701) had a shear wound. When (Resident #701) was admitted to the hospital on 8/15/21, the wound had gone from a shear wound to a stage four (pressure ulcer) . Review of Resident #701's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive supervision to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident was at risk for pressure ulcer development but had no pressure ulcers. Resident #701 was transferred to the hospital from the facility on 8/15/21 due to a change in condition and potential GI Bleeding. Review of Resident #701's care plan revealed a care plan entitled, The resident has an actual impairment to skin integrity on coccyx and buttock. Stage 3 (full thickness tissue loss with subcutaneous fat visible) PI (Pressure Injury) to coccyx with surrounding red blanchable tissue (Initiated: 7/16/21; Revised: 8/11/21). The care plan included the following interventions: - Encourage good nutrition and hydration in order to promote healthier skin (Initiated: 7/16/21) - Low air loss mattress to assist with weight distribution (Initiated: 7/30/21) - Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician/provider (Initiated: 7/30/21) - Reposition side to side every 2 hours and as needed (Initiated: 8/12/21) - ROHO cushion in wheelchair (Initiated: 8/13/21) - Soft boots in place at all times to assist with bilateral heel elevation while in bed (Initiated: 7/30/21) - Tx (treatment) as ordered (Initiated: 8/9/21) - Up in chair for meals for 1 hour only, then assist with transfer back to bed (Initiated: 8/12/21) - Wedge cushion to assist with positioning side to side every 2 hours and PRN (as needed) as Resident allows (Initiated: 7/30/21; Revised: 8/11/21) - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations (Initiated: 7/30/21) Review of Resident #701's Nursing Admission Evaluation (Signed/Lock Date: 7/16/21 at 4:14 AM) included identified skin conditions/wounds as follows: - Coccyx . Open: 1 centimeter (cm) length X 1 cm width . No depth documented. - Right Buttocks . Shearing . 2 cm length X 2 cm width . No depth documented. Review of Resident #701's weekly Skin Assessment documentation revealed the following assessments had been completed: - 7/22/21: Are there any new abnormal skin areas? Yes . Site . Chest: breast skin fold red without drainage . Groin: Bilat redness . Are there any existing abnormal skin areas? Yes . Other: R (right) knee horizontal linear scab D/I/OTA (Dry/Intact/Open to Air) . R breast skin fold and bilat groin redness cleansed and antifungal applied; order written . - 8/6/21: Are there any new abnormal skin areas? No . Are there any existing abnormal skin areas? Yes . Coccyx: Pressure ulcer, 100% grey/yellow slough. unstageable. TX (treatment) continues. Irregularly shaped superficial openings x 3 peri wound . Other: Perineum red, excoriated . - 8/13/21: Are there any new abnormal skin areas? No . Are there any existing abnormal skin areas? Yes . Sacrum: excoriated area . Sacrum: pressure ulcer . Review of Resident #701's Wound Evaluation documentation revealed the following: - 7/30/21 at 9:32 AM: #1 - Pressure - Unstageable (Slough and/or eschar) . Coccyx . Monitoring - Age Unknown . Length 1.96 cm (centimeters); Width 1.09 cm . Wound Bed: Slough: Yes . % Slough 100% . Additional Care: Heel Suspension/Protection device . Mattress with Pump . Moisture barrier . Nutrition/Dietary supplementation . Positioning Wedge . Healable . Notes Base dry with 100% yellow soft slough, edges pink and attached to wound bed, surrounding tissue with intact skin although slightly red peri skin, no drainage/odor noted. Interventions in place, added low air loss mattress . - 8/4/21 at 1:47 PM: #1 - Pressure - Unstageable (Slough and/or eschar) . Coccyx . Monitoring - Age Unknown . Length 1.1 cm; Width 0.91 cm; Deepest Point 0.4 cm . Wound Bed: Slough: Yes . % Slough 100% . Exudate . Light . Serous . Edges: Non-Attached . Surrounding Tissue: Erythema; Fragile . Additional Care: Heel Suspension/Protection device; Mattress with Pump; Moisture barrier; Nutrition/Dietary supplementation; Positioning Wedge; Turning/repositioning program . Healable . Notes Base moist with 100% yellow soft slough, edges nonattached to wound bed r/t (related to) yellow slough slowly sloughing off, depth now 0.4 cm, surrounding tissue with intact although reddened skin, skin barrier applied, light serous drainage noted without odor . - 8/11/21 at 1:21 PM: #1 - Pressure - Unstageable (Slough and/or eschar) . Coccyx . Length: 0.82 cm; Width: 1.1 cm; Deepest Point: 1.5 cm . Edges: Non-Attached . Surrounding Tissue: Erythema; Excoriated . Light . Serous . Notes Base now with 100% pink base and moist, edges pink nonattached to wound base, the yellow slough that was present over entire wound bed has now resolved, which now shows depth, MD notified and TX (treatment) changed . surrounding tissue is reddened with superficial excoriation . will limit time up in wheelchair and discuss different wheelchair cushion for resident . An interview was conducted with the Director of Nursing (DON) on 9/9/21 at 9:05 AM. When queried if the facility had a wound care nurse, the DON revealed Unit Manager Licensed Practical Nurse (LPN) O and Staff Development Coordinator (SDC) LPN A complete wound care assessments and implement interventions at the facility. With further discussion, the DON revealed floor nursing staff also complete wound care treatments. When queried regarding Resident #701's stay in the facility, the DON stated, (Resident #701) had a change in condition so we sent them out to the hospital. With further inquiry regarding the nature of Resident #701's change in condition, the DON replied, Not sure. (Resident #701) was not here very long. The DON then revealed they were contacted by the nursing manager at the hospital where the Resident was sent to inform them that the hospital was reporting us to the Ombudsman because (Resident #701) had a large wound that was not there before per their documentation. When queried regarding the wound, the DON stated, (Resident #701) was only here once and then went back to (Hospital). (Resident #701) did (have a wound). The DON indicated the wound had been documented at the facility and that the facility spoke to Resident #701's family regarding the wound. On 9/9/21 at 9:28 AM, an interview was completed with SDC LPN A. When queried regarding facility procedure related to wound care including measurements, assessments, and implementation of interventions, SDC LPN A replied, I take pictures and update the family and doctor every week. When queried regarding Resident #701's wounds, SDC LPN A stated, (Resident #701) was admitted with open area on coccyx and shearing. SDC LPN A stated, (Resident #701) had a yellow base to the wound. When asked the location of the shearing, SDC LPN A was unable to recall. SDC LPN A stated, There were interventions in place. When queried regarding Resident #701's wound progression, SDC LPN A stated, We changed the treatment a couple times. Right before we discharged (Resident #701) back to the hospital, the wound measurements got smaller, but it got deeper because the slough (necrotic tissue) came off. Review of Resident #701's wound documentation was completed with SDC LPN A at this time. When queried why there were no pictures present in the Electronic Medical Record (EMR) Wound Evaluation documentation, SDC LPN A stated, This system does not save pics. SDC LPN A revealed they outline the edges of the open area of the wound bed and that is what Is maintained in the EMR rather than the actual wound images. When queried if regarding abnormal skin tissue outside of the open wound is included in the outlined image of the wound, SDC LPN A stated, Only shows open area, not any outside area (of wound) is included. SDC LPN A was queried why Resident #701 did not have a Wound Evaluation completed until 7/30/21 when they were admitted on [DATE] and replied, I am not gonna lie. We (wound care) were not notified. When asked for clarification, SDC LPN A revealed they were not notified by floor nursing staff that Resident #701 had a wound and therefore did not complete a Wound Evaluation and measurements. When queried regarding facility process/procedure for notification of wounds, SDC LPN A revealed nursing staff are supposed to notify them or LPN O of new wounds either verbally or by leaving them a note. When queried regarding the efficiency of the procedure, SDC LPN A indicated the procedure had not worked for Resident #701. SDC LPN A was then queried regarding skin assessment completion and revealed skin assessments are completed by floor staff. Resident #701's Skin Assessment documentation was reviewed with SDC LPN A at this time. When asked how frequently skin assessments should be completed, per facility policy/procedure, SDC LPN A stated, Should be done weekly. When asked why Resident #701 did not have a weekly skin assessment completed, SDC LPN A was unable to provide explanation. SDC LPN A additionally stated that assessments should include (documentation of) both existing and new wounds or skin alterations. When queried why Resident #701's Skin assessment dated [DATE] did not include any documentation indicating the Resident had an open wound on their coccyx, SDC LPN A revealed staff should document any wound a Resident has. No further explanation was provided. Review of Resident #701's Hospital documentation, prior to their admission to the facility on [DATE], revealed no documentation of and open wound/pressure ulcer present on their coccyx when they were in the hospital. A note, dated 7/13/21 at 3:00 PM, detailed, Service: Wound Care . Posterior aspect assessed, small intact shearing, no open. Use barrier cream to protect . For any deterioration of wound . notify WOC (Wound, Ostomy and Continence Nurse) . Review of Resident #701's healthcare providers orders and Treatment Administration Record (TAR) at the facility revealed a treatment was not initialed until two days after being admitted to the facility. A detailed review of Resident #701's orders/TAR showed the following: - Cleanse Coccyx wound with NS (Normal Saline). Apply Calcium Ag (Alginate) topically to wound bed and cover with Bordered Foam QD (every day) and prn (as needed) . (Start: 7/17/21; Discontinued: 7/30/21) - Cleanse Coccyx wound with NS. Apply Hydrogel to wound bed and cover with Bordered Foam QD and prn . (Start: 7/31/21; Discontinued: 8/12/21) - Cleanse coccyx wound with wound cleanser, apply hydrogel to wound bed, then fill depth of wound with calcium alginate, apply skin prep peri wound, cover wound with border foam dressing changing daily every day shift for coccyx wound (Start: 8/12/21) - Cleanse R buttock wound with NS. Apply Calcium Ag topically to wound bed and cover with Bordered Foam QD and prn . (Start: 7/17/21; Discontinued: 7/31/21) - Cleanse . bilat buttocks and perineum, and labia with soap and water, rinse, pat dry. Apply (barrier cream) topically to all areas BID (twice daily) and prn until resolved. CNA (Certified Nursing Assistant) may apply every day and night shift for scattered open areas with minimal bleeding (Start: 7/31/21) . Resident #701's medical records from the hospital admission following their transfer from the facility on 8/15/21 were obtained and reviewed. Review revealed the following documentation: - 8/15/21: Wound Properties . Date First Observed: 7/15/21 . Wound Type: Shear . Location . Sacrum . Adult Assessment . Wound Properties . Posterior Sacrum . Viable Tissue Assessment: Small . Pale . Non-Viable Tissue Assessment: Wet; Medium (34-66%) . Tan . Grey . Peri-wound assessment: Denuded/eroded; Painful/Tender . Drainage: Foul odor; Yellow; Small . Odor Present: Small . Bone Palpable . Full Thickness . Length: 3.5 cm . Width: 2.5 cm . Depth: 1.5 cm . Undermining: 2 cm from 12-5, 1 cm from 9-12 . Pressure Stage: 4 . - 8/16/21: (Physician) Progress Note . also has a coccyx wound that . is necrotic and Wound Care came and saw yesterday, and they did say (Resident #701) has a necrotic wound there . did start to treat it . sounds like may need more than just topical treatment . If going to have treatment . may need surgical debridement . Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Resident #701's daughter, Confidential Witness P on 9/10/21 at 11:45 AM. When queried regarding Resident #701, Witness P stated, (Resident #701) passed away on 8/19/21. When asked what had happened, Witness P revealed the Resident had been living at home with their spouse when were hospitalized due to a [CONDITION(S)]. Witness P indicated the Resident had suffered a stroke during their hospitalization and were transferred to the facility because of their need for therapy to gain strength and return home. Witness P further revealed the Resident was transferred from the facility to the local hospital and then to hospice. When queried regarding Resident #701's time at the facility, Witness P stated, It was neglect, just absolutely horrible. (Resident #701's) whole entire well-being declined while they were there. Witness P revealed (Resident #701 had a Urinary Tract Infection ([CONDITION(S)]) and stated, I don't think they cared for the Foley (indwelling urinary catheter) properly. (Resident #701) never even got to their urology appointment. When asked if they saw Resident #701 while they were at the facility, Witness P indicated they did and revealed they saw the Resident several times a week when they were at the facility. Witness P stated, Every time I went there, (Resident #701) was on their back and it took weeks to get a special mattress there. With further inquiry regarding the special mattress, Witness P indicated they were referring to an alternating air mattress (specialty mattress designed to relieve, reduce, and redistribute pressure). When asked Witness P revealed Resident #701 wasn't on it (mattress) for very long before they were transferred to the hospital. When queried if Resident #701 had a pressure ulcer when they were admitted to the facility, Witness P revealed the Resident had a small area on their bottom that was not opened when they were in the hospital. With further inquiry regarding Resident #701's pressure ulcer, Witness P revealed they were notified by the facility of the wound. With further inquiry, Witness P stated, I had a call (from facility), they told me that it (pressure ulcer) was getting better. That was a lie because the tailbone was visible. When asked how they were aware of Resident #701's tailbone being visible in the wound bed, Witness P revealed the nurse at the hospital was was appalled when they saw (the Residents) condition. Witness P then stated, The nurse at Hospice told me they had never seen one (pressure ulcer) that bad. (The Hospice Nurse) said that was pure neglect. Resident #707: Review of facility wound list provided by the Director of Nursing (DON) on 9/9/21 revealed Resident #707 had two wounds, a Stage III pressure ulcer on their coccyx and a surgical incision on their abdomen. On 9/9/21 at 12:15 PM, Resident #707 was observed in their bed positioned on their back. A [CONDITION(S)] (surgically created hole through the front of the neck into the trachea to allow air passage) was noted and a PICC (Peripherally Inserted Central Catheter) was present in the Resident's Right Upper Extremity (RUE). When spoke to, Resident #707 opened their eyes but did not respond verbally. The Resident's hands were contracted with joint distortions visible in their fingers. The Resident's Bilateral Lower Extremities (BLE) were positioned directly on the mattress with positioning boots present on both lower extremities. The boots were noted to have a hard, plastic support on the back and bottom. The Resident's feet were incorrectly positioned in the boots, visibly creating placing pressure on their heels and the soles of their feet. An interview was conducted with Registered Nurse (RN) N at this time. When queried regarding the Resident's skin integrity and medical condition, RN N revealed the Resident recently began [CONDITION(S)] about two hospitalization s ago and have a pressure ulcer on their coccyx. RN N was queried regarding the PICC line and revealed Resident #707's pressure ulcer had become infected, necessitating intravenous (IV) antibiotics. Record review revealed Resident #707 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed the Resident was in a vegetative state and was totally dependent upon others to perform ADLs. Review of Resident #707's active and discontinued care plans revealed an active care plan entitled, The resident has actual impairment to skin integrity. Coccyx pressure stage 4, abdominal incision now resolved, left inner upper arm abrasion now resolved, excoriation under left breast old PEG tube site, Skin tear left gluteal fold, left abdomen fissure site, Old PEG site superficial area, left heel, soft, fluid filled (Initiated: 7/19/21; Revised: 9/8/21). The care plan included the following active and resolved interventions: - Assist resident with turning and repositioning every 2 hours and as needed side to side (Initiated: 8/31/21) - Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician/provider (Initiated and Revised: 7/19/21) - The resident uses the following devices to relieve/prevent friction/sheer/pressure (low air loss pressure relieving/reducing mattress) (Initiated and Revised: 7/19/21) - TX (Treatment) as ordered (Initiated: 8/31/21) - Wedge cushion positioning device in place to assist with repositioning while in bed (Initiated: 7/19/21) - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations (Initiated and Revised: 7/19/21) - Soft boots on at all times when in bed and chair, may remove for skin assessment and hygiene then reapply (Initiated: 7/19/21; Revised: 7/26/21) - RESOLVED: Float heels during the following times/activities [at all times while in bed and pillow boots with heel cutout while up in CHAIR] (Initiated: 7/19/21; Revised and Resolved: 7/26/21) - RESOLVED: Foot cradle to protect feet from blankets resting on top of them and causing pressure injury d/t (due to) hx (history) of PI (Pressure Injury) to foot (Initiated: 11/16/20; Revised and Resolved: 2/15/21) - RESOLVED: Soft cut out heel boots when up in chair. Check skin integrity Q (every) day and night shift (Initiated: 7/19/21; Revised and Resolved: 7/26/21) Another care plan titled, The resident has and/or is at risk for pressure ulcer development to the following areas [Coccyx] (Initiated and Revised: 7/19/21) was present in Resident #707's medical record. The care plan included the interventions: - Daily skin evaluations by licensed nurse if current pressure ulcer (see TAR) (Initiated: 7/19/21) - Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #707's medical record revealed the Resident had one pressure ulcer on their coccyx. Wound Evaluation Documentation dated 9/8/21 revealed, Pressure - Stage 4 . Coccyx . Length 4.98 cm (centimeters) . Width 5.91 cm . Deepest Point: 4 cm . Wound Bed . Granulation: Yes . 100% . Evidence of Infection: None . Exudate . Moderate .Sanguineous/Bloody . Odor . None . Edges: Non-attached . Notes Base moist with 100% red tissue, scattered thin slough noted, moderate serosang drainage noted without odor, surrounding tissue with intact skin . Will continue with current plan of care at this time . At 3:30 PM on 9/9/21, Resident #707 was observed in their room, in bed and positioned on their back. Resident #707's BLE remained positioned directly on the mattress with the incorrectly placed positioning boots in place placing pressure on the heels and the soles of the Resident's feet. Wound care observation completion was completed with RN N and Certified Nursing Assistant (CNA) Q at this time. When queried regarding the Resident's pressure ulcer including the origin, RN N and CNA Q both indicated the Resident had the pressure ulcer for a significant amount of time. RN N indicated they believed the pressure ulcer was documented as a stage three facility acquired. After turning Resident #707 onto their side, RN N removed the dressing in place in place over the Resident's sacral/coccyx area. Upon removing the dressing, a foul permeating odor was immediately noted. The removed dressing was noted to have a significant amount of copious, thick gray colored drainage. Upon inspection of the removed dressing, the foul odor became overpowering and increasingly putrid closer to the dressing. The wound was larger than a softball with unattached edges. Visible undermining around the wound. When asked the depth of the wound and undermining, RN N revealed they do not measure the wounds during wound care. RN N was then observed placing their entire hand inside the wound in a C shape. The unattached edges were as deep as RN N's fingers. When asked if the wound undermining was as deep or deeper than their fingers, RN N indicated it was. Visible tunneling was also noted in the wound bed, at approximately the five o'clock position. The depth of the tunneling was unable to be visualized. After cleansing wound bed, RN N packed the wound bed and applied a new dressing. When queried regarding Resident #707's BLE positioning boots, CNA Q stated, They never come off except for with bathing. Upon request, RN N and CNA Q removed the positioning boots on Resident #707's BLE. Upon removing the boot on Resident #707's right foot, a substantial amount of scaly dried skin was observed on the boot and the bed. A visibly noticeable indentation was present on the right heel, where Resident's heel had been observed positioned directly on the hard plastic portion of the positioning boot. The skin on the bottom and sides of Resident #707's right foot was completely covered with a substantial build-up scaly flakes of dead skin tissue covering the living tissue of the foot. When staff touched the foot to move it, large flakes of dead skin and tissue fell from the foot. Visualization of the skin on the Resident's foot was drastically hindered due to the substantial amount of scaling and flaking skin. When queried regarding the condition of the skin on Resident #707's foot, RN N was unable to provide an explanation and stated, I will lotion (Resident #707) up and see. After lotion was applied, a dark colored area, irregularly shaped area, approximately the size of a dime, was noted on the lateral side of the Resident's foot. The area on the foot correlated where Resident #707's foot was observed positioned directly against the hard area of positioning boot. When queried, RN N revealed the skin was not blanchable. RN N then proceeded to remove the boot from the Resident's left foot. The skin on the left foot was also dry and scaly. RN N applied lotion and a dark purplish discolored area, slightly larger than a quarter, was observed on the lateral side of the left foot. The area was directly over the area where the foot had been observed positioned directly against the hard area of the positioning boot. The skin surrounding the area was reddened. Another darkened area, approximately the size of a pencil eraser was observed on the Resident's left heel. When queried, RN N revealed the center, purplish area was not blanchable and the surrounding red skin had minimal blanching. When queried what the areas were, RN N stated, Unstageable Pressure Ulcers. When queried regarding observations of the BLE positioning boots creating pressure on the Resident's foot, RN N was unable to provide an explanation and indicated they would get different boots. RN N and CNA Q were queried again regarding the frequency in which the boots were received. CNA Q stated, Twice a week. RN N and CNA Q were queried regarding Resident #707's alternating air mattress including how staff know what the mattress settings are supposed to be set at, CNA Q stated, My job is to not know it off. RN N then stated, I don't know. Just make sure it is on. An interview was conducted with the facility Administrator on 9/9/21 at 4:49 PM. When queried regarding observations of Resident #707's BLE braces and identification of new, facility acquired, unstageable Deep Tissue Injury (DTI) pressure ulcers, the Administrator was unable to provide an explanation. The Administrator was then asked how staff know what settings alternating air mattresses should be set on for pressure reduction and staff statements, the Administrator did not provide an explanation but indicated a process would be implemented. Resident #709: On 9/9/21 at 12:55 PM, Resident #709 was observed sitting in a Geri chair (padded, reclined rolling chair) in the central dining area of the facility. A staff member was providing total assistance to feed the Resident lunch. Resident #709's hands were under a blanket on their lap and not visible. Record review revealed Resident #709 was originally admitted to the facility 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 to total assistance to perform ADLs. The MDS further revealed the Resident had impaired Range of Motion (ROM) in one upper and one lower extremity, was at risk for pressure ulcer development but did not have any pressure ulcers. Review revealed Resident #709 was admitted to Hospice services on 2/3/21. Review of Resident #709's EMR documentation on 9/9/21 revealed the Wound Evaluation documentation was blank. Review of Resident #709's Skin Assessment documentation detailed the following: - 7/15/21: List site(s) of any existing abnormal skin areas . Left hand (palm) . R/T (related to) contracture of hand the skin of the palm appears red and non-blanch-able . - 7/22/21: Are there any new abnormal skin areas? . Yes . Sacrum 1 X 2 cm approx. List site(s) of any existing abnormal skin areas . L (left) Thumb . - 7/28/21: List site(s) of any existing abnormal skin areas . Left thumb at first joint . Attempted to take a wound picture of left thumb, however even with medication given prior to completing TX, unable to open hand or thumb wide enough to take a picture. Left hand cleansed with normal saline, dried, no new skin disruptions noted, left thumb has a 1 cm circular area noted with intact skin, in the center of the intact skin there is a 0.2 circular area with a depth of 0.2 cm white center, no drainage noted, resident denied pain during TX and tolerated well. ABD pad placed between fingers and palm of hand to thumb, border foam dressing placed over open area and carrot in palm of resident hand . -8/4/21: List site(s) of any existing abnormal skin areas . (blank) . Left thumb assessed; area remains open measures 1 cm circular in shape, base is moist with 100% pink tissue present, resident pre-medicated prior to dressing change, however, would not allow ABD pad to be placed between fingers and palm of hand, nurse notified to attempt again . -8/11/21: List site(s) of any existing abnormal skin areas . (blank) . Assessed left inner thumb, area continues to measure 1 cm circular, base is pink, light serous drainage without odor, resident premedicated prior to dressing change, fingers and palm of hand cleansed, skin intact, resident did allow carrot to be placed in palm of hand although not between fingers, skin between fingers with intact skin, denied any pain during TX. Will continue to manually measure area as staff cannot open hand wide enough to obtain picture . Review of Resident #709's SOC- Skin documentation detailed the following: - 8/20/21: Inner left thumb: 1 cm round circle, Red base with linear yellow slough in center, no odor, pre medicated prior to treatment, no odor 1st digit red blanchable . -8/25/21: Inner left thumb: 1 cm round circle, Red base with linear yellow slough in center, no odor, pre-medicated prior to treatment, no odor 1st digit red blanchable, appears slightly deeper, taking the shape of 1st digit knuckle . -9/4/21: Inner left thumb:0.2 x 0.3 cm, pink, no drainage . At 3:20 PM on 9/9/21, Resident #709 was observed sitting in their Geri chair in their room. The Resident's left hand was observed to be severely contracted with their fingers and fingernails pressed against the palm of their hand. The Resident's left thumb was positioned tightly against the contracted and bent first digit of their hand. No dressing and/or positioning device were present. An interview was completed at this time. When asked if they were having pain, Resident #709 indicated their hand hurt but was unable to rate their pain on a numeric scale. When asked if they had any wounds, Resident #709 did not provide a response. An interview was conducted with RN N on 9/9/21 at 3:29 PM. When queried regarding Resident #709's pressure ulcer, RN N revealed the Resident developed a facility acquired pressure ulcer on the inside portion of their thumb. RN N further revealed the pressure ulcer resulted from their contracted hand. With further inquiry regarding the pressure ulcer, RN N stated, Really bad. You could see the bone. Review of historical MDS data revealed Resident #709's upper extremity ROM impai [TRUNCATED]

This Citation Pertains to Intake Numbers: MI 598, MI 031, and MI 039 Based on interview and record review, the facility failed to ensure pressure ulcers were assessed, monitored, and appropriate interventions were in place for one resident (Resident #1) of three residents reviewed for pressure ulcers from a total sample of six residents, resulting in Resident #1 developing a facility-acquired pressure ulcer on the right buttocks that progressed and extended to the bone with black necrotic (dead) tissue. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set (MDS) assessment, dated 7/6/21, indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status (BIMS) score of 11/15 and needed extensive 2-person assistance with bed mobility, transfers, dressing, bathing, and toileting. The MDS assessment dated [DATE] indicated the resident had a Stage 3 pressure ulcer (Full thickness loss of skin, in which adipose (fat) is visible in the ulcer .) The MDS assessment dated [DATE] indicated there was no pressure ulcer. A review of the progress notes indicated Resident #1 was transferred to another facility on 7/15/21 per his request. A review of a progress note titled, SOC Skin, dated 7/14/21 at 3:10 PM, provided . right gluteal fold: 3.17 (centimeters/cm length) x 2.92 (cm/width) x 4.5 cm (depth), 100% dark brown eschar (dead tissue), edges red, light bleeding with odor . Contributing medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . followed by wound clinic . Treatment history/Current treatment change: wound vac. Review of an SOC Infection note dated 7/12/21 at 11:05 AM revealed, Type of infection/Signs & Symptoms: Wound to bottom. Antibiotic ordered/Susceptibility: [MEDICATION(S)] 1 gm IV (daily) x 10 days . Resident had a PICC (Peripherally Inserted Central Catheter) placed on 7/9/21 Resident seeing wound care and currently has a wound vac in place . A Wound Clinic Note dated 7/7/2021, (Resident #1) is here today for follow-up of a right ischial/buttock ulcer. He has had this for a couple of months now. He has been on IV [MEDICATION(S)] . he has had a foul smell from the right ischial ulcer. Bone scan is scheduled for tomorrow . Skin: Examination shows that he has a very foul smell coming from the ischial ulcer. There is a significant amount of necrotic (dead) tissue within the ulcer. This goes right down to the bone but there is still soft tissue covering the bone . Viable Tissue Assessment: Red; Small (1-33%); Non-Viable Tissue Assessment; Black; Brown; Large (67-100%); Peri-wound Assessment: Irregular; Drainage: Serosanguinous; Moderate; Odor Present after Cleansing: Yes; Wound Length (cm): 4.8 cm; Wound Width: 4.5 cm; Wound Depth: 4 cm; Wound Surface Area (cm2): 21.6 cm2 . Sharp debridement was performed today for the removal of devitalized tissue . A Wound Clinic Note dated 5/11/2021, Here for initial visit Pressure Ulcer buttock; History of Present Illness: Ulcer has been present for about a month. No treatment as of yet .: Viable tissue assessment- Pink; small (1-33%); Non-viable Tissue Assessment- Yellow; Large (67-100%);Peri-wound assessment- Irregular; Painful/Tender; Drainage- Serosanguinous; Moderate; Wound length- 3 cm; Wound Width 1.5 cm; Wound depth- 1 cm; Wound Surface Area (cm2): 4.5 cm2 . Pressure Injury Stage: 3; Operation Performed: Debridement (removal of dead tissue) of wound was medically necessary to remove devitalized tissue, biofilm (film covering wound composed of microorganisms) and exudate (drainage) . 5/11/2021 at 7:01 AM, physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin right gluteal wound infection . Acute Morganella Morganii wound infection . patient has polymicrobial multiple drug-resistant infection . I started patient on [MEDICATION(S)] 500 mg IV 3 times a day for a total duration of 10 days . 5/4/2021 at 7:13 AM, a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . 4/28/2021 at 11:36 AM, SOC Skin note, Area: 3.03 (length) x 1.4 cm (width). Red Base, no drainage, irregular shape, pinpoint yellow center . Interventions: Turn and reposition every 2 hours and PRN (as needed) . Treatment change: petroleum gauze and dry dressing . 4/23/2021 at 12:27 PM, SOC Skin note, Area 1: right gluteal fold, moisture, red beefy base, no drainage noted, no odor noted. 4/20/2021 at 7:18 AM, a Physician's Progress Note provided, . Skin intact . 4/17/21 at 2:33 AM, Nurses Note 4/16/2021 @2300 hours- (11:00 PM) This RN noted that resident's right gluteal fold 5.2 (cm length) x 3.5 (cm width) x 0.2 cm (depth), with black speckles in proximal end and yellow base throughout, with irregular edging . CNA (Certified Nursing Assistant) notified to assist resident to reposition laterally in bed during HS (night) and report to following shift to reposition resident out of w/c (wheelchair) after meals during waking hours . Wound care nurse notified . 4/10/2021 at 10:57 AM, Nurses Note, Says he has been having diarrhea for the past 3 days. Advised him to refrain from coffee and increase intake of cheese and/or bananas. Report back if it did not subside. 3/30/2021 at 7:11 AM, a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Skin Assessments for Resident #1 revealed the following: -4/9/2021 at 11:32 PM, locked 4/10/2021 at 3:49 AM, Are there any new abnormal skin areas- 'Yes.' Right gluteal fold: Ruddy skin with open areas with (irregular) edges 5 x 5 x 0.2 cm total area; Treatment initiated: 'Yes. Comments: EPC (barrier cream) for right gluteal fold ordered BID (twice a day) until resolved. -4/16/2021 at 2:59 PM, Are there any new abnormal skin areas? 'No.' . Are there any existing abnormal skin areas? 'Yes.'; List sites of any existing abnormal skin areas, (no documentation); Comments: Right gluteal fold red, irritated area noted, continue treatment. -4/23/2021 at 11:32 PM and locked on 4/24/2021 at 1:02 AM, Are there any new abnormal skin areas? 'No'; Are there any existing abnormal skin areas? 'Yes,'; List site of any existing abnormal skin areas: Other: Right inner thigh open area; treatment continues. -4/30/2021 at 11:32 PM, Are there any existing abnormal skin areas? 'Yes.'; Right gluteal fold: Open wound with treatment continues . -5/7/2021 at 11:32 PM, Are there any existing abnormal skin areas? 'Yes.'; Site: unstageable open area with thick yellow slough and dark area inside depth, pink granulous tissue on edges; treatment continues . -5/16/2021 at 3:58 AM, Are there any existing abnormal skin areas? 'Yes.'; Site: Right gluteal fold: open area with treatment continues . A review of the Physician Orders for Resident #1 provided the following: 4/9/2021 at 22:51 PM, Cleanse right gluteal fold with soap and water, rinse, pat dry. Apply EPC (barrier cream) topically BID and prn until resolved. CNA (Nurse Aide) may apply, every day and night shift. The treatment continued until 4/19/2021 (10 days). 4/19/2021 at 12:00 PM, Cleanse right gluteal fold with wound cleanser, pat dry, apply dry dressing daily and prn, every day shift. The treatment continued until 4/21/2021. 4/22/2021 Cleanse right gluteal fold with wound cleaner, pat dry apply [MEDICATION(S)] gauze (Vaseline) and dry dressing daily and prn, every day shift. The treatment continued until 5/5/2021. The wound orders for Resident #1 varied based on the Wound Clinic recommendations after the first visit on 5/11/2021. 4/17/2021, a large right gluteal wound was described with wound measurements. A review of the progress notes and skin assessments indicated the resident develop a right gluteal wound on 4/9/2021; a treatment with ointment/cream was ordered on 4/9/2021 to be applied by the nurse aides. The resident complained of diarrhea on 4/10/2021. On 4/17/2021, a large right gluteal wound was described with wound measurements and black spot (necrosis); The nurse recommended repositioning of the resident to relieve pressure to the area. The treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses were not seeing the wound daily and the weekly skin assessments had little description of the wound. The treatment was changed on 4/19/2021. A consult with the Wound Clinic occurred on 5/11/2021. The physician did not document findings of a wound on the resident's right gluteal fold until 5/11/2021- 1 month and 2 days after it was identified. The Wound Nurse's first 'SOC Skin' note on 4/23/2021 was very brief with little description of the wound and no measurements. The next 'SOC Note' was on 4/28/2021 with measurements. On 4/17/2021, a nurse on the night shift provided a detailed description with measurements of the wound. A treatment was not initiated to address the enlarging wound with necrotic areas until much later- 5/5/2021 . 'Apply [MEDICATION(S)] to slough (stringy dead tissue) in wound bed . This was almost 3 weeks after the resident's wound was noted to worsen with Black speckles. On 7/16/21 at 4:43 PM, during an interview with Confidential Person C, she stated, He had a stroke and didn't have use of his right side. He needed 2-assist with transfer and would not always get transferred. He was in bed or wheelchair for prolonged periods of time. People just would not get him up. He would not get changed every 2 hours. He developed a wound on his right buttock; a Stage 2. He asked me repeatedly for a Wound consult. I told him I would ask Nurse B and said, We are in the process of handling it. He would say, They didn't change my dressing yesterday. During an interview with Resident #1 on 7/22/2021 at 9:25 AM, he was asked about his right gluteal fold wound and stated, I explained to them about turning. They were supposed to turn me every 2 hours, once in awhile they would and more often than not they wouldn't. I got the wounds from not being turned. Laying the same way all the time. The Wound doctor said I was supposed to be turned and I was supposed to get up in the chair every day, but only for so long. An interview with Wound Care Nurses B and P, on 7/22/2021 at 4:56 PM revealed Nurse B completed the wound log and SOC notes, and Nurse P took pictures, measured and documented the resident's wounds. Nurse B said the nurses took measurements and wound pictures on Wednesdays; If I'm here, we do the more complex wounds together. During the interview, the Nurses were asked about the right gluteal wound on Resident #1 and said it began on 4/26/21 (this was 17 days after it was identified) and was a Stage 2 pressure ulcer (partial-thickness skin loss with exposed dermis). The Nurses said repositioning was one of the interventions recommended More side-to-side- as much as he would allow. The facility standard is every 2 hours. The nurses said they set up a Wound clinic visit as the wound worsened. Nurse B said the wound continued to decline to a Stage 4 on discharge (7/15/2021), with a dark brown base, odorous and increased depth. A review of the facility policy titled, Pressure Injury Prevention and Management, date reviewed/revised 10/30/2020 and date implemented 1/1/2021, provided: Policy: this facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. Definitions: Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. The facility shall establish and utilize a systematic approach for pressure injury prevention and management including prompt assessment and treatment . Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly and after any newly identified pressure injury. Findings will be documented in the medical record . Assessment of pressure injuries will be performed by a licensed nurse, and documented in the medical record . Interventions will be documented in the care plan and communicated to all relevant staff . Monitoring: The attending physician will be notified of: The presence of a new pressure injury upon identification; The progression towards healing, or lack of healing, of any pressure injuries weekly .

This citation pertains to intake MI 829. Based on interview and record review, the facility failed to 1) ensure resident pain was controlled, 2) follow physician orders [REDACTED]. Review of the face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 5/11/19, Physician, Nurses and Social Service note's and physician orders [REDACTED]. Resident #10 was [AGE] years old, admitted to the facility on [DATE], moderately cognitively impaired until a sudden change of condition on 3/8/19, required staff assistance with all Activities of Daily Living (ADL's) and was receiving Hospice services for comfort care due to a terminal prognosis. The resident's [DIAGNOSES REDACTED]. The resident fell at the facility on 3/8/19 at 11:30 p.m. and was transferred to the hospital due to a left wrist fracture on 3/9/19. The resident had a history of [REDACTED]. Review of the physician order [REDACTED]. Review of the residents Terminal Prognosis care plan dated 4/6/17, up-dated 2/19/18, stated Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain (pain that is not controlled with scheduled pain medication). Review of the nurse's notes, and facility Incident/Accident report dated 3/8/19, revealed Resident #10 had fallen on 3/8/19 at 11:30 p.m., and was found by staff sitting on the floor next to the bed. Review of the nurse's notes dated 3/9/19, revealed the resident was transferred to the hospital on [DATE], due to a fractured left wrist with verbalization of extensive pain and discomfort. Review of the hospital ED (Emergency Department) physician progress notes [REDACTED]. [MEDICATION NAME] (antianxiety medication) 1 mg PO (by mouth) given for agitation, [MEDICATION NAME] 50 mcg (opioid pain medication patch) applied for continued pain control. Injury or trauma; fall Initial encounter; [MEDICATION NAME] trauma, found on floor this morning, pain in wrist area. Review of the residents EMAR (Electronic Medication Administration Record) dated 3/19, accompanied by Assistant Director of Nursing (ADON) L revealed, the physician order [REDACTED].>-On 3/4/19 at 6:00 a.m. the MS was not given for other reason. Nurses notes dated 3/4/19 at 5:05 a.m. (medications can be given 1 hour before and 1 hour after scheduled time), stated resting quietly in bed, no documentation of assessing or waking the resident up for a scheduled pain medication or calling the physician to inform him that a scheduled medication was held was found. -On 3/4/19 at 8:00 a.m., the MS was not given due to sleeping. Nurses notes dated 3/4/19 at 8:00 a.m., had no documentation why resident was not given MS or the physician called and informed. -On 3/4/19 at 12:00 p.m., the MS was not given due to sleeping. Nurses notes dated 3/4/19 at 11:15 a.m., stated resident sleeping comfortably at this time. No documentation of why the nurse did not wake the resident up and give the scheduled medication or inform the physician was found. -On 3/4/19 at 2:00 p.m., 4:00 p.m. and 6:00 p.m., the MS was not given due to sleeping. Review of the nurse's notes dated 3/4/19 at 11:15 a.m. through 10:06 a.m., revealed no documentation at all. No documentation of why the nurse did not wake the resident up and give the scheduled medication or inform the physician was found. -On 3/4/19 at 10:00 p.m., the MS was not given due to Hold. Review of the nurse's notes dated 3/4/19 at 10:07 p.m., stated Patient resting comfortably. No documentation of why the nurse did not wake the resident up and give the scheduled medication or inform the physician was found. -On 3/5/19 at 4:00 a.m., the MS was not given due to Hold. Review of the nurse's notes dated 3/5/19 at 3:26 a.m., stated Patient resting comfortably. No documentation of why the nurse did not wake the resident up and give the scheduled medication or inform the physician was found. -On 3/5/19 at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m. and 6:00 p.m., the MS was not given due to refused or sleeping. Review of the nurse's notes dated 3/5/19 at 3:26 a.m. through 10:46 p.m., revealed no documentation at all. No documentation of why the nurse did not wake the resident up and give the scheduled medication or inform the physician was found. -On 3/6/19 at 6:00 a.m., 2:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m., the MS was not given due to sleeping and refuse. Review of the nurse's notes dated 3/6/19, revealed on one entry at 12:48 p.m., stating Late Entry, no abdominal discomfort. No documentation of why the nurse did not wake the resident up and give the scheduled medication or inform the physician was found. -On 3/7/19, at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m. and 10:00 p.m., the MS was not given due to refused and hold. Review of the nurse's notes dated 3/7/19, revealed only one entry related to not giving the residents MS, at 10:24 p.m., due to patient is resting comfortably. No documentation of why the nurse did not wake the resident up and give the scheduled medication or inform the physician was found. -On 3/8/19, at 2:00 a.m., 6:00 a.m., 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m. and 10:00 p.m., the MS was not given due to refused, hold, other, and sleeping. Review of the nurse's notes dated 3/8/19 at 2:40 a.m., 2:41 a.m. and 5:00 a.m., stated Patient resting comfortably, Med held at this time. No documentation of why the nurse did not wake the resident up and give the scheduled medication or inform the physician was found. -On 3/9/19 at 2:00 a.m., 6:00 a.m., 8:00 a.m. and 2:00 p.m. (should have been given at 1:00 p.m., prior to transfer to the hospital) MS was not given due to, hold, and sleeping. Review of the nurse's notes dated 3/9/19, revealed only two entries, at 4:15 p.m. and 5:30 p.m., with no documentation regarding the MS not given or of the physician being informed of the scheduled medication not given found. Review of the EMAR dated 3/4/19 through 3/9/19, revealed a total of 40 times the resident did not receive a scheduled pain medication (MS 2 mg) with no documentation found confirming the physician was contacted regarding the medication not given. During a phone interview done on 3/20/19 at 12:05 p.m., the Hospice Nurse, RN W stated On 3/9/19 at about 10:30 a.m., (Resident #10) was laying down, sitting up, uncomfortable. She was moaning, her arm (left arm/wrist area) was extremely swollen, black and blue. I noticed she was rocking and moaning, (Nurse, RN P) was her nurse. I found the nurse and we went in the room. About a little bit after 11:00 a.m., I called the hospice doctor to get an order for [REDACTED]. She was in a lot of pain. I gave the verbal order from (physician I) to (Nurse P), that's the facility policy. She (the resident) fell on [DATE] at 11:30 p.m., and I found the arm fracture about eleven hours later. She had a history of [REDACTED]. During an interview done on 3/20/19 at approximately 1:00 p.m., this surveyor requested of the Director of Nursing/DON and Administrator the facility policy for physician orders [REDACTED]. The Administrator and DON said the facility did not have a policy for hospice residents physician orders. Review of the Hospice notes dated 3/9/19, stated (Physician I) notified and was given order for [MEDICATION NAME] 0.5 ml (an opioid pain medication) every 1 hour as needed. (Nurse P) stated she would continue to give scheduled [MEDICATION NAME] and [MEDICATION NAME] as well as PRN (as needed) [MEDICATION NAME] ([MEDICATION NAME] .5 ml) until symptoms were managed. (Hospital Nurse, RN W) stated she told (Nurse P) to administer 1 p.m. dose of [MEDICATION NAME] before sending patient to ER. Resident #10 was transferred to the ER due to a fractured left wrist with severe pain. During a phone interview done on 3/20/19 at 3:13 p.m., Primary Physician MD I stated Yes, I do remember giving the order for [MEDICATION NAME] to be given to her (the resident, prior to being transferred to the hospital on [DATE]). The facility had a difficult time keeping her pain free and they had to change the dosage several times. Review of Resident #10's physician orders [REDACTED]. Review of the facility Medication Orders policy dated 12/2017, stated A current list of orders must be maintained in the clinical record of each resident. During a phone interview done on 3/20/19 at 3:13 p.m., Nurse, RN P stated I misunderstood (Hospice Nurse, W), it was a miscommunication. It was lack of education, after we (nursing staff) were educated (after the MS doses were not given to the resident per physician order). There were nurses who said they were not comfortable with how much [MEDICATION NAME] she was getting. I wasn't educated before, they (nursing management) just said, give it, give it. We meet after, the (ADON Nurse L) noticed it was being held. When this surveyor asked Nurse P if she was educated on pain control medications or hospice residents physician pain mediation orders during her facility orientation she stated, they didn't really touch on orders. During an interview done on 3/21/19 at 12:41 p.m., Nurse, LPN S stated, There was lots of times she refused it (pain medication) or was sleeping. You are supposed to call the doctor if you don't give it; I did not call the doctor. It was a mistake, I should have called the doctor. During an interview done on 3/21/19 at 12:55 p.m., Nurse, LPN T was asked by this surveyor why she did not give the residents scheduled pain medication and she stated, The reason is because she was resting comfortably. I did not call the doctor, she was resting peacefully, and I now know that was wrong. Review of the facility Clinical Protocol for Pain dated 3/22/11, stated The staff will discuss significant changes in levels of comfort with the Attending Physician who will adjust interventions accordingly. During an interview done on 3/20/19 at 10:50 a.m., the ADON Nurse, RN L stated I spoke to (the hospital ER nurse V) on the phone (on 3/9/19), she said she (the resident) appeared uncomfortable and they were going to try [MEDICATION NAME] Patch. I would have woken her up and given it (the scheduled MS). ADON L revealed after she became aware the residents scheduled MS had not been given per orders, the facility began to educate the nurses regarding scheduled medications stating, our education (education done on 3/11/19 and 3/12/19) was about the nurses and not giving a scheduled medication. Review of the facility Investigation Conclusion (un-dated), stated Immediate education provided to the nurse on duty at the time of the fall that Doctor's order must be obtained to hold medications. All nurses given education from (the Facility) regarding pain management in the end of life palliative care. Review of the facility Nurse Meeting and In Service dated 3/12/19 and 3/13/19, revealed nursing staff had been educated on scheduled medications and physician orders [REDACTED]. Review of the facility Administering Medications policy dated 5/2018, stated Medications must be administered in accordance with the orders, including any required time frame. If a drug is withheld by nursing judgement or physician order [REDACTED]. Opioids are one of the most common medications administered to terminal patients. The risk of intense pain from withholding pain medications can cause severe hemodynamic consequences like respiratory depression, [MEDICAL CONDITION] or stroke. The pain medication dose should not be changed abruptly or decreased (withholding scheduled opioid pain medications). AMA (American Medical Association) Journal of Ethics, Common Misconceptions about Opioid Use for Pain Management at the End of Life, Jack M. Berger, MS, MD, PhD and Nalini Vadivelu MD Cass And Commentary (MONTH) 2013

This citation pertains to intake number MI 939. Based on interviews and records review, the facility failed to initiate, timely, the administration of medications specified for the methodic, medical management of constipation (bowel protocol), and in accordance with Primary Care Provider's (PCP) orders, for 1 of 4 sampled residents (#101) who developed constipation, from a total sample of 4 residents reviewed for bowel protocol followed, resulting in Resident #101 experiencing abdominal pain, fever, nausea, vomiting and emergent transfer to a local hospital. Findings include: The face sheet revealed Resident #101 was an [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Discharge Summary dated 7/28/2014 at 1:37 PM, and present in the facility's medical file for review by the State Surveyor, Resident #101 had been hospitalized with a UTI (urinary tract infection) and did develop [MEDICAL CONDITION] and [MEDICAL CONDITION], initially, and did require a stay in the ICU (intensive care unit) for some time with vasopressors. Resident #101 was documented to have been discharged from the hospital to the facility on [DATE]. Review of the Nursing Comprehensive Admission Data Collection and Assessment form dated 7/28/2014 at 1710 (5:10 PM) revealed Resident #101 was asked on admission to the facility about her usual bowel pattern; it was documented that her response was daily. The Resident was asked when she had last had a bowel movement; it was documented that her response was 'can't remember.' According to the Nursing Comprehensive Admission Data Collection and Assessment, Resident #101 was assessed as oriented to both person and time. The Skilled Care Alert Charting Form dated 7/28/2014 (untimed) revealed facility staff identified Resident #101 with a gastrointestinal issue; constipation. The Minimum Data Sets ((MDS) dated [DATE] assessed Resident #101 as requiring minimal to extensive assistance from facility staff for activities of daily living (ADL's), including toileting, and had no entry relative to the Resident's level of cognition. The PCP orders dated 7/28/2014 (untimed), and revised 7/31/2015 (untimed), specified Resident #101 was to receive twice daily administration of [MEDICATION NAME] Sodium (stool softener), orally, for constipation. According to the Medication Administration Records (MAR) for July 2014 and August 2014, Resident #101 received [MEDICATION NAME] sodium as ordered by her PCP. The PCP orders dated 7/28/2014 (untimed), and revised 7/31/2015 (untimed) specified that facility staff was to initiate a bowel program for Resident #101 beginning with 30 milliliters of Milk of Magnesia, orally, if the Resident did not have a bowel movement after 8 shifts (defined by Resident #101's attending physician, witness I during a phone interview on 9/16/2015 at 1:10 PM, as 8, 8 hour shifts). If no results (bowel movement) were achieved from the administration of the Milk of Magnesia, the physician order [REDACTED]. If no results (bowel movement) were achieved from the administration of the suppository, the Resident was to receive rectal administration of a Fleets enema. Review of the Alteration in Bowel Elimination Plan of Care initiated 7/29/2014, revealed Bowel Assessment indicates Resident's bowel dysfunction appears related to the following conditions: decreased mobility and dementia. Identified as a goal of care, Resident #101 was tohave a BM (bowel movement) every 3 days. Interventions identified in the Plan of Care included monitor bowel elimination using CareTracker and provide medication as ordered to aid elimination as ordered (see MAR). According to the Bowel and Bladder Chart Detail Report (CareTracker) for the period 7/28/2014 through 8/4/2014 (date of Resident #101's transfer to a local hospital for evaluation), Resident #101, who had not been able to recall the date of her last bowel movement to facility staff on the date of her admitted d 7/28/2014, did not have a bowel movement until 8/3/2014 (medium sized stool); according to the MAR, initiation of the bowel protocol had not occurred until 8/2/2014 with the administration of Milk of Magnesia; approximately 12, 8 hour shifts from the date of her admission to the facility and minimally 12, 8 hour shifts from her self-report to facility staff that she could not recall when she had last had a bowel movement. According to the Nurses Progress Note dated 8/4/2014 at 1530 (3:30 PM), Resident #101 had developed fever, was vomiting, complained of an upset stomach, and unable to hear a blood pressure at 6:40 AM; the Resident's attending physician was documented as notified of the Resident's change of condition and was sent to the first of two local hospitals for emergent evaluation. According to the Operative Report dated 8/4/2014 at 4:48 PM, Resident #101 was diagnosed with [REDACTED]. Resident #101 was documented to have continued care in the intensive care unit. During an interview on 9/15/2015 at 10:35 AM, Registered Nurse C said she had provided care for Resident #101. I remember the Resident's daughter, an aide here, told me that her mother (Resident #101) hadn't had a stool, yet. The Resident had been given Milk of Magnesia the day before, on 8/2/2014 at 10:00 PM. She had a medium stool on 8/3/2014; we don't count small stools. For her (Resident #101), the bowel protocol should've been started by 7/30/2014; the doctor's orders weren't followed. The doctor's order was hard to follow because it reads to follow the protocol if there's no BM after 8, 8 hour shifts. It should read if no BM after so many hours, start the protocol. The order was open to interpretations. During an interview on 9/15/2015 at 11:10 AM, Director of Nursing B said, We didn't follow the doctor's orders for this resident (Resident #101). She went for 5 days without a stool; we don't count small stools. I wasn't aware we had an issue with her and BM's. It's obvious we had an issue, but didn't follow the bowel protocol. If a resident hasn't had a BM in 24 hours, we give the resident a bran muffin, if they're able to have one. After 48 hours and no BM, we give Milk of Magnesia. After 72 hours with no BM, we give a [MEDICATION NAME] suppository, then after 96 hours, we give a Fleet's enema. After that, if no BM we contact the doctor. We dropped the ball on her. The doctor's wording on his order is unclear. During a phone interview on 9/16/2015 at 1:10 PM, Resident #101's attending physician, witness I said he did not recall that facility staff had notified him that Resident #101 had experienced a prolonged period of constipation, or that the Resident had told facility staff on admission to the facility, dated 7/28/2014, that she could not recall when she had last had a stool. Witness I said, I expect staff to follow my orders. Review of the Nurses Progress Notes for the period 7/28/2014 through 8/3/2014 revealed no communication to the Resident's attending physician regarding Resident #101's prolonged period of constipation, or that the Resident had told facility staff on admission to the facility, dated 7/28/2014, that she could not recall when she had last had a stool. ( )

This citation pertains to intake number MI 939. Based on interviews and records review, the facility failed to follow Primary Care Provider's (PCP) orders which specified the initiation of a bowel protocol to treat constipation for 1 of 4 sampled residents (#101) who developed constipation, from a total sample of 4 residents reviewed for Physician orders [REDACTED].#101 experiencing abdominal pain, fever, nausea, vomiting and emergent transfer to a local hospital. Findings include: The professional standard of quality for physician orders [REDACTED]. The face sheet revealed Resident #101 was an [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Discharge Summary dated 7/28/2014 at 1:37 PM, and present in the facility's medical file for review by the State Surveyor, Resident #101 had been hospitalized with a UTI (urinary tract infection) and did develop [MEDICAL CONDITION] and [MEDICAL CONDITION], initially, and did require a stay in the ICU (intensive care unit) for some time with vasopressors. Resident #101 was documented to have been discharged from the hospital to the facility on [DATE]. Review of the Nursing Comprehensive Admission Data Collection and Assessment form dated 7/28/2014 at 1710 (5:10 PM) revealed Resident #101 was asked on admission to the facility about her usual bowel pattern; it was documented that her response was daily. The Resident was asked when she had last had a bowel movement; it was documented that her response was 'can't remember.' The Skilled Care Alert Charting Form dated 7/28/2014 (untimed) revealed facility staff identified Resident #101 with a gastrointestinal issue; constipation. The PCP orders dated 7/28/2014 (untimed), and revised 7/31/2015 (untimed), specified Resident #101 was to receive twice daily administration of [MEDICATION NAME] Sodium (stool softener), orally, for constipation. According to the Medication Administration Records (MAR) for July 2014 and August 2014, Resident #101 received [MEDICATION NAME] sodium as ordered by her PCP. The PCP orders dated 7/28/2014 (untimed), and revised 7/31/2015 (untimed) specified that facility staff was to initiate a bowel program for Resident #101 beginning with 30 milliliters of Milk of Magnesia, orally, if the Resident did not have a bowel movement after 8 shifts (defined by Resident #101's attending physician, witness I during a phone interview on 9/16/2015 at 1:10 PM, as 8, 8 hour shifts). If no results (bowel movement) were achieved from the administration of the Milk of Magnesia, the physician order [REDACTED]. If no results (bowel movement) were achieved from the administration of the suppository, the Resident was to receive rectal administration of a Fleets enema. Review of the Alteration in Bowel Elimination Plan of Care initiated 7/29/2014, revealed Bowel Assessment indicates Resident's bowel dysfunction appears related to the following conditions: decreased mobility and dementia. Identified as a goal of care, Resident #101 was tohave a BM (bowel movement) every 3 days. Interventions identified in the Plan of Care included monitor bowel elimination using CareTracker and provide medication as ordered to aid elimination as ordered (see MAR). According to the Bowel and Bladder Chart Detail Report (CareTracker) for the period 7/28/2014 through 8/4/2014 (date of Resident #101's transfer to a local hospital for evaluation), Resident #101, who had not been able to recall the date of her last bowel movement to facility staff on the date of her admitted d 7/28/2014, did not have a bowel movement until 8/3/2014 (medium sized stool); according to the MAR, initiation of the bowel protocol had not been initiated until 8/2/2014 with the administration of Milk of Magnesia; approximately 12, 8 hour shifts from the date of her admission to the facility and minimally 12, 8 hour shifts from her self-report to facility staff that she could not recall when she had last had a bowel movement. According to the Nurses Progress Note dated 8/4/2014 at 1530 (3:30 PM), Resident #101 had developed fever, was vomiting, complained of an upset stomach, and unable to hear a blood pressure at 6:40 AM; the Resident's attending physician was documented as notified of the Resident's change of condition and was sent to the first of two local hospitals for emergent evaluation. According to the Operative Report dated 8/4/2014 at 4:48 PM, Resident #101 was diagnosed with [REDACTED]. Resident #101 was documented to have continued care in the intensive care unit. During an interview on 9/15/2015 at 11:10 AM, Director of Nursing B said, We didn't follow the doctor's orders for this resident (Resident #101). She went for 5 days without a stool; we don't count small stools. I wasn't aware we had an issue with her and BM's. It's obvious we had an issue, but didn't follow the bowel protocol. If a resident hasn't had a BM in 24 hours, we give the resident a bran muffin, if they're able to have one. After 48 hours and no BM, we give Milk of Magnesia. After 72 hours with no BM, we give a [MEDICATION NAME] suppository, then after 96 hours, we give a Fleet's enema. After that, if no BM we contact the doctor. We dropped the ball on her. The doctor's wording on his order is unclear. During a phone interview on 9/16/2015 at 1:10 PM, Resident #101's attending physician, witness I said he did not recall that facility staff had notified him that Resident #101 had experienced a prolonged period of constipation, or that the Resident had told facility staff on admission to the facility, dated 7/28/2014, that she could not recall when she had last had a stool. Witness I said, I expect staff to follow my orders. ( )

This citation pertains to intake number MI 173. Based on interviews and record review, the facility failed to prevent falls in 2 of 5 sampled residents (Residents #102 and #103) reviewed for falls, from a total sample of 5 residents, resulting in Resident #102 experiencing a fall with dehiscence (rupture of a wound closure) of a recent surgical incision (right high proximal, above the knee amputation; extension of an above the knee amputation to the right hip) and hospitalization , and also resulting in Resident #103 experiencing a fall and sustaining a large skin tear to her left forearm and a bump to the left side of her head. Findings include: Resident #102 The facesheet revealed Resident #102 was a [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets ((MDS) dated [DATE] (untimed), revealed Resident #102 was mildly cognitively impaired, and required extensive assistance from a facility staff member with activities of daily living (ADL's), including transfers (movements from surface to surface). The Admission Skin assessment dated [DATE] at 1:30 PM, revealed Resident #102 had an incision of her right groin area (site of the right above knee amputation which extended to the area of the Resident's right hip) revealing presence of 30 sutures. According to the Physician Admitting History and Physical dated 5/3/2014 (untimed), Resident #102 was assessed with [REDACTED]." According to the facility Resident Incident form dated 5/10/2014 (untimed), Resident #102 was found on the "right side of her bed, next to the commode with blood on the floor and draining from her right amputation" on 5/10/2014 at 4:00 AM. The report included, "three stitches altogether had split. One in the upper part closer to the hip had a quarter size blood clot." The location of the injury was documented as "right anterior upper thigh." The report included the incident was not witnessed, and that the Resident had stated she was 'trying to use the commode to go to the bathroom." The report included a call light was available, was within reach, and was functioning at the time of the incident; it did not include whether or not the call light had been utilized. The report included the use of a bedside commode was "Provider ordered." According to the Progress Notes dated 5/10/2014 at 5:45 AM, Resident #102 had experienced a fall and was found by a CNA (nurse aide) on the floor of her room, "leaning bodily next to the commode, right amputation bleeding. There was blood on the floor. Grabbed fresh abd. pads (thick pads used to absorb large amounts of body fluids) to assess site to see where bleeding was coming from. Three stitches had split open. One area had a quarter size clot. Intervention is to educate the importance on need for assistance for commode for safety. Left facility at 5:10 AM." According to the Transfer Summary dated 5/16/2014 (untimed) hospital assessment of Resident #102 on 5/10/2014 documented "she was trying to transfer herself and fell , sustained injury to the stump and started bleeding, also some sutures came out. Resident #102 was documented to have remained at the hospital until the date of her discharge on 5/16/2014. Review of Resident #102's medical file, including the Physician orders, interdisciplinary Progress Notes, Care Plans, Care Delivery Guide, or Therapy (PT, OT) notes did not include specific instructions/documentation, given prior to Resident #102's fall on 5/10/2014 at 4:00 AM, that she was not to use the commode placed at her bedside by facility staff, without assistance. During an interview on 5/29/2014 at 9:50 AM, Physical Therapist "E" said, "She (Resident #102) was at risk for falls. As of 5/9/2014 (identified as the last day Resident #102 was seen by therapy staff at the facility prior to the Resident's fall on 5/10/2014, and subsequent hospitalization ) she could transfer with use of a walker and use of a gait belt, to a bedside commode by CGA (contact guard assist; a facility staff member holding onto a gait belt for safety). She was not safe for self transfer. Someone would have to hold onto her belt." During a phone interview on 5/29/2014 at 11:10 AM, Resident #102 (who resided on "D" hallway) said she had put her call light on for assistance on 5/10/2014, and had waited for approximately 30 minutes. She said facility staff had placed a commode next to her bed, but had not educated her that she could not use it without assistance. "No one told me I couldn't use it on my own; I'd been practicing in therapy. If they didn't want me to use it, why did they put it next to my bed." During a phone interview on 5/29/2014 at 1:25 PM, CNA "F" said she had been assisting a nurse with another resident experiencing a blood sugar problem on the "B" wing, taking about 10 minutes, then left the building for a 10 minute cigarette break. CNA "F" said when she returned to "D" hallway, Resident #102's call light was on. CNA "F" was unable to determine the exact length of time Resident #102's call light had been on. "I found the Resident (#102) on the floor between the commode and the bed. She was bleeding. She just got up by herself." During an interview on 5/30/2014 at 11:45 AM, interim director of Nursing "B" reviewed Resident #102's medical file and said, "The Nurses Notes for this Resident on 5/10/2014 at 5:45 AM says "to educate importance on need for assistance for commode, for safety. This is written as an intervention, after the Resident (#102) had already fallen. We don't have any documentation in this file that the Resident received education not to use the commode placed at her bedside, without assistance; if it's not charted, it's not done." On 5/30/2014 at 12:25 PM, the Nursing Home Administrator (NHA) said that all residents receive, on admission to the facility, an admission packet that includes a "Fall Prevention" leaflet; the NHA, DON, and Regional Director of Clinical Operations (RDCO, witness "O") acknowledged there was no documentation that Resident #102 received the leaflet or that facility staff reviewed the leaflet with her. Resident #103 The facesheet revealed Resident #103 was a [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets ((MDS) dated [DATE] (untimed), revealed Resident #103 was severely cognitively impaired, experienced both long- and short-term memory loss, experienced recent falls, and required extensive assistance from a facility staff member with activities of daily living (ADL's), including transfers (movements from surface to surface) and toileting. The Fall/Injury Assessment Care Plan revised 5/11/2014 (untimed), specified Resident #103 was to be toileted every 2 hours while awake, and toileted every 3 hours during the night. The Care Delivery Guide (care guide used by nurse aides to provide care) initiated 5/2/2014, was revised (undated) to include Resident #103 was to be toileted every 2 hours while awake, and toileted every 3 hours during the night. According to the facility Resident Incident form dated 5/28/2014 (untimed), Resident #103 experienced a fall on 5/28/2014 at 6:25 AM, which was heard by Therapy Aide "G." Resident #103 was reported as found sitting in a pool of urine by her night stand. She was reported to have sustained a large skin tear of her left forearm, and a bump to the left side of her head. Resident #103 was documented to have remained at the facility for continued care/assessments. Documented in the report was "staff were educated on the importance of following the care plan." Documentation within the report included Resident #103, who was care planned for toileting every 3 hours during the night, had last received toileting at 12:15 AM; she was found seated on the floor of her room, in urine, at 6:25 AM. An unsuccessful attempt was made on 5/28/2014 at 4:30 PM to interview Resident #103 who responded to questions with confused conversation. During interviews on 5/29/2014 at 3:00 PM with therapy aide "G," on 5/29/2014 at 3:15 PM with CNA "I," and on 5/30/2014 at 8:55 AM with LPN "M," all of the above said they had not witnessed Resident #103's fall, but had observed the Resident on the floor of her room on 5/28/2014 at 6:25 AM, sitting in a "puddle of urine." During an interview on 5/30/2014 at 11:45 AM, the interim Director of Nursing said it was expected that facility staff follow Care Plans/Care Delivery Guides.

The following citation pertains to MI 883: Based on observation, interview and record review, the facility failed to maintain wound assessments in the clinical record, and failed to identify, monitor and provide appropriate treatment in order to prevent pressure ulcers developing for 1 of 4 residents (#1) reviewed for pressure ulcers, out of a total sample of 4 residents, resulting in potentially avoidable pressure areas to the resident's left thumb and buttocks, and unstageable wounds (wounds with necrosis) to the resident's right and left ears. Findings include: According to the Face Sheet dated 5/12/14 Resident #1 was a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of "2", meaning Resident #1 had severe cognitive impairment. Further review of the medical record revealed a "Transfer Form" dated 5-4-14 at 1830 (6:30 p.m.) from the nursing home facility to the hospital. The reason for the transfer was "(increased) blood sugar 509, (decreased) BP (Blood Pressure) 92/56, lethargic (drowsiness/weak)." Review of the hospital "Registration Admission" dated 5/5/14 revealed "Chief Complaint/admitting [DIAGNOSES REDACTED]." The Hospital "Physician Documentation" dated 5/4/14 stated: "...The patient appears lethargic, obviously ill, unkempt." Review of the Hospital "Patient Care Notes" dated 5/4/14 stated: "...Pt (Patient) has contractures of bilateral hands, red circular blister to left thumb, black necrotic appearing spot on left lateral earlobe. She has extensive open wounds to bilateral buttocks, coccyx which are pink, raw and oozing serous fluid. White thin skin midline buttock with open area beneath. Pt's hair is oily, unkept, lips are crusting and peeling in large layers, teeth and tongue are covered with thick plaque, eyelids are crusted. (See photos on chart)." This surveyor's review of the Hospital "Photo Documentation Record" dated 5-4-14 revealed that Resident #1's left ear had a black area surrounded by redness midline on the outer lobe. The photo of Resident #1's left thumb showed a circular brownish/red area. Resident #1's buttocks showed the coccyx (tailbone) area as being red and having open areas. The resident's left buttocks were also red and had several open areas. The facility's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1's Functional Status for "Bed Mobility" was a "3", meaning she needed "extensive assistance" from staff in order to reposition herself in bed. Resident #1's "Dressing", "Eating", "Toilet Use" and "Personal Hygiene" were all "3's" ("extensive assistance"). "Bathing" for Resident #1 was a "4", meaning "Total Dependence" on staff. On 5-14-14 at 10:30 a.m. in Resident #1's room, the resident's wound care to her buttock, coccyx and ear lobes was observed being performed by facility nurse "A" and nurse aide "H". Resident #1's buttock and coccyx areas were observed to be red in color with several open areas. Nurse "A" was observed to apply [MEDICATION NAME] ointment (a zinc oxide topical cream that is used to protect the skin and dry oozing/weeping [MEDICAL CONDITION]) to the buttocks and coccyx areas. Both the left and right ear had a black area (necrotic tissue) located in the middle of the ear of the outer lobe. Resident #1's left thumb was observed to have a brown circular pressure area that was not open. No wound care was provided to the ears or thumb during the observation. Review of Resident #1's "Skin Grids" for April 2014 (facility documentation of her skin condition) revealed her buttocks were last assessed on 4-21-14, 11 days before Resident #1 was transferred to the hospital. The "Skin Grid" for the Right Lower and Upper Buttock and the Left Buttock described the areas as "moisture excoriation." The size of the left buttock wound was measured as 2 cm (centimeters) long by 1.1 cm wide by 0.1 cm deep. The size of the right upper buttock wound was 2 cm long by 1 cm wide by 0.1 cm deep. The size of the right lower buttock wound was 0.4 cm long by 0.2 cm wide by 0.1 cm deep. There were no "Skin Grids" completed for either the right or left ear, or the left thumb to show that those areas were identified as areas of concern. The facility treatment binder, and Resident #1's clinical record, were reviewed for additional skin grids, and none were located. On 5-14-14 at 1:45 p.m. a phone call was placed to the facility wound care nurse "B". Wound care nurse "B" said she had made extensive notes related to Resident #1. Wound care nurse "B" said she remembered the wounds being excoriated, and she felt the wounds were moisture associated [MEDICAL CONDITION] (MAD). Wound care nurse "B" said, when a resident is incontinent and immobile, it is very common. Wound care nurse "B" said to review her notes and, if this surveyor had further questions, to call. During an interview on 5-14-14 at 2:00 p.m. the wound care nurse notes referred to by Nurse "B" were requested from the DON. The DON said she did not have any wound care notes. A return phone call was then placed to the wound care nurse "B" on 5-15-14 at 8:50 a.m. The wound care nurse "B" offered to fax her notes. Review of the wound care notes received by fax from Nurse "B" and dated 4/15/14 revealed that Resident #1's buttock wounds were described as "Pressure & (and) MAD (moisture associated [MEDICAL CONDITION])." Wound measurements were documented as "Rt. Buttock Prox (Proximal/center) 2.5 /3.4/0.2" "Rt. Buttock dist (distal/lower) 3.6/4.7/0.2" "Lt (left) Buttock 2.0/3.0/0.1". On 5-14-14 at 2:35 p.m. an interview was conducted with nurse aide "F". Aide "F" stated she cared for Resident #1 on the day the resident was transferred to the hospital. Aide "F" said the resident was tired out and sweating. Aide "F" said she gave the resident a bed bath that day and her buttocks were excoriated. Aide "F" said she had put EPC (Extra Protective Cream) on the excoriated areas on the buttocks. Aide "F" said the EPC provided a barrier for the skin. Aide "F" was asked if the resident had anything wrong with her ears. Aide "F" said she had not observed any treatments to the ears. On 5-14-14 at 2:50 p.m. an interview was conducted with nurse aide "C". Aide "C" was asked if Resident #1 had anything wrong with her ears. Aide "C" said she had not noticed any areas on the resident's ears. On 5-14-14 at 3:10 p.m. an interview was conducted with Licensed Practical Nurse (LPN) Nurse "A" who cared for Resident #1 on the day she was transferred to the hospital. Nurse "A" said the resident was clammy that morning so she checked her blood sugar. Nurse "A" said she had seen the resident's buttocks and had applied cream. Nurse "A" said she did not see the resident's ears before she went to the hospital and did not know how the ear wound/skin breakdown had happened. Nurse "A" said she went home in the early afternoon and turned Resident #1's care over to another nurse (Nurse "G"). On 5-15-14 at 9:55 a.m. an interview was conducted with Nurse "G". Nurse "G" said she picked up Resident #1's hall around 2:30 p.m. on the day the resident was transferred to the hospital. Nurse "G" said she did apply cream to the buttocks and observed the excoriation. When asked if the facility had different briefs for different residents (with different absorptive capacities for moisture), Nurse "G" said she did not think so. On 5-15-14 at 11:07 a.m. an interview was conducted with nurse aide "D". Aide "D" said she was working the afternoon that Resident #1 was transferred to the hospital. When asked if she saw the resident's buttocks, Aide "D" said no, because the resident's face was turned toward her when she assisted the other aide in changing the residents brief, but they did put EPC cream on the resident's buttocks. On 5-15-14 at 11:35 a.m. an interview was conducted with the Interim DON (Director of Nursing). The DON said she was familiar with Resident #1. The DON said she was aware the resident had been transferred to the hospital. When asked if she had received a call from the hospital, regarding the resident's condition upon arrival to the hospital, the DON said, yes, she had, and she went to the hospital to see the resident. When asked if she assessed the resident at the hospital, the DON said, no, she just saw her and talked to her sister and left. When asked if the facility had utilized any special intervention, such as special briefs that would wick away the moisture to prevent excoriation and breakdown, the DON did not think the facility utilized any special briefs. When asked if she had done an investigation as to the hospital's concerns regarding the resident's appearance upon arrival and her wounds, the DON said she had looked at the facility's "Treatment Sheets" and the resident had a skin check documented on 4-28-14 and nothing had been documented as additional skin concerns. However, the facility policy "Wound Prevention and Management" dated "Revised July 2013, stated: "Weekly Skin Assessment...This assessment includes a head to toe visualization of the residents skin." The DON said she had interviewed staff (about the resident's condition), but she did not document the interviews. The DON said she felt the buttocks looked the way they did at the hospital because the resident laid on a stretcher in the emergency room . The DON was asked if she had investigated the wounds to the resident's ears. The DON said she had asked the nurses, and no one knew how the wounds had started. The DON made no comment regarding the the pressure sore on the resident's left thumb. Resident #1's "Care Delivery Guide" date, initiated 11-8-13, was reviewed for facility skin care interventions. Resident #1's aide care guide stated, "Skin Care: No EPC to buttocks" (even though two aides had stated during interviews, noted above, that they had applied EPC to the resident's buttocks for the excoriation). "Bladder and Bowel" had incontinent checked, and a check mark with the symbol for "change" written in with every 2 hours also wrote in, but no identification of special interventions or briefs to be used to aide in preventing moisture breakdown of the skin. Review of the facility policy "Pressure Ulcer Prevention/Treatment" dated "Revised April 2009", stated: "...2.b. Manage Moisture-Use appropriate moisture barrier, Use absorbent incontinent products, Address underlying cause if possible, Offer toileting and fluids with turning schedules." ( )

Based on interview and record review, the facility failed to provide adequate care for Resident #101 who was care planned for safety alarms and direct care staff was unaware of alarms and failed to increase direct observation of Resident #101. Findings include: Review of MDS (Minimum Data Set) dated 1/25/11 revealed Resident #101 had [DIAGNOSES REDACTED]. The MDS indicated Resident #101 was cognitively intact. Review of "Physician Orders" dated 1/30/11 revealed "Fall Precautions". Review of facility policy " Supervision/Adequate Supervision " dated 1998 revealed use of alarms " ...does not eliminate the need for staff vigilance and are not to be utilized in lieu of supervision. " Review of I/A report (Incident/Accident) dated 2/8/11 revealed the following accident description: " ( ...heard loud crash and scream ...Resident #101 lying on stomach on floor ...) " (sic) Report indicated Resident #101 " with history of non-compliance " . Review of X-Ray report dated 2/9/11 revealed Resident #101 sustained " ...commuted fracture of the distal radius ( right wrist fracture)sic ... " as a result of fall. Review of care plan dated 6/5/10 revealed the following update dated 8/24/10 and 11/8/10: " Bed alarm and chair alarm stand by assist 8-24-10 " ; " Fall precautions 11-8-10 " . CNA (Certified Nursing Assistant) Staff #4 was interviewed on 3/2/11 at 3:00 pm in a conference room. Said, Prior to fall Resident #101 was sitting in room watching TV. Heard Resident #101 scream and found Resident #101 on stomach, on floor. Said, " ...there were no alarms on, none ordered, because (Resident #101)sic made a fuss about them. Said it appeared Resident #101 was transferring self from wheelchair to bed; one side of wheelchair was locked and other side was unlocked. CNA Staff #5 was interviewed on 3/2/11 at 3:07 pm in a conference room. Said, was a couple of rooms down from Resident #101 ' s room and heard a loud noise; Resident #101 was on the floor. Said, " I don ' t think (Resident #101)sic had alarms at that time. " RN (Registered Nurse) Staff #2 was interviewed on 3/2/11 at 3:35 pm in a conference room. Staff #4 indicated Resident #101 was care planned for bed/wheelchair alarms 2/8/11. Resident #101 was interviewed on 3/2/11 at 12:45 pm in resident room and 1:00 pm in dining room. Resident #101 requested interview to be confidential.

THIS CITATION PERTAINS TO MIOOO . BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY IN 1 OF 7 SAMPLED RESIDENTS (RESIDENT #500), WHO EXITED THE FACILITY ON 2/9/11 VIA THE FRONT DOORS UNDETECTED, WITHOUT WINTER CLOTHING, PROPELLING IN HER WHEELCHAIR ACROSS THE FACILITY DRIVEWAY AND CROSSING A 25 MPH ROAD (TOTAL OF 453 FEET), RESULTING IN AN IMMEDIATE JEOPARDY FOR RESIDENT #500, WHO WAS AT RISK FOR SERIOUS HARM, INJURY AND/OR DEATH, AND PLACING 6 ADDITIONAL RESIDENTS IDENTIFIED AS AT RISK FOR ELOPEMENT AND 10 RESIDENTS WITH A HISTORY OF BEHAVIORS, AT HIGH RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: THE FACE SHEET IN THE CLINICAL RECORD INDICATED RESIDENT #500 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS, RESIDENT ASSESSMENT TOOL) DATED 12/23/10, ACTIVITY OF DAILY LIVING (ADL) RESIDENT ASSESSMENT PROTOCOL (RAP) DATED 4/29/10, PHYSICAL THERAPY PLAN OF TREATMENT DATED 5/31/10, ADL/MOBILITY ASSESSMENT AND PLAN OF CARE DATED 4/16/10, MOOD AND BEHAVIOR ASSESSMENT AND PLAN OF CARE DATED 4/26/10, NURSES NOTES DATED 4/16/10 THROUGH 2/14/11, physician progress notes [REDACTED].#500 HAD TREMORS, GENERALIZED WEAKNESS, AN UNSTEADY BALANCE AND GAIT, NEEDED SUPERVISION AND LIMITED ASSIST WITH ADL'S AND LOCOMOTION ON AND OFF THE UNIT. RESIDENT #500 EXHIBITED SEVERE CONFUSION, AND BECAME MORE AGGRESSIVE AND COMBATIVE 2 WEEKS PRIOR TO HER ELOPEMENT ON 2/9/11. REVIEW OF THE FACILITY TRANSFER FORM DATED 2/14/11 AT 8:30 P.M., REVEALED DURING THE INVESTIGATION (2/14/11 THROUGH 2/28/11) RESIDENT #500 WAS TRANSFERRED TO THE HOSPITAL FOR EVALUATION DUE TO HAVING "INCREASED DEMENTIA WITH HALLUCINATIONS, DELUSIONS, WITH HOMICIDAL AND SUICIDAL IDEATIONS". REVIEW OF THE FACILITY INCIDENT INVESTIGATION REPORT DATED 2/15/11, REVEALED ON 2/9/11 BETWEEN 6:22 P.M. AND 6:25 P.M., RESIDENT #500 WAS OBSERVED BY A STAFF MEMBER UNSUPERVISED OUTSIDE IN HER WHEELCHAIR AT THE END OF THE DRIVEWAY. THE RESIDENT WHEELED HERSELF OUTSIDE THROUGH THE UNALARMED FRONT DOUBLE DOORS, THROUGH THE PARKING LOT, AND DOWN THE DRIVEWAY. THE INVESTIGATION REPORT STATED "ON 2/8/11, RESIDENT KISSED ANOTHER RESIDENT AND WAS PLACED ON 1:1 (ONE-ON-ONE SUPERVISION) OBSERVATION RELATED TO AFFECTION SEEKING BEHAVIORS". RESIDENT #500 WAS ASSESSED AS NOT NEEDING A WANDER GUARD (DEPARTURE ALERT SYSTEM), AND THE FRONT DOORS ONLY HAD A WANDER GUARD SYSTEM IN PLACE, NOT A DOOR ALARM SYSTEM. THE INVESTIGATION CONCLUDED RESIDENT #500 WAS OUTSIDE FOR APPROXIMATELY 3 TO 8 MINUTES. RESIDENT #500 WAS ASSESSED TO NOT NEED A WANDER GUARD PRIOR TO HER ELOPEMENT ON 2/9/11. ACCORDING TO THE WWW.WUNDERGROUND.COM WEATHER SITE, ON 2/9/11 AT 6:14 P.M., THE TEMPERATURE WAS 14.0 DEGREES FAHRENHEIT WITH A WIND SPEED OF 8.1 MILES PER HOUR. SUNSET WAS AT 5:55 P.M. EASTERN STANDARD TIME. OBSERVATION OF THE FACILITY FRONT DOORS, PARKING LOT, DRIVEWAY, AND ROAD WAS MADE ON 2/16/11 AT 1:10 P.M. WITH THE DIRECTOR OF MAINTENANCE. THE DIRECTOR OF MAINTENANCE AND SURVEYOR MEASURED THE DISTANCE FROM THE FACILITY FRONT DOOR TO THE LOCATION WHERE RESIDENT #500 WAS SEEN ON 2/9/11, TO BE A TOTAL OF 453 FEET. THE DIRECTOR OF MAINTENANCE ESTIMATED THE DRIVEWAY INCLINE TO BE "10 DEGREES". THE DIRECTOR OF MAINTENANCE CONFIRMED ON 2/9/11, THE FACILITY FRONT DOORS WERE NOT EQUIPPED WITH A DOOR ALARM (WHEN THE DOORS OPEN AN ALARM GOES OFF), ONLY A WANDER GUARD ALARM SYSTEM (ALARMS IF A RESIDENT WITH A WANDER GUARD TRANSMITTER OPENS THE DOORS). IN AN INTERVIEW ON 2/14/11 AT 2:30 P.M., THE SOCIAL WORKER (SW) CONFIRMED ON 2/9/11 AT "6:25 P.M.", RESIDENT #500 WAS SEEN OUTSIDE IN HER WHEELCHAIR UNSUPERVISED BY NURSE #1. THE SW REVEALED ON 2/9/11, THERE WERE A TOTAL OF 10 RESIDENTS ON BEHAVIOR TRACKING DUE TO TARGETED BEHAVIORS. AN INTERVIEW WAS DONE ON 2/15/11 AT 12:38 P.M., WITH NURSE #1 (ON 2/9/11, ASSIGNED TO WORK SECOND SHIFT 7:00 P.M. TO 7:00 A.M.). NURSE #1 REVEALED ON 2/9/11 AT APPROXIMATELY 6:20 P.M., SHE WAS COMING TO WORK AND SAW RESIDENT #500 IN HER WHEELCHAIR, UNSUPERVISED IN THE 25 MPH ROAD ACROSS THE STREET FROM THE FACILITY. NURSE #1 SAID RESIDENT #500 DID NOT HAVE ON A COAT, HAT OR GLOVES. NURSE #1 SAID RESIDENT #500 WAS EXTREMELY CONFUSED AND SAID SHE WAS GOING TO "CARO". NURSE #1 STATED, "I SAW A CAR IN MY LANE, SO I SLOWED DOWN, AND I SAW THE REFLECTION OF THE WHEELCHAIR, I STOPPED AND GOT OUT. ANOTHER CAR CAME TOWARDS ME AND I STOPPED THAT CAR. I GOT HER (RESIDENT #500) OUT OF THE WAY OF THE CARS AND THEN I CALLED THE FACILITY, I TOLD THEM WHAT HAPPENED. I TOOK OFF MY COAT AND PUT IT ON HER; I PUT MY GLOVES AND A BLANKET ON HER FROM MY CAR. SHE WAS SO CONFUSED AND WAS TALKING INCOHERENTLY. TWO CNA'S (NURSING ASSISTANT'S) BROUGHT HER IN. SHE WAS TRYING TO GET BACK OUT THAT NIGHT. THEY USE TO HAVE AN ALARM ON THE FRONT DOOR, BUT THEY TOOK IT OFF". AN INTERVIEW WAS DONE ON 2/15/11 AT 11:00 A.M., WITH CNA#1 (ON 2/9/11, SECOND SHIFT, 3:00 P.M., TO 11:00 P.M., ASSIGNED TO THE HALL THE RESIDENT WAS ON). CNA #1 STATED ON 2/9/11, "DINNER STARTED AT 5:30 P.M. AND SHE (RESIDENT #500) CAME OUT TO THE DINING ROOM. I WENT OUT AFTER SHE DID ABOUT 6:15 P.M., AND SHE WENT TO HER ROOM. (NURSE #2 ON 2/9/11, ASSIGNED 7:00 A.M. TO 7:00 P.M.) SAID SHE PUT A MESSAGE FOR HER TO BE A ONE-ON-ONE ON THE CARE TRACKER (COMPUTER SYSTEM FOR CNA DOCUMENTATION, CARE INSTRUCTIONS AND RESIDENT SAFETY ALERTS), AND I LOOKED AND IT WAS NOT THERE, AND THEY (NURSE'S) DON'T GIVE US (CNA'S) REPORT. WHEN (THE PREVIOUS ADMINISTRATOR) WAS HERE, SHE TOOK THE FRONT DOOR ALARM OUT. SHE SAID IT WAS IRRITATING, SO SHE TOOK IT OFF". REVIEW OF THE FACILITY ELOPEMENT PREVENTION POLICY DATED 1/11, REVEALED "ASSESS THE SECURITY OF POTENTIAL INTERNAL ENVIRONMENTAL HAZARDS INCLUDING, BUT NOT LIMITED TO, THE FOLLOWING: EXIT DOORS. MAINTAIN DOOR ALARMS AND WANDER CONTROL SYSTEMS (WANDER GUARD SYSTEM)". REVIEW OF CNA #1'S WRITTEN STATEMENT DATED 2/15/11, STATED "ON 2/9/11 I SAW (RESIDENT #500) SITTING ON HER BED APPROXIMATELY 6:15 P.M., SHE SAID SHE WAS TIRED. I WAS PUTTING RESIDENTS IN BED AND TOILETING THEM WHEN I HEARD (RESIDENT #500) WAS FOUND OUTDOORS. THERE WAS NOTHING IN THE CARE TRACKER TO WARN OF ANY ELOPEMENT RISK OR 1-ON-1 CARE". AN INTERVIEW WAS DONE ON 2/15/11 AT 12:10 P.M., WITH NURSE #2 (ON 2/9/11, FIRST SHIFT 7:00 A.M. TO 7:00 P.M., ASSIGNED TO THE HALL THE RESIDENT WAS ON). NURSE #2 STATED, "I PUT IT IN THE CARE TRACKER; (THE MANAGER) SAID (THE NURSE CONSULTANT) WANTED HER (RESIDENT #500) ON A ONE-ON-ONE. I PUT IT IN THE CARE TRACKER AT APPROXIMATELY 8:00 P.M. ON 2/8/11. I SAW IT IN THERE, BUT IT WAS NOT FLAGGED "YELLOW" TO INDICATE A "RESIDENT ALERT/CHANGE". I WENT UP TO (CNA #1) ON 2/9/11 AROUND 3:00 P.M., AND SAID (RESIDENT #500) IS TO BE A ONE-ON-ONE WHEN SHE WAS OUT OF HER ROOM. ON 2/8/11, (THE MANAGER) AND ADMINISTRATOR AGREED TO THIS. IT COULD HAVE BEEN PREVENTED IF SHE HAD A WANDER GUARD ON. (CNA #1) SAID THE LAST TIME SHE SAW HER, SHE WAS IN HER BED ABOUT 6:15 P.M., THEN IT WAS OK FOR THE CNA TO CARE FOR HER OTHER RESIDENTS". REVIEW OF NURSE #2'S WRITTEN STATEMENT DATED 2/15/11, STATED "I PUT NOTE IN CARE TRACKER NOTIFYING STAFF THAT (RESIDENT #500) WAS TO BE ONE-ON-ONE WHEN AWAKE AND UP AND OUT OF ROOM. THE DRIVEWAY SLOPE WAS ICED AND CRUSTED OVER THAT EVENING THAT (RESIDENT #500) GOT OUTSIDE. ON 2/9/11, THE INCLINED DRIVEWAY LEADING TO THE BUSY ROAD HAD CRUSTED OVER ICE ON IT, SO THE RESIDENT COULD HAVE ROLLED DOWN IT IN HER WHEELCHAIR, AND INTO THE ROAD". REVIEW OF THE CARE TRACKER DATED 2/9/11 (NO TIME DOCUMENTED), STATED "DUE TO RECENT BEHAVIOR CHANGES (RESIDENT #500) IS TO BE ONE-ON-ONE WITH STAFF WHILE AWAKE". AN INTERVIEW WAS DONE ON 2/16/11 AT 10:45 A.M., WITH CNA #4 (ON 2/9/11, ASSIGNED ON SECOND SHIFT). CNA #4 REVEALED WHEN A RESIDENT IS ONE-ON-ONE, IT SHOULD BE FLAGGED YELLOW, AND COME UP ON THE CARE TRACKER FOR ALL STAFF TO BE INFORMED. CNA #4 STATED, "NO ONE TOLD ME THAT (RESIDENT #500) WAS A ONE-ON-ONE (ON 2/9/11). WE WERE TAUGHT A ONE-ON-ONE IS WHEN YOU ARE WITH THE PERSON ALL THE TIME". A TELEPHONE INTERVIEW WAS DONE ON 2/28/11 AT 12:50 P.M., WITH CNA #5 (ON 2/9/11, ASSIGNED ON SECOND SHIFT). CNA #5 STATED "NO ONE TOLD ME SHE (RESIDENT #500) WAS A ONE-ON-ONE. IT DOES NOT MAKE SENSE TO ME, A ONE-ON-ONE WHILE OUT OF THEIR ROOM". REVIEW OF THE FACILITY RESIDENT SUPERVISION POLICY/PROCEDURE DATED 1/09, STATED "CLOSE VISUAL SUPERVISION, SIGNIFICANT AND/OR IMMEDIATE RISK TO SELF OR OTHERS. STAFF RESPONSIBILITY: 1 TO 1 CONTACT AT ONE OR TWO ARMS LENGTH, NO OTHER ASSIGNMENTS EXCEPT 1:1, DOCUMENT EVERY 15 MINUTES". AN INTERVIEW WAS DONE ON 2/15/11 (AT 3:25 P.M.) AND ON 2/16/11 (AT 2:50 P.M.), WITH NURSE #3 (ON 2/8/11 AND 2/9/11, ASSIGNED AS MANAGER). NURSE #3 REVEALED ON 2/8/11 VIA A PHONE CALL, SHE WAS TOLD BY THE FACILITY NURSE CONSULTANT TO MAKE RESIDENT #500 A ONE-ON-ONE. NURSE #3 WAS UNABLE TO RECALL THE TIME OF THE PHONE CALL. NURSE #3 REPORTED, PER THE NURSING POLICY AND PROCEDURE BOOKS AT THE NURSES STATION, A "ONE-ON-ONE" IS WHEN A STAFF MEMBER IS ASSIGNED TO A RESIDENT 24 HOURS A DAY, WITHOUT BEING ASSIGNED TO ANY OTHER RESIDENTS. AN INTERVIEW WAS DONE ON 2/16/11 AT 10:55 A.M., WITH CNA #2 (ON 2/9/11, ASSIGNED ON SECOND SHIFT). CNA #2 STATED, "I WAS COMING OUT OF THE DINNING ROOM AFTER SUPER TIME AT APPROXIMATELY 6:30 P.M., AND A VISITOR CAME AND TOLD ME SHE PASSED A LADY IN A WHEELCHAIR OUTSIDE. I RAN OUT THE FRONT DOOR. I SAW THE RESIDENT (RESIDENT #500); THE NURSE (NURSE #1) WAS PUTTING A BLANKET AROUND RESIDENT #500. SHE FELT COLD, BUT DIDN'T COMPLAIN OF BEING COLD; SHE WAS VERY CONFUSED. THERE WAS ICE IN THE DRIVEWAY THAT NIGHT AND IT WAS VERY COLD. I THEN BROUGHT HER IN THE BUILDING. WHEN I ASKED (NURSE #2) WHO WAS ASSIGNED TO DO ONE-ON-ONE, SHE SAID WHOEVER'S IN EYE SIGHT". AN INTERVIEW WAS DONE ON 2/16/11 AT 11:15 A.M., WITH CNA #3 (ON 2/8/11 AND 2/9/11, ASSIGNED ON SECOND SHIFT). CNA #3 STATED, "I DON'T REMEMBER BEING TOLD (RESIDENT #500) WAS A ONE-ON-ONE. I DON'T REMEMBER SEEING IT IN THE CARE TRACKER ON THE 8TH OR 9TH. AROUND 6:30 P.M. (ON 2/9/11), I WENT TO THE DINING ROOM TO GET SOMETHING AND (A FAMILY MEMBER) SAID TO ME, YOU MIGHT HAVE SOMEONE OUTSIDE, AND I RAN OUT. I RAN BACK AND GOT A BLANKET FOR (RESIDENT #500), SHE WAS CONFUSED. I SAW HER IN THE ROAD WITH THE NURSE (NURSE #1) AND THE OTHER CNA'S. A ONE-ON-ONE MEANS SOMEBODY IS WITH THE RESIDENT CONSISTENTLY". AN INTERVIEW WAS DONE ON 2/16/11 AT 11:40 A.M., WITH AN ALERT, UN-SAMPLED FACILITY RESIDENT (RESIDENT "A"). RESIDENT "A" STATED, "ON 2/9/11, MY (FAMILY MEMBER) TOLD ME THERE WAS A LADY OUT THERE (OUTSIDE) IN A WHEELCHAIR AND SHE WAVED TO THEM. (ANOTHER FAMILY MEMBER) WAS WITH HER AND HE SAID 'WE SAW THIS LITTLE OLD LADY BOLTING DOWN THE DRIVEWAY'. I TOLD HIM TO GO TO THE DESK AND TELL THE NURSE". A TELEPHONE INTERVIEW WAS DONE ON 2/16/11 AT 1:35 P.M., WITH RESIDENT "A"'S FAMILY MEMBER (FAMILY MEMBER #1). FAMILY MEMBER #1 CONFIRMED SHE AND ANOTHER FAMILY MEMBER SAW RESIDENT #500 IN HER WHEELCHAIR UNSUPERVISED WHEELING HERSELF IN THE FACILITY DRIVEWAY ON 2/9/11 AROUND DINNER TIME AS THEY WERE DRIVING INTO THE FACILITY TO VISIT. FAMILY MEMBER #1 STATED, "WHEN I SAW HER SHE WAS IN THE DRIVEWAY ALONE IN HER WHEELCHAIR". IN AN INTERVIEW ON 2/15/11 AT 3:50 P.M., THE IN-SERVICE DIRECTOR REPORTED THE DIFFERENT TYPES OF SUPERVISION WERE, GENERAL SUPERVISION (WHEN THE RESIDENT CAN MOVE FREELY IN THE FACILITY), INCREASED SUPERVISION (EVERY 15 MINUTE CHECKS), INCREASED SUPERVISION (ONE-ON-ONE, STAFF WITH RESIDENT AT ALL TIMES), AND UNIT SUPERVISION (THE RESIDENT REMAINS ON THEIR UNIT). THE IN-SERVICE DIRECTOR STATED, "I HAVE NEVER SEEN A NURSING ORDER WRITTEN WITH WHILE AWAKE. I IN-SERVICE STAFF ON THE POLICY ONLY". REVIEW OF THE NURSES AND IDT (INTERDISCIPLINARY TEAM) IN-SERVICE DATED 6/18/10, 6/20/10 AND 6/22/10, REVEALED STAFF WERE IN-SERVICED ONE-ON-ONE SUPERVISION IS WHEN A STAFF MEMBER IS ASSIGNED TO BE WITH A RESIDENT AT ALL TIMES, AND IS NOT ASSIGNED OTHER RESIDENTS. AN INTERVIEW WAS DONE ON 2/15/11 AT 4:17 P.M. WITH THE ADMINISTRATOR. THE ADMINISTRATOR STATED, "ON 2/8/11, WE MET IN IDT (INTERDISCIPLINARY TEAM MEMBERS MEETING) REGARDING THE RESIDENTS BEHAVIORS, AND AT 7:00 P.M. I MET WITH (A CHARGE NURSE) AND TOLD HER TO MAKE HER (RESIDENT #500) A ONE-ON-ONE". THE ADMINISTRATOR CONFIRMED ON 2/8/11, SECOND SHIFT (3:00 P.M. TO 11:00 P.M.) RESIDENT #500 WAS MADE A ONE-ON-ONE SUPERVISION, THAT THE FRONT DOORS WERE NOT EQUIPPED WITH A DOOR ALARM SYSTEM, ONLY A WANDER GUARD SYSTEM, AND RESIDENT #500 DID NOT HAVE A WANDER GUARD TRANSMITTER IN PLACE. REVIEW OF THE ADMINISTRATORS WRITTEN STATEMENT DATED 2/9/11, REVEALED "AT APPROXIMATELY 6:28 P.M. OR 6:29 P.M., I WAS SUMMONED TO THE NURSES STATION WHERE I WAS NOTIFIED OF (RESIDENT #500'S) CONDITION (ELOPEMENT)". REVIEW OF RESIDENT #500'S FACILITY INVESTIGATION (UN-DATED) FROM RESIDENT #500'S 2/9/11 ELOPEMENT REVEALED "RESIDENT HAD DEMONSTRATED AN ACUTE CHANGE IN MOOD BEGINNING ON 2/6/11. MOOD CHANGES CONTINUED AEB (AS EVIDENCE BY) RESIDENT TAKING CLOTHES OFF, TOUCHING STAFF, AND REQUESTING TO KISS OTHER RESIDENTS. ON 2/8/11 RESIDENT KISSED ANOTHER RESIDENT AND WAS PLACED ON 1:1 OBSERVATION RELATED TO AFFECTION SEEKING BEHAVIORS". (RESIDENT #500 WAS PUT ON 1:1, BUT ONLY WHILE AWAKE, DEVIATING FROM THE FACILITY'S SUPERVISION POLICY). AN INTERVIEW WAS DONE ON 2/15/11 AT 4:50 P.M., WITH THE FACILITY NURSE CONSULTANT AND THE ADMINISTRATOR. THE CONSULTANT AND ADMINISTRATOR BOTH CONFIRMED ON 2/8/11 PER A TELEPHONE CALL, THEY AGREED RESIDENT #500 WOULD BE MADE A ONE-ON-ONE SUPERVISION DUE TO HER RECENT BEHAVIOR CHANGES. THE CONSULTANT AGREED THE FACILITY FRONT DOORS DID NOT HAVE A DOOR ALARM SYSTEM, ONLY A WANDER GUARD SYSTEM. AN INTERVIEW WAS DONE ON 2/16/11 AT 9:05 A.M., WITH THE BUSINESS MANAGER/SAFETY COMMITTEE FACILITY REPRESENTATIVE. THE SAFETY COMMITTEE REPRESENTATIVE REVEALED THE FRONT DOOR ALARM SYSTEM WAS REMOVED IN 2009 (BY THE PRIOR ADMINISTRATOR), AND THE SAFETY COMMITTEE NEVER DISCUSSED THE UN-ALARMED FRONT DOORS AS A RESIDENT SAFETY ISSUE AT THE SAFETY COMMITTEE MEETINGS. REVIEW OF SAFETY COMMITTEE MEETING SUMMARIES DATED 1/12/11 AND 2/9/11, REVEALED NO DOCUMENTATION REGARDING THE FRONT DOORS NOT HAVING AN ALARM SYSTEM OTHER THEN THE WANDER GUARD OR THAT THEY COULD BE A SAFETY CONCERN. REVIEW OF THE ON-SITE SERVICE FORM DATED 6/26/09, STATED "CODE ALERT ALARM/DOOR LOCKS AND UNLOCKS; ALARM DOES NOT SOUND WHEN RESIDENT EXITS". REVIEW OF THE INVOICE DATED 8/26/09, REVEALED A WANDERER MANAGEMENT SYSTEM (WANDER GUARD SYSTEM) WAS INSTALLED. REVIEW OF RESIDENT #500'S NURSES NOTES DATED 2/6/11 AT 11:00 A.M., REVEALED RESIDENT #500 "SMILES AND ASKED IF SHE COULD WALK HOME". REVIEW OF NURSE'S NOTES DATED 2/7/11 AT 3:00 P.M., REVEALED RESIDENT #500 HAD "SEXUALLY INAPPROPRIATE BEHAVIOR ESCALATING. RES (RESIDENT #500) TAKING OFF CLOTHES, TOUCHING STAFF (MALE/FEMALE) INAPPROPRIATELY". REVIEW OF NURSE'S NOTES DATED 2/8/11 AT 3:00 A.M., REVEALED RESIDENT #500 WAS "WANDERING IN HALL IN W/C (WHEELCHAIR) FOR 15 MINUTES". REVIEW OF NURSE'S NOTES DATED 2/9/11 AT 4:30 P.M., REVEALED RESIDENT #500 "HAS BEEN ONE ON ONE WITH STAFF WHILE AWAKE, SEVERAL ATTEMPTS TO KISS AND HUG STAFF, RETURNED FROM BREAKFAST AND ATTEMPTED STRIPPING CLOTHES OFF IN HALL". REVIEW OF NURSE'S NOTES DATED 2/9/11 AT 9:10 P.M., REVEALED "ORDERS RECEIVED FOR WANDER GUARD". REVIEW OF RESIDENT #500'S SOCIAL WORKER PROGRESS NOTES DATED 2/7/11, REVEALED "NURSING REPORTS THAT RESIDENT IS EXHIBITING ABNORMAL BEHAVIORS SUCH AS INAPPROPRIATE CONVERSATION AND SEXUAL BEHAVIORS, INCREASED CONFUSION WAS NOTED AS WELL AS RUDE COMMENTS TO HER ROOMMATE AND ATTEMPTING TO KISS OTHER RESIDENT'S". REVIEW OF SOCIAL SERVICE NOTES DATED 2/7/11, REVEALED THE SOCIAL WORKER "OBTAINED VERBAL CONSENT FROM DPOA (DURABLE POWER OF ATTORNEY) FOR PSYCH EVAL (PSYCHIATRIC EVALUATION)". REVIEW OF PHYSICIAN ORDERS [REDACTED].#500) MAY BE EVALUATED AND TREATED BY: PSYCH SERVICES". REVIEW OF RESIDENTS #500'S CLINICAL RECORD REVEALED THERE WAS NO DOCUMENTATION THAT THE RESIDENT HAD BEEN EVALUATED OR TREATED BY MENTAL HEALTH SERVICES. THE RESIDENT WAS EVALUATED BY A NEUROLOGIST PRIOR TO HER ELOPEMENT ON 2/9/11, DUE TO PARKINSON'S DISEASE AND TREMORS FOR A MEDICATION REVIEW. REVIEW OF RESIDENT #500'S BEHAVIORAL TRACKING SHEETS DATED 2/7/11 AND 2/8/11 REVEALED RESIDENT #500 WAS EXHIBITING VERBAL AND PHYSICAL ABUSIVE BEHAVIORS, SOCIALLY INAPPROPRIATE BEHAVIORS AND HALLUCINATIONS (ON 2/7/11 AT 3:04 A.M., HEARING VOICES). REVIEW OF THE RESIDENTS PSYCHOSOCIAL WELL BEING/MOOD ASSESSMENT AND CARE PLAN DATED 2/7/11, REVEALED STAFF WERE ATTEMPTING TO "KEEP RES. (RESIDENT #500) AT ARMS LENGTH FROM OTHER RESIDENTS WHILE OUT OF HER ROOM", AND "REDIRECTING THE RESIDENT WHEN EXHIBITING AGGRESSIVE OR INAPPROPRIATE BEHAVIORS". REVIEW OF THE COGNITIVE ASSESSMENT AND CARE PLAN DATED 4/26/10, REVEALED "SHE (RESIDENT#500) CONTINUES TO REQUIRE 24 HOUR CARE AND SUPERVISION". REVIEW OF THE FACILITY ELOPEMENT PREVENTION: RESIDENT PROCEDURE DATED 10/08, STATED RISK FACTORS FOR ELOPEMENT "MAY INCLUDE, EXPRESSED DESIRE TO LEAVE CENTER, EXPRESSED DESIRE TO RETURN HOME" AND, "COGNITIVE IMPAIRMENT". REVIEW OF THE FACILITY ELOPEMENT PREVENTION: CENTER PRACTICES PROCEDURE DATED 1/11, STATED "ASSESS THE SECURITY OF POTENTIAL INTERNAL ENVIRONMENTAL HAZARDS INCLUDING, EXIT DOORS". REVIEW OF RESIDENT #500'S HOSPITAL emergency room NOTES DATED 2/11/11, STATED "(FAMILY MEMBER) STATES THAT SHE HAS WATCHED (RESIDENT #500) UNDERGO A FAIRLY STEADY DECLINE BEING ABLE TO CONTROL HER BEHAVIOR OVER THE PAST THREE WEEKS. SHE HAS BECOME MORE AGGRESSIVE AND COMBATIVE". RESIDENT #500 WAS ASSESSED BY THE FACILITY NOT TO NEED A WANDER GUARD PRIOR TO HER ELOPEMENT ON 2/9/11, AND THE FRONT DOORS DID NOT HAVE A DOOR ALARM SYSTEM. RESIDENT #500 HAD A KNOWN HISTORY OF ACUTE BEHAVIOR CHANGES INCLUDING VERBALIZATION OF WANTING TO GO HOME, AND NOT CARING WHAT HAPPENED TO HER. ON 2/8/11, DUE TO ESCALATING BEHAVIORS, RESIDENT #500 WAS MADE A ONE-ON-ONE STAFF SUPERVISION BY THE ADMINISTRATOR AND NURSE CONSULTANT. ON 2/9/11, A STAFF MEMBER COMING TO WORK AND 2 FAMILY MEMBERS OBSERVED RESIDENT #500 UNSUPERVISED, IN HER WHEELCHAIR, OUTSIDE OF THE FACILITY IN THE DRIVEWAY AND IN THE ROAD. RESIDENT #500 DID NOT HAVE ON A COAT, HAT OR GLOVES, AND STAFF WERE UNAWARE SHE HAD LEFT THE BUILDING. THE FACILITY DRIVEWAY WAS ICY WITH AN INCLINE, WHICH LEAD TO A 25 MILE PER HOUR BUSY ROAD. ON 2/17/11 AT 8:55 A.M., NOTIFICATION OF IMMEDIATE JEOPARDY WAS GIVEN TO THE ADMINISTRATOR AND FACILITY NURSE CONSULTANT THAT BEGAN ON 2/9/11 AT 6:25 P.M., AS A RESULT OF THE FACILITIES FAILURE TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF RESIDENT #500, WHO EXHIBITED RECENT ACUTE BEHAVIOR CHANGES, AND THE FAILURE TO ENSURE STAFF WERE AWARE WHEN AN UNSUPERVISED CONFUSED RESIDENT EXITED THE FACILITY THROUGH THE FRONT DOORS. ON 2/17/11, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. ON 2/9/11: -VERIFICATION OF RESIDENT #500'S SAFETY AND WELL BEING WAS DONE BY THE NURSING SUPERVISOR. -NOTIFICATION OF PHYSICIAN AND FAMILY. -A WANDER GUARD BRACELET WAS PLACED ON THE RESIDENT AND SHE WAS PLACED ON 1:1 DIRECT SUPERVISION, THE ELOPEMENT BOOK, CARE PLAN AND CARE DELIVERY GUIDE WERE UP-DATED. -DIRECT STAFF SUPERVISION OF THE FACILITY FRONT DOOR WAS INITIATED, AND SIDE ACCESS DOOR ALARMS WERE ASSESSED AND FUNCTIONING PROPERLY. -VERIFICATION OF ALL FACILITY RESIDENTS' LOCATION WAS DONE. -THE INVESTIGATION WAS INITIATED. 2. ON 2/10/11: -THE INITIATION OF STAFF EDUCATION (58 OUT OF 117), BEGAN ON THE FACILITY ELOPEMENT POLICY. -ALL RESIDENTS WERE ASSESSED FOR POTENTIAL ELOPEMENT RISK WITH THE ELOPEMENT BOOK, CARE PLANS AND CARE DELIVERY GUIDES UP-DATED. -CONTINUOUS STAFF SUPERVISION OF THE FRONT DOOR WAS DONE. -THE ADMINISTRATOR CONTACTED THE ALARM COMPANY FOR AN ALARM TO BE PLACED ON THE FRONT DOORS. -EDUCATION WAS PROVIDED FOR STAFF PROVIDING 1:1 SUPERVISION WITH RESIDENTS AND ADDITIONAL STAFF WILL RECEIVE EDUCATION PRIOR TO 1:1 SUPERVISION. 3. ON 2/11/11: -STAFF EDUCATION WAS COMPLETED (106 OF 117) ON THE FACILITY ELOPEMENT POLICY, WITH THE REMAINING 11 STAFF TO BE EDUCATED PRIOR TO RETURNING TO WORK. -RESIDENT #500 WAS TRANSFERRED TO THE HOSPITAL FOR EVALUATION AND WAS RETURNED to the facility on [DATE]. ON 2/14/11, RESIDENT #500 WAS TRANSFERRED TO THE HOSPITAL FOR EVALUATION AND WAS THEN TRANSFERRED TO A PSYCHIATRIC UNIT FOR FURTHER EVALUATION. 4. ON 2/17/11: -THE FACILITY HAD AN ALARM INSTALLED ON THE THE FRONT DOUBLE DOORS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 2/11/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND SEVERITY OF NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM BUT NO IMMEDIATE JEOPARDY DUE TO SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

THIS CITATION PERTAINS TO INTAKE #MI 603. BASED ON OBSERVATIONS, INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO MAINTAIN HOUSEKEEPING AND MAINTENANCE SERVICES NECESSARY TO MAINTAIN A SANITARY ENVIRONMENT IN 22 OF 47 RESIDENT ROOMS, AND FAILED TO MAINTAIN THE INTEGRITY OF THE ROOF IN 2 (A-4 AND B-1) OF 47 RESIDENT ROOMS, RESULTING IN THE POTENTIAL FOR RODENT INFESTATION, THE SPREAD OF COMMUNICABLE DISEASE, AND AN UNSAFE ENVIRONMENT. FINDINGS INCLUDE: ENVIRONMENTAL OBSERVATIONS WERE MADE ON 12/2/10 DURING THE INITIAL FACILITY TOUR AND ARE AS FOLLOWS: OBSERVATIONS MADE AT 7:55 A.M., ON BUTTERFLY BOULEVARD HALL: -WHITE BLANKETS WERE ROLLED-UP, SITTING ON THE WINDOW SEALS OF ROOM'S B-7, B-3, AND B-5. ROOM B-5'S WHITE BLANKET SITTING ON THE WINDOW SEAL HAD DRIED YELLOW WATER-LIKE STAINS ON THE BOTTOM. OBSERVATIONS MADE AT 8:10 A.M., ON COUNTRY CORNERS HALL: -WHITE BLANKETS WERE ROLLED-UP, SITTING ON THE WINDOW SEALS OF ROOMS C-3, C-7, C-12, AND C-11. AN INTERVIEW WAS DONE ON 12/2/10 AT 8:15 A.M., WITH A RESIDENT IN ROOM C-3. THE RESIDENT REVEALED FACILITY STAFF PUT WHITE BLANKETS ON THE WINDOW SEALS BECAUSE WATER COMES IN AROUND THE CLOSED WINDOWS, AND THE WINDOW CURTAINS BLOCK THE HEAT FROM CIRCULATING. THE BLANKETS HOLD THE CURTAINS BACK, SO THE HEAT CAN CIRCULATE IN RESIDENT ROOMS. -ROOM C-3: PAINT WAS CHIPPING OFF THE INSIDE AND OUTSIDE OF THE ROOM DOOR. -ROOM C-4: BEHIND THE RESIDENT'S HEADBOARD, THE CHAIR RAIL WAS PARTLY OFF THE WALL. IN THE CLOSET ON THE FLOOR WAS A PAIR OF DIRTY DARK BLUE PANTS AND A WINE COLORED SHIRT. -ROOM C-6: HALF A SANDWICH AND BAKED POTATO SOUP WAS SITTING ON THE WINDOW SEAL, WITH NO NAME OR DATE ON THEM. AN INTERVIEW WAS DONE ON 12/2/10 AT 8:13 A.M., WITH A RESIDENT IN ROOM C-6. THE RESIDENT SAID AFTER DINER (ON 12/1/10), STAFF PUT THE SANDWICH AND SOUP ON THE WINDOW SEAL TO KEEP IT COLD, BECAUSE SHE WANTED TO EAT IT FOR BREAKFAST (ON 12/2/10). -ROOM C-8: IN THE BATHROOM ON THE BACK OF THE TOILET WERE 8 WASH CLOTHES. ON THE WINDOW SEAL WERE DIRTY PAPER TOWELS. -ROOM C-16 BED 2: A DIRTY WASH CLOTH WAS ON THE FLOOR UNDER THE RESIDENT'S BED. OBSERVATIONS MADE AT 8:35 A.M., ON DAYBREAK HARBOR HALL: -WHITE BLANKETS WERE ROLLED-UP, SITTING ON THE WINDOW SEALS OF ROOM'S D-1, D-4 AND D-12. -ROOM D-1 BED 2: A THREE PACK OF GRAHAM CRACKERS WITH THE RESIDENTS NAME ON THEM, DATED 11/25/10, WAS SITTING ON THE WINDOW SEAL UN-OPENED. A BAGGIE OF ASSORTED COOKIES WITH THE RESIDENTS NAME ON IT (UN-DATED) WAS OPEN ON THE FLOOR BETWEEN THE BED AND THE HEATER. ROOM D-9 BED 1: A PINK WASH BASIN WAS UNDER THE BED, AND A DIRTY HOSPITAL GOWN WAS ON THE FLOOR NEAR THE BED. THE NURSE ASSIGNED TO THE HALL THE RESIDENT WAS ON, STOPPED PASSING RESIDENT MEDICATIONS AT 8:45 A.M., PICKED UP THE DIRTY GOWN AND THREW IT ON THE BATHROOM FLOOR, UNDER THE SINK. SHE THEN WASHED HER HANDS, PICKED THE DIRTY GOWN UP WITHOUT GLOVES ON, AND PUT IT IN THE DIRTY CLOTHES HAMPER IN THE HALL UN-BAGGED. OBSERVATIONS MADE AT 8:50 A.M., ON AMERICAN WAY HALL: -WHITE BLANKETS WERE ROLLED-UP, SITTING ON THE WINDOW SEALS OF ROOM'S A-8 AND A-16. -ROOM A-2: A DIRTY WASH CLOTH WAS ON THE FLOOR IN FRONT OF BED 1'S CLOSET. -ROOM A-5: BED 2'S CLOSET HAD SEVERAL DIRTY CLOTHING ITEMS ON THE FLOOR. BED 2'S WHITE METAL SHELF WAS BROKEN OFF THE INSIDE WALL OF THE CLOSET. THE BROKEN SHELF WAS SITTING ON THE SECOND METAL SHELF IN THE CLOSET. BED 1 AND 2'S CLOSET DOORS DID NOT LATCH SHUT. -ROOM A-8: A PILLOW WAS UP AGAINST THE WINDOW. PAINT WAS CHIPPING OFF THE INSIDE OF THE BATHROOM DOOR. BED 1 AND 2'S CLOSET DOORS DID NOT LATCH SHUT. AN INTERVIEW WAS DONE ON 12/2/10 AT 9:00 A.M., WITH A RESIDENT IN ROOM A-8. THE RESIDENT STATED "YOU HAVE TO HOLD THEM (THE CLOSET DOORS) BOTH TOGETHER WHEN YOU CLOSE THEM, IT (THE LATCH) DOES NOT WORK" . -ROOM A-10: THREE AREAS OF DRIED WATER-LIKE STAINS WERE OBSERVED ON THE CEILING TILES ABOVE BED 1. AN INTERVIEW WAS DONE ON 12/2/10 AT 9:20 A.M., WITH A RESIDENT IN ROOM A-10. THE RESIDENT STATED "I FEEL WATER DROPS COME DOWN (FROM THE CEILING) WHEN IT RAINS" . -ROOM A-11: THE WINDOW WAS VERY DIRTY ON THE INSIDE. DRIED DRIP MARKS FROM THE TOP OF THE WINDOW WERE OBSERVED. THE CLOSET DOORS DID NOT LATCH SHUT, AND SEVERAL DIRTY CLOTHING ITEMS WERE ON BOTH SIDES OF THE CLOSET FLOOR. -ROOM A-14: THE PINK PRIVACY CURTAIN AROUND BED 1 HAD SEVERAL DRIED DARK SOILED AREAS, AND PART OF IT WAS HANGING IN THE WASTE BASKET THAT WAS NEXT TO THE BED. OBSERVATIONS AND INTERVIEWS REGARDING THE FACILITY ROOF OBSERVATIONS WERE MADE ON 12/2/10 AT 9:25 A.M., OF ROOM A-4 (ON AMERICAN WAY). A SMALL DRIED WATER SPOT WAS OBSERVED ABOVE BED 1. A RESIDENT IN ROOM A-4 STATED, "THEY (THE FACILITY) MOVED ME A COUPLE OF DAYS AGO". THE RESIDENT WAS MOVED OUT OF HER ROOM DUE TO A ROOF LEAK, THE WATER WAS DRIPPING IN THE ROOM. AN INTERVIEW WAS DONE ON 12/2/10 AT 9:30 A.M., WITH CNA #1 (THE NURSING ASSISTANT ASSIGNED TO "B" HALL ON 12/2/10). CNA #1 REVEALED THE FACILITY MOVED THE RESIDENT'S IN ROOM A-4, BED 1 AND BED 2, OUT OF THEIR ROOM (ON 11/28/10), BECAUSE THE ROOF WAS LEAKING. CNA #1 STATED "THEY (THE FACILITY) JUST REPLACED THE TILES (CEILING TILES IN ROOM A-4)". AN INTERVIEW WAS DONE ON 12/2/10 AT 9:40 A.M., WITH HOUSEKEEPING STAFF #1. HOUSEKEEPING STAFF #1 STATED "I JUST MOVED A-4 AND B-1 OUT OF THEIR ROOMS DUE TO LEAKS, THEY JUST REPLACE THE TILES, THEY DID NOT FIX THE ROOF". OBSERVATIONS WERE MADE ON 12/2/10 AT 10:05 A.M., OF ROOM B-1 (ON BUTTERFLY BOULEVARD). A LARGE DRIED WATER-LIKE SPOT WAS OBSERVED ON A CEILING TILE IN THE CORNER NEAR, THE EXTERIOR WALL, ABOVE BED 2. THE SURVEYOR REQUESTED MAINTENANCE REMOVE A CEILING TILE ABOVE BED 2, AND A WHITE PLASTIC BUCKET WAS SEEN SITTING ON THE ELECTRICAL CONDUIT (A PIPE TO PASS ELECTRIC WIRES THROUGH) ABOVE THE TILES, DIRECTLY OVER BED 2. A LARGE AMOUNT OF DRIED WATER MARKS WERE SEEN ABOVE THE CEILING TILES, ON THE EXTERIOR CEMENT BLOCKED WALL BEHIND THE BUCKET. THE DIRECTOR OF MAINTENANCE CONFIRMED THEY WERE WATER MARKS FROM WHEN IT RAINED. AN INTERVIEW WAS DONE ON 12/2/10 AT 11:30 A.M., WITH RESIDENT #505, IN ROOM B-1. THE RESIDENT REVEALED WHEN IT RAINS HARD, THE CEILING IN HIS ROOM OVER BED 2, LEAKS. THE RESIDENT STATED "IT LEAKS IN HERE; IT RUNS DOWN THE WALL AND WINDOW IF IT RAINS HARD. WE (THE RESIDENT AND HIS ROOMMATE) HAD TO MOVE BEFORE BECAUSE OF THE LEAKS. I TRIED TO TALK TO ONE OF THOSE CORPORATE GUYS, BUT THEY WERE TO BUSY FOR ME". AN INTERVIEW WAS DONE ON 12/2/10 AT 11:40 A.M., WITH VISITOR #1 (A FRIEND OF RESIDENT #505'S). VISITOR #1 REVEALED SHE WAS AWARE THAT RESIDENT #505'S ROOM HAD LEAKS IN THE CEILING, AND SHE SAID RESIDENT #505 HAD BEEN MOVED FROM HIS ROOM SEVERAL TIMES DUE TO LEAKS. REVIEW OF RESIDENT #505'S ANNUAL MINIMUM DATA SET (RESIDENT ASSESSMENT TOOL) DATED 9/9/10, REVEALED HE WAS ALERT, INDEPENDENT IN DECISION MAKING, WITH NO SHORT OR LONG TERM MEMORY LOSS. THE SURVEYOR WAS UNABLE TO INTERVIEW RESIDENT #507 (IN B-1), DUE TO HIS COGNITIVE STATUS. OBSERVATIONS WERE MADE ON 12/2/10 AT 10:15 A.M., OF ROOM A-4 WITH THE DIRECTOR OF MAINTENANCE. THE SURVEYOR REQUESTED MAINTENANCE REMOVE A CEILING TILE ABOVE BED 2, AND A WHITE PLASTIC BUCKET WAS SEEN SITTING ON THE CEILING FRAME WITH A SMALLER BLUE BUCKET SITTING ON 2 ELECTRICAL CONDUITS ABOVE THE WHITE BUCKET, DIRECTLY OVER BED 2. AN INTERVIEW WAS DONE ON 12/2/10 AT 10:15 A.M., WITH THE DIRECTOR OF MAINTENANCE. THE DIRECTOR OF MAINTENANCE REVEALED THE FACILITY HAD A FLAT METAL ROOF WITH RUBBER ON IT. THE DIRECTOR OF MAINTENANCE STATED "THE WATER LEAKS INTO THE RUBBER AND PLYWOOD, IT LEAKS AT THE POINT WHERE THEY WELD IT". AN INTERVIEW WAS DONE ON 12/6/10 AT 10:00 A.M., WITH FAMILY MEMBER #1 (A FAMILY MEMBER OF A RESIDENT IN ROOM A-4). FAMILY MEMBER #1 STATED "IT'S BEEN A YEAR THAT HER ROOM WAS LEAKING; THEY MOVED HER OUT OF THE ROOM SEVERAL TIMES BECAUSE OF THE LEAKS. THE FLOOR GETS SO WET IT HAS RUINED ITEMS, THIS HAS GONE ON FOR YEARS". FAMILY MEMBER #1 REVEALED IN ROOM A-4, THE CEILING LEAKS OVER BED 2 NEAR THE TOP AND AT THE BOTTOM OF BED. FAMILY MEMBER #1 REVEALED WHEN THE FACILITY TEMPORARILY MOVED HER MOTHER TO A DIFFERENT ROOM, THEY SEPARATED HER FROM HER ROOMMATE, WHICH CAUSED HER MOTHER TO BECOME UPSET AND WORRIED ABOUT HER ROOMMATE. THE SURVEYOR WAS UNABLE TO INTERVIEW THE RESIDENT IN A-4, BED 2 DUE TO HER COGNITIVE STATUS. OBSERVATIONS WERE MADE ON 12/6/10 AT 10:15 A.M.; OF A LARGE CARDBOARD BOX OF CLOTHING BELONGING TO RESIDENT #509, SITTING IN HER ROOM CLOSET (THE RESIDENT LIVES IN ROOM A-4). ON THE BOTTOM OF THE BOX AND GOING UP THE SIDES WERE DRIED WATER-LIKE MARKS, AND THE BOTTOM WAS PARTLY OPEN DUE TO WATER DAMAGE. THE BOX WAS FILLED WITH THE RESIDENTS DAMAGED CLOTHING. A PHONE INTERVIEW WAS DONE ON 12/14/10 AT 9:00 A.M., WITH THE DIRECTOR OF MAINTENANCE. THE DIRECTOR OF MAINTENANCE CONFIRMED THERE WERE A TOTAL OF 17 RESIDENT ROOMS ON AMERICAN WAY HALL (HALL RESIDENT ROOM A-4 IS ON), AND A TOTAL OF 3 RESIDENT ROOMS ON BUTTERFLY BOULEVARD HALL (HALL RESIDENT ROOM B-1 IS ON). OBSERVATIONS WERE MADE ON 12/2/10 AT 10: 40 A.M., OF THE FACILITY ROOF. SEVERAL PATCHED AREAS WERE SEEN DIRECTLY OVER ROOM'S A-4 AND B-1, NEAR THE EDGE OF THE SIDE OF THE BUILDING. A LOT OF ICE HAD ACCUMULATED ON THE ROOF ABOVE ROOMS A-4 AND B-1. THE ROOF WAS SOFT WHEN WALKED ON, ABOVE ROOM'S A-4 AND B-1. AN INTERVIEW WAS DONE ON 12/2/10 AT 10:48 A.M., WITH THE DIRECTOR OF MAINTENANCE. THE DIRECTOR OF MAINTENANCE STATED "THAT'S WHERE THE WOOD HOLDS WATER; IT SWELLS UP". AN INTERVIEW WAS DONE ON 12/2/10 AT 10:55 A.M., WITH THE DIRECTOR OF MAINTENANCE. THE DIRECTOR OF MAINTENANCE REVEALED HE TOOK THE ADMINISTRATOR UP TO SEE THE ROOF APPROXIMATELY 3 MONTHS AGO, AND EXPLAINED TO HIM THE POOR CONDITION IT WAS IN. AN INTERVIEW WAS DONE ON 12/6/10 AT 10:45 A.M., WITH MANAGER #1. MANAGER #1 REVEALED RESIDENT #509'S FAMILY MEMBER (FAMILY MEMBER #1) INFORMED HER THE ROOF LEAKING IN THE RESIDENT'S ROOM, AND STATED "IT HAS BEEN GOING ON FOR AWHILE". MANAGER #1 STATED "(RESIDENT #505) SAID THE WINDOW IN HIS ROOM (B-1) LOOKS LIKE A WATER FALL (WHEN IT RAINS). THE DON (THE DIRECTOR OF NURSING) AND THE ADMINISTRATOR ACTED LIKE IT WAS NO BIG DEAL BECAUSE IT HAPPENED SO MANY TIMES". AN INTERVIEW WAS DONE ON 12/6/10 AT 12:25 P.M., WITH MANAGER #2. MANAGER #2 STATED "IT'S BEEN LEAKING FOR AT LEAST 3 YEARS. SOME FAMILY MEMBERS HAVE COMPLAINED ON C-WING. THEY DO SPOT-TO-SPOT FIXING. WHEN IT'S ICE, THE MAINTENANCE MAN HAS TO GO UP THERE (ON THE ROOF) AND SWEEP IT OFF. I HAVE SEEN WATER COMING DOWN THE WINDOW IN B-1, I ALSO SAW WATER ON THE FLOOR IN B-1". AN INTERVIEW WAS DONE ON 12/2/10 AT 12:55 P.M., WITH THE ADMINISTRATOR. THE ADMINISTRATOR STATED "WE MOVED THEM (THE RESIDENT'S IN ROOM'S B-1 AND A-4); BECAUSE OF THE RAIN WE HAD ON THE WEEKEND (11/27/10 AND ON 11/28/10)". THE ADMINISTRATOR REVEALED THE DIRECTOR OF MAINTENANCE "SWEEPS OFF THE WATER" FROM THE ROOF WHEN IT RAINS. THE ADMINISTRATOR SAID A ROOFING CONTRACTOR HAD NOT BEEN CONTACTED (AS OF 12/2/10 AT 12:55 P.M.) TO FIX THE RECENT WATER LEAKS OVER ROOM'S A-4 AND B-1. OBSERVATIONS MADE ON 12/2/10 OF ROOM A-4 AT 10:30 A.M., AND ROOM B-1 AT 11:30 A.M., REVEALED THE FOUR RESIDENT'S (RESIDENT'S #505, #506, #507 AND #509) WERE MOVED BACK INTO THEIR ROOMS, WITHOUT THE ROOF BEING FIXED AFTER THE CEILING LEAKS ON 11/27/10 AND 11/28/10. AN INTERVIEW WAS DONE ON 12/6/10 AT 11:40 A.M., WITH THE ADMINISTRATOR AND THE DIRECTOR OF NURSING (DON). THE ADMINISTRATOR AND THE DON REVEALED THE RESIDENT'S IN ROOM A-4 (RESIDENT #506 AND #509) WERE MOVED OUT OF THEIR ROOM DUE TO LEAKS IN THEIR CEILING ON 11/28/10, AND RETURNED TO THEIR ROOM ON 11/29/10. THE RESIDENT'S IN ROOM B-1 (RESIDENT #505 AND #507) WERE MOVED OUT OF THEIR ROOMS DUE TO LEAKS IN THEIR CEILING ON 11/28/10, AND RETURNED TO THEIR ROOM ON 12/2/10. THE ADMINISTRATOR REVEALED HE WAS FIRST INFORMED OF THE CEILING LEAKS IN ROOM'S, AND THE RESIDENT'S HAVING TO BE MOVED ON 11/29/10, IN THE MORNING WHEN HE ARRIVED AT THE FACILITY. THE DON SAID SHE WAS FIRST INFORMED ON 11/29/10, AT 4:00 A.M. AND SHE INSTRUCTED STAFF TO MOVE THE RESIDENT'S TO OTHER ROOMS, AND PUT IT ON THE "TO DO" MAINTENANCE LIST. REVIEW OF THE HAND WRITTEN NOTE REGARDING THE CONDITION OF THE FACILITY ROOF DATED 4/3/09, STATED "OUR BUILDING HAS A RUBBER COATED ROOF WHICH IS APPROXIMATELY [AGE] years OLD. THE CURRENT CONDITION OF THE ROOF IS AS FOLLOWS: A-WING (WHERE ROOM A-4 IS LOCATED) HAS SEVERAL LEAKS WHICH HAS BEEN PATCHED ON A CONTINUOUS BASIS. IT ALSO HAS AN AREA IN WHICH THE PLYWOOD UNDERNEATH IS BUCKLED UP AND WARPED AND IS STRETCHING THE RUBBER FURTHER THAN IT SHOULD. B-WING (WHERE ROOM B-1 IS LOCATED) HAS SEVERAL LEAKS WHICH GETS PATCHED ON A CONTINUOUS BASIS. DURING A SEVERE STORM AND WIND THIS WINTER (THE WINTER OF 2009), THE RUBBER WAS PEELED BACK OVERTOP OF ROOM'S B-1 AND B-3, AND HAD TO BE REATTACHED THE BEST WE COULD. C-WING WHICH HAS SEVERAL LEAKS WHICH HAVE BEEN PATCHED ON A CONTINUOUS BASIS, AND HAS SEVERAL AREAS WHERE THE PLYWOOD IS ROTTED AND SINKS-IN. C-WING ALSO HAD THE RUBBER PEELED BACK IN THE STORM, EXPOSING THE WOOD UNDERNEATH. WE COULD NOT GET THE RUBBER STRETCHED BACK OUT ENOUGH TO FULLY COVER THE AREA; ROOF PATCH IS BEING USED ON THE UNCOVERED AREA. D-WING ONLY HAS 1 LEAK AND 1 SPOT WHERE THE WOOD IS ROTTED UNDERNEATH THE RUBBER. THE SERVICE WING HAS SEVERAL LEAKS AND ROTTED AREAS ALSO. THE OUTSIDE FASCIA AND EAVES ARE RUSTED THROUGH, CRACKED AND FALLEN OUT". REVIEW OF THE FACILITY STANDARD PURCHASE ORDER FROM A CONTRACTED ROOFING COMPANY DATED 9/28/09, STATED "INSPECT AND ATTEMPT TO REPAIR LEAK AREAS ON ENTIRE FACILITY". A PHONE INTERVIEW WAS DONE ON 12/14/10 AT 9:00 A.M., WITH THE DIRECTOR OF MAINTENANCE. THE DIRECTOR OF MAINTENANCE REVEALED ON 9/28/09, THE CONTRACTED ROOFING COMPANY PATCHED AREAS ON THE ROOF. REVIEW OF THE CONTRACTED ROOFING COMPANY LETTER DATED 12/6/10, STATED "I INSPECTED THE ROOF ON FRIDAY, DECEMBER 3, 2010. THE ROOF IS IN POOR CONDITION AND NEEDS SEVERAL REPAIRS. THE IMMEDIATE REPAIRS NEED TO BE MADE ON THE FOLLOWING AREAS: AREA A-4, AREA B-1 AND THE SERVICE WING". REVIEW OF THE FACILITY ALL STAFF ENVIRONMENTAL IN SERVICE DATED 5/3/10, 5/4/10, 5/5/10 AND 5/6/10, STATED "STAFF WILL BE AWARE OF THE ENVIRONMENT AND WILL CORRECT OR REPORT ANY PROBLEMS. STAFF WILL LOOK AT THE ENVIRONMENT WITH FIRST IMPRESSION EYES". ( )