Every finding on record at Medilodge of Cheboygan

Based on observation, interview and record review the facility failed to ensure wound care was completed according to physician order and professional standards of practice for one Resident (#6) of one resident reviewed for pressure ulcers.Findings include:Resident #6 (R6)Review of the electronic medical record (EMR) revealed R6 was admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's Disease. Review of the Minimum Data Set (MDS) assessment, dated 2/01/2026, revealed R6 had severely impaired cognition and an unhealed, facility-acquired Stage 3 (full-thickness tissue loss) pressure ulcer.Further review of the EMR revealed R6 was currently undergoing daily monitoring for signs and symptoms of sepsis (severe systemic response to infection). Review of the Pertinent Charting - Infections/Signs/Symptoms, dated 4/13/2026 at 3:08 a.m., revealed the following: Follow up to infection signs/symptoms . Site of originally identified infection: sacral wound.Review of the April 2026 Medication Administration Record (MAR) revealed R6 was prescribed Ciprofloxacin HCL [antibiotic medication] 500 MG [milligram] Tablet . by mouth two times a day for wound infection for 10 days.On 4/14/2026 at 2:00 p.m. R6's wound care was observed performed by RN L. Upon initiation of care, R6 was positioned on her right side and as her brief was removed, a border gauze dressing was observed partially adhered to R6's sacral region (area at the bottom of the spine and above the tailbone). The dressing was saturated with a brownish-tan discharge and was adhered on the left side of the dressing only causing the non-adhered portion to be pushed to the left side, exposing the entire wound. It was noted there were initials on the dressing and RN L straightened out the gauze to reveal a written date of 4/13/2026, indicating who performed the dressing change and the date the dressing was applied. The Assistant Director of Nursing (ADON), who was present at the time of the observation, reported the initials on the soiled dressing belonged to RN M, who worked the day shift on 4/13/2026.Further observation during the provision of wound care revealed R6 had a large Stage 3 pressure injury located on her sacrum. The wound was approximately 8 centimeters (cm) long by 7 cm wide, with an approximate depth of 4 cm. The wound bed was observed to be a beefy red with scattered white slough (dead tissue) noted near the center and a foul odor noted coming from the wound.During an interview immediately following completion of wound care, RN L reported R6's wound to be a Kennedy ulcer (ulcer appearing at end of life due to oxygenated blood shifting from the periphery of the body to vital organs). RN L reported R6's was being administered an antibiotic due to the wound currently being infected. When asked about the initials on the dressing that was removed upon initiation of wound care, the ADON confirmed the initials and date on the soiled dressing indicated the wound was last changed the previous day shift by RN M. The ADON and RN confirmed R6's physician order for wound care was for the dressing to be changed twice daily.Review of the April 2026 Treatment Administration Record (TAR) revealed the following order: Wound Care . cleanse with wound spray, apply dakins moistened gauze, cover with bordered dressing. Change dressing BID [twice daily] . Start date: 4/08/2026 .Review of the Pertinent Charting - Infections/Signs Symptoms, dated 4/13/2026 at 5:43 p.m. by RN M, revealed, Dressing change continued as ordered.Review of the Pertinent Charting - Infections/Signs Symptoms, dated 4/14/2026 at 2:08 a.m. by RN C, revealed, Dressing change completed as ordered.Further review of the TAR revealed RN M documented wound care completed on 4/13/2026 for the 8:00 a.m. scheduled dressing change. It was noted, RN C documented the 8:00 p.m. scheduled wound care and dressing change as completed, contrary to the observation during R6's wound care of the presence of the dressing applied by RN M on 4/13/2026 and the ADON's report.During an interview on 4/15/2026 at 10:38 a.m., the Director of Nursing (DON) confirmed the ADON had alerted her to the observation indicating R6's twice daily wound care and dressing change had not been performed on 4/13/2026 per the physician's order. The DON acknowledged the potential for worsening infection and deterioration of the wound if wound care was not performed as ordered. The DON was queried regarding the process for documentation of wound care to which she confirmed staff should not document care that was not provided.Facility wound care policies were requested on 4/14/2026 at 9:00 a.m. and 4/15/2025 at approximately 10:00 a.m. but were not provided prior to survey exit on 4/15/2026 at 2:00 p.m.

Based on observation, interview, and record review, the facility failed to accurately dispense insulin to two Residents (Residents #2, #11) of seven residents reviewed for medication administration resulting in 2 errors in 34 opportunities for error and a 5.88% medication error rate.Findings Include: On 4/13/26 at 7:39 PM, Registered Nurse (RN) B was observed administering insulin to Resident #2 (R2) and held the subcutaneous injection site for six seconds.On 4/13/26 at 7:40 PM, an interview was conducted with RN B regarding how long she was to hold the injection site and replied, Ten seconds. RN B was made aware she only held the needle in place for six seconds. RN B remarked, I must have counted fast .On 4/13/26 at 8:03 PM, RN C was observed administering insulin to Resident #11 (R11) and held the subcutaneous injection site for 5 seconds.On 4/13/26 at 8:05 PM, an interview was conducted with RN C regarding how long she was to hold the injection site and replied, Ten seconds. RN C was made aware she only held the needle in place for five seconds. RN C remarked, I thought I held it longer, you know it's hard to count when talking to the resident .On 4/14/26 at 9:05 AM, an interview was conducted with the Director of Nursing (DON) was asked about medication administration expectations and acknowledged nurses should follow the five rights of medication administration. The DON stated she knew that some insulin pens had different medication administering times, but felt staff should always do the 10 seconds to be safe.Per insulin step by step guide (2022) .STEP 5.INJECT YOUR DOSE Clean site with an alcohol swab. Please see injectionsite options on page 2. Keep the pen straight, insert the needle into your skin. Use your thumb to press the injection button all theway down. When the number in the dose windowreturns to 0 as you inject, slowly count to 10 beforeremoving. (Counting to 10 will make sure you getyour full insulin dose.) Release the button and remove the needle fromyour skin .Review of policy titled, Medication Administration, dated 1/17/23, read in part, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines.10. Review MAR (Medication Administration Record) to identify medication to be administered. 11. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time of administration.

Based on interview and record review, the facility failed to offer and administer COVID vaccinations to two Resident (#2 & #4) of five residents reviewed for immunizations.Findings include:Resident #2 (R2)R2 was admitted to the facility on [DATE]. Vaccination consent forms for pneumococcal and Influenza vaccinations were e-signed by R2 on 1/20/26. A vaccination consent form for COVID-19 was not located in the medical record of R2.A Michigan Care Improvement Registry (MCIR - a statewide immunization information system that tracks vaccinations and health data for residents of Michigan) was reviewed on 4/15/26. The MICR documented R2 was [AGE] years of age. The MCIR indicated the immunization status of the COVID-19 2025-26 vaccine was Overdue.On 4/15/26 at 12:53 PM, Registered Nurse (RN) I was interviewed. RN I confirmed she was responsible for tracking vaccine consents and administrations. RN I said R2 was not provided the COVID-19 vaccination consent form when she was admitted on [DATE].Resident #4 (R4)Resident #4 (R4) was admitted to the facility on [DATE]. R4 signed a consent form for COVID-19 vaccine administration. R4 received one dose of the COVID-19 vaccination on 10/6/25.The MCIR of R4 was reviewed on 4/15/26. The MCIR documented R4 as [AGE] years of age. The MCIR indicated a COVID-19 2025-26 vaccine had an accelerated due date of 12/6/25 and was overdue to be administered as of 4/6/26.On 4/15/26 at 12:53 PM, RN I was asked the reason R4 had not received the second COVID-19 vaccination. RN I acknowledged R4 should have had the second COVID-19 vaccination on or before 4/6/26.The facility policy COVID-19 Vaccination dated as reviewed/revised 10/20/23 documented, in part: .It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. The policy referenced outdated guidelines and vaccines that are no longer in use or recommended by the Centers for Disease Control (CDC).

Based on observation, interview, and record review the facility failed to provide assessment, monitoring, and care per facility policy and professional standards for treatment with a nebulizer for one Resident (Resident #2) of one resident reviewed for inhaled medication administration.Findings include: On 4/13/26 at 7:30 PM, during medication administration, Registered Nurse (RN) B was not observed to perform vital signs or respiratory assessment/lung sounds prior or post administration of a nebulized respiratory treatment. RN B did not instruct Resident #2 (R2) to take deep breaths during the treatment and did not remain with resident to observe for change in condition. After completion of the treatment, RN B stated to R2 shh I am trying to listen to your lungs, RN B then leaned closer to the resident. RN B did not have a stethoscope.On 4/13/26 at 7:50 PM, an interview was conducted with RN B regarding assessment pre and post administration of a nebulizer treatment. RN B stated you should listen to lung sounds pre and post treatment. When asked if she had completed a respiratory assessment, she felt she had.Review of R2's Electronic Medical Record (EMR) indicated R2 had no vitals performed since 7:24 AM on 4/13/26. R2 did not have another set of vitals documented until 8:15 AM on 4/15/26, confirming no vitals were completed pre or post nebulizer treatments. Review of treatment log, nurse assessments, and progress notes did not indicate a complete respiratory assessment had been completed for any of R2's 4/9/26 order for three times a day nebulizer treatment.Review of the facility's Nebulizer Therapy policy last reviewed/revised on 5/15/24 indicated . Policy Explanation and Compliance Guidelines: 1. Care of the Resident.f. Obtain resident's vital signs and perform respiratory assessment to establish a baseline.n. Observe resident during the procedure for any change in condition.3. Documentation Record the following information in the resident's medical record .d. Resident vital signs and respiratory assessment. e. Resident's response to treatment.According to Mosby's Clinical Nursing Skills & Techniques 10th edition (2021) checklist for administering medication via a nebulizer: Perform Assessment: Record baseline vital signs, including heart rate, respiratory rate, oxygen saturation, and auscultate lung sounds.Breathing: Instruct the patient to take slow, deep breaths.Reassess: Monitor the patient for adverse reactions, reevaluate lung sounds and respiratory effort.Documentation: Record the medication given, dose, time, patient's pre and post treatment status, and their tolerance of the procedure.

Based on observation, interview, and record review, the facility failed to:Identify appropriate required Transmission Based Precautions (TBP),Obtain a physician's order timely for isolation precautions,Appropriately apply and remove personal protective equipment (PPE),Utilize PPE when indicated, and;Discontinue an antibiotic medication or document justification for continuing antibiotic medication when test results were negative for Resident #2, affecting three Residents (#2, #16, & #12) of six residents reviewed for infection prevention and control.Findings include:Resident #2 (R2) On 4/13/26 at 11:35 AM, a sign for airborne precautions (an isolation measure used to prevent the spread of infectious agents that can be spread through the air over long distances) was observed posted outside the door of R2's room. The airborne precautions sign read: STOP: AIRBORNE PRECAUTIONS. EVERYONE MUST [sic]: Clean their hands, including before entering and when leaving the room. Put on a fit-tested N-95 [filtering facepiece respirator] or higher-level respirator before room entry. Remove respirator after exiting the room and closing the door. Door to room must remain closed. There was no waste receptacle outside of R2's room to dispose of respirator masks after removing the mask after exiting the room in accordance with the sign instructions. A sign for droplet precautions (an isolation measure used to prevent the spread of infectious agents that are transmitted through respiratory droplets) was observed on a PPE cart outside of R2's room. The sign read: STOP: DROPLET PRECAUTIONS. EVERYONE MUST [sic]: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. On 4/13/26 at 11:41 AM, a visitor was observed approaching R2's room. The visitor stopped at a PPE cart outside of the room and applied a surgical mask. The visitor then entered R2's room. Certified Nurse Aide (CNA) O was observed exiting the room of R2 on 4/13/26 at 11:49 AM. CNA O was not wearing any PPE when she exited R2's room, including an N-95 respirator in accordance with the airborne precautions posting, or eye protection as indicated on the droplet precautions posting. Registered Nurse (RN) F was interviewed on 4/13/26 at 11:53 AM. RN F confirmed she was the nurse assigned to care for R2 on 4/13/26. RN F was asked the type of TBP required in the room where R2 resided. RN F said both residents in the room were in airborne precautions for RSV (Respiratory Syncytial Virus – a contagious respiratory virus that can cause severe illness in older adults). RN F said R2 tested positive for RSV and R2's roommate was in airborne precautions due to exposure to RSV. RN F was asked regarding masking requirements. RN F indicated she wore an N-95 respirator mask when she had to enter the room. When asked about removing and disposing of the N-95 respirator mask, RN F said she removed of the mask inside the room and disposed of the mask inside the room. The airborne precautions sign posted on the door was reviewed with RN F, specifically the portion directing: Remove respirator after exiting the room and closing the door. RN F said there was nowhere immediately outside of the room to dispose of PPE, so she removed the N-95 respirator mask and disposed it in the room. When asked about the droplet precautions posting on the PPE cart outside of the room, RN F reviewed the posting and said she did not know the reason the posting was on the cart because droplet precautions required a face shield or goggles and staff were not wearing eye protection when in the room. RN F was asked which precautions the physician had ordered for R2. RN F said she would contact R2's physician to determine the required precautions. The Director of Nursing (DON) was observed placing several signs on the door of R2's room on 4/13/26 at 11:58 AM. The signs were for airborne precautions, droplet precautions, and contact precautions (an isolation measure used to prevent the spread of infectious agents that can be transmitted through direct or indirect contact with patients or their environment). The contact precautions sign read, in part: STOP: CONTACT PRECAUTIONS. EVERYONE MUST [sic]: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO [sic]: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. On 4/13/26 at 11:58 AM, RN J was observed approaching R2's room. RN J was asked the PPE requirements for R2. RN J said, Well, since there's three signs now, I guess I'll put on everything. RN J put on a gown, N-95 respirator mask, a face shield, and gloves. At 12:05 PM on 4/13/26, RN J exited R2's room wearing gloves, an N-95 respirator mask, and a face shield. RN J and RN F had a discussion in the hallway regarding where to dispose of the PPE. When asked where the PPE should be disposed, both RN J and RN F said they did not know. RN J went to the nurses' office and removed the PPE and disposed of the PPE in the open waste receptacle in the nurse's office. According to the electronic medical record (EMR), Resident #2 (R2) was admitted to the facility on [DATE]. R2 tested positive for RSV on 4/10/26. An order in the EMR dated 4/13/26 read: Place resident in transmission-based precautions related to RSV All [sic] care and services received in room every shift. An additional order dated 4/13/25 read: Place residents in droplet precautions related to diagnosis of: RSV All [sic] care and services provided in room every shift. There were no physician's orders for TBP prior to 4/13/26, during the three days after R2 tested positive for a contagious respiratory illness. A physician's progress note in the EMR dated 4/9/26 documented, in part: . upon exam [R2] is noted to have newly present congestion and malaise [feeling of discomfort or illness] . [R2] has a new onset cough with congestion concerning for bronchopneumonia [an infection that inflames the air sacs in the lungs] vs pneumonia. Influenza and COVID testing today is negative. Plan: Orders given for chest x-ray 2 v [view], 5 day prednisone [steroid medication], Levaquin [an antibiotic for bacterial infections] 500 mg [milligrams] qd [every day] x 7 days [for] bronchopneumonia vs pneumonia, Rocephin [an antibiotic for bacterial infections] 1 g [gram] IM [intramuscularly] x 3 days [for] bronchopneumonia vs pneumonia. A chest x-ray was obtained on 4/10/26. The x-ray report read, in part: .Conclusion: No acute abnormality identified. The Medication Administration Record (MAR) of R2 documented administration of Rocephin on 4/9/26, 4/10/26, and 4/11/26. Further review of the MAR disclosed R2 started Levaquin on 4/10/26 and was still receiving the Levaquin as of 4/15/26, five days after the negative chest x-ray was obtained. The Infection Preventionist (IP) E was interviewed on 4/15/26 at 11:32 AM. IP E confirmed R2 was initially prescribed antibiotics for suspected pneumonia. IP E was asked if the physician was notified when the chest x-ray results were reported to determine the need for continued antibiotic therapy. IP E said she provided R'2 nurse with the results of the x-ray, and she expected the nurse to call the physician and follow-up on the need to continue the antibiotic. IP E reviewed the EMR of R2 and said the NP (Nurse Practitioner) acknowledged the chest x-ray result, but the progress note did not include a reason for continuing the antibiotic. IP E said she would have questioned the physician regarding the need to continue with an antibiotic when the chest x-ray was negative for an active disease process. IP E was asked if antibiotics were beneficial to a resident with RSV. IP E responded, No – RSV is a virus not a bacteria. IP E was queried regarding PPE to be worn for the care of R2. IP E said staff should be wearing gowns, gloves, goggles or face shields, and an N-95 respirator mask. IP E was told a staff member had exited the room of R2 with all PPE except a gown and disposed of the PPE in the nurses' office. IP E said PPE should be removed in R2's room and placed in the waste receptacle in the room, and the staff member should not have exited the room and walked to the nurse's office to dispose of the PPE. IP E was asked about precautions for a resident with RSV. IP E said the facility practice was to utilize standard, droplet, and airborne precautions. IP E was asked if the facility had negative pressure rooms (a specialized isolation space designed to prevent airborne contaminants from escaping by maintaining negative air pressure inside the room, also referred to as AIIR [airborne infection isolation room]) or air filtration systems in the rooms. She said they did not. The Centers for Disease Control (CDC) recommendations titled Transmission-Based Precautions Infection Control Basics at www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html, read, in part: .Use Airborne Precautions for patients known or suspected to be infected with pathogens transmitted by the airborne route. Ensure appropriate patient placement in an airborne infection isolation room (AIIR) constructed according to the Guideline for Isolation Precautions. In settings where Airborne Precautions cannot be implemented due to limited engineering resources, masking the patient and placing the patient in a private room with the door closed will reduce the likelihood of airborne transmission until the patient is either transferred to a facility with an AIIR or returned home. The policy Transmission-Based (Isolation) Precautions dated as reviewed/revised 12/31/25 read, in part: .It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission.An order for transmission-based precautions/isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents.The order for transmission-based precautions/isolation will specify the type of precaution. Resident #16 (R16) The medical record for R16 revealed an admission date of 1/21/2026 with a progress note titled Pertinent Charting Infections/Signs Symptoms by nursing on 4/9/2026 which read in part, . Type Other RSV Symptom(s): Abnormal lung sounds (rales, rhonchi, wheezes, etc.) acute functional decline Acute mental status change from baseline. Dry cough. Increased respiratory rate. New or increased sputum production. Oxygen saturation <94% on room air. A Physician order dated 4/9/2026 read, Place resident in transmission-based precautions related to RSV. All care and services received in room. every day and night shift. A follow-up progress note titled Pertinent Charting Infections/Signs Symptoms by nursing on 4/13/2026 read in part, . Follow up to infection signs/symptoms type: .(R16) remains in droplet, contact and airborne precautions at this time. No cough, afebrile and VSS (Vital Signs Symptoms). A follow-up progress note titled Pertinent Charting Infections/Signs Symptoms by nursing on 4/14/2026 read in part, Follow up to infection signs/symptoms type: Respiratory Site of originally identified infection: RSV . RESIDENT REMAINS IN ISOLATIN (sic) AT THIS TIME. NO cough or congestion noted. During observations of the lunch meal delivery on 4/13/2026 at 12:25 PM, CNA R removed a meal tray from the food cart and carried the tray into R16's room without any infection precautions and without wearing PPE. The door for R16's room contained notices including: CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Issued by the U.S Department of Health and Human Services Centers for Disease control and Prevention (CDC) AND DROPLET PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. Issued by the U.S Department of Health and Human Services Centers for Disease control and Prevention (CDC) CNA R did not put on gloves before room entry. CNA R did not put on a gown before room entry. CNA R did not put on a face covering before room entry. During an interview on 4/13/2026 at 12:28 PM, CNA Q stated for R16 . on contact precautions you must glove and gown up when going in and out of the room. The policy titled, Transmission Based Precautions dated as last reviewed on 12/31/25 read in part, . 9 e. Signage that includes instructions for use of specific PPE (personal protective equipment) will be placed in a conspicuous location outside the resident's room, wing, or facility wide. f. The facility will have PPE readily available near the entrance of the resident's room. Staff and visitors will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. 10. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. noroviruses, and other intestinal tract pathogens, RSV). Resident #12 (R12) The medical record for R12 revealed an admission date of 3/5/2026 with diagnoses including : cancer of the lip, oral cavity, pharynx (throat), and history of digestive tract resection (surgical removal of parts of the digestive tract) which made R12 dependent on a PEG (percutaneous endoscopic gastrostomy) tube (a flexible feeding tube surgically placed into the stomach), a Physician order dated 3/5/2026 read, Use enhanced barriers (enhanced barrier precautions or EBP) while performing high-contact activity with the resident r/t (related to) PEG tube every day and night shift. There was a sign on R12's door which read: ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room Wear gloves and a gown for the following High-Contact Resident Care Activities. Device care or use: Central line, urinary catheter, feeding tube. On 4/14/2026 at 12:01 PM, RNP was observed administering R12's feeding via the PEG tube. RN P only wore gloves while administering the tube feeding. When exiting the room, the EBP policy on the door was reviewed with RN P including the requirement for gown and gloves while administering tube feeding. RN P stated: I never wear a gown for a tube feed. On 4/14/2026 at 12:13 PM, the EBP expectations were discussed with Regional RN K who stated PPE including gloves and gown should be worn for the administration of a tube feeding. The Care Plan for R12 included a focus of: Resident requires enhanced barrier precautions related to leg wound from bone graft retrieval & PEG tube Date Initiated: 03/04/2026. The interventions included: - Use gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray. Date Initiated: 03/04/2026 Revision on: 04/12/2026 - Utilize Enhanced Barrier Precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, wound care, dialysis) Date Initiated: 03/04/2026 The facility policy titled Enhanced Barrier Precautions (EBP) and dated as last reviewed 3/26/2024 read in part, Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high-contact resident care activities. High-contact resident care activities to consider include: dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, wound care for chronic wounds.

Based on observation, interview, and record review, the facility failed to monitor fluids and provide the diet as ordered for one Resident (R99) of three residents reviewed for fluid concerns.Findings include:Resident #99 (R99)The Electronic Medical Record (EMR) for R99 revealed an admission date of 4/9/2026 with diagnoses including : altered mental status, unspecified, chronic kidney disease, essential (primary) hypertension, and retention of urine. The Physician's orders of 4/9/2026 included, Diet order Fluid Restriction-1200 ml (milliliters) diet Regular texture, Regular fluid, thin consistency.The EMR contained a care plan for R99 which included Focus -Resident is at risk for fluid volume deficit related to POST COVID-19 CONDITION, UNSPECIFIED; CHRONIC KIDNEY DISEASE, STAGE 3A Date Initiated: 04/09/2026. The interventions for this care plan included, Encourage resident to drink fluids of choice unless contraindicated (i.e., fluid restriction); assist as needed. The care plan also included, Offer fluids during activities. Offer fluids of choice. Ensure all beverages offered comply with diet/fluid restrictions and consistency requirements Date Initiated: 04/09/2026 The care plan was updated by the RD with fluid restriction interventions added 4/13/26 to include: Fluid intake restriction as ordered. 1200ml daily fluid restriction. Date Initiated: 04/13/2026, Provide meals/fluids based on resident food preferences and as ordered Date Initiated: 04/13/2026, Provide nutritional supplement(s) as ordered: Family bringing in premier protein or (brand name) protein shake. 325ml each, provided with each meal does not wish to receive drinks from dietary.During a room observation on 4/14/2026 at 8:33 AM, two 16-ounce (oz) styrofoam cups were noted at R99's bedside. One was filled with a brown carbonated beverage and the other was filled with ice water and the cup dated 4/14 DAY. There was also a 12 oz coke bottle at bedside with approximately 3 oz left in the bottle. This amount equals 960 ml in the styrofoam cups and an additional 90 ml in the cola bottle to total 1050 ml of fluid during the morning observation.During an interview on 4/14/2026 at 9:05 AM, Registered Dietitian (RD) H confirmed the bedside waters are 16 oz. This is 480 ml of water toward the fluid diet order.The EMR contained an RD assessment dated [DATE] and read in part, 1200ml daily fluid restriction (family requests only protein shake come with meals [325 ml each]) .During a dining room observation on 4/14/2026 at 11:53 AM, R99 was eating his meal with Family member U. The meal included a 4 oz lemonade and did not contain a protein shake. Family member U stated the shake had been given to R99 in the room.During an interview on 4/14/2026 at 3:20 PM, Nurse Aide (NA) S was observed passing water to each room on the hall. She stated, I pour everyone the same on this hall. I fill up their cups. R99's room included a 16 oz styrofoam cup filled with ice water. She stated water is passed two times per day.On 4/15/2026 at 8:09 AM R99's room was observed and the bedside table had a 16 oz styrofoam cup filled with approximately 8 oz of water.During an interview on 4/15/2026 at 8:20 AM, Registered Nurse (RN) P stated, Yes, (R99) is on a fluid restriction and gets nothing from dietary but a (protein shake) 325 cc at each meal. Everyone knows he is a fluid restriction. (This would total 975 ml from the protein shakes per day.) When asked who tracks R99's fluids she said, The aides do that. When asked how CNAs (Certified Nurse Aides) know the amount of fluid given with medications passed by the nurses, RN P stated, I only give him sips at med pass. RN P confirmed fluid given at medication pass was not accounted for.During an interview on 4/15/2026 at 8:56 AM, the Director of Nursing (DON) stated she would expect a focus that addressed a fluid restriction and she stated the EMR has the totals and referred this surveyor to Assistant Director of Nursing (ADON) I who would know where the totals were found.During an interview on 4/15/2026 at 9:20 AM, ADON I said there are totals for each shift, but each day was not totaled by nursing. ADON I stated the RD totaled the fluids and alerted the staff if the resident was meeting or exceeding the Physician order for fluid restrictions each day.During an interview on 4/15/2026 at 9:24 AM, RD H stated, I do not total the fluids. I know what he is provided from dietary. It was also noted the RD was not present in the facility every day to total the daily fluids.During an interview on 4/15/2026 at 11:39 AM, Family member U stated she brought in the protein shakes daily. She brought them in over the weekend (4/12/26) and left more for the nurses to give to him. Family member U was present each day of the survey and stated she was here every day and made sure (R99) received the supplement at every meal. She went on, He takes it well and drinks it all.The EMR contained fluid intake from the CNA task documentation and revealed a fluid intake of:240 ml, 240 ml, 240 ml on 4/12/26,100 ml, and 240 ml on 4/13/26 325 ml, 525 ml, and 240 ml on 4/14/26These totals do not reflect all of the observed water delivered and present in 16 oz (480 ml) styrofoam cups twice per day (960 ml) , or the cola present in the room, or the 325 ml protein shakes given each day each meal (975 ml), or any fluid given by nursing with medications, or fluids given with meals (such as the observed lemonade on 4/14/26).During an interview on 4/15/2026 at 8:56 AM, the DON was asked to provide a policy on Fluid Restrictions. Only a policy titled Hydration dated as last reviewed 10/26/2023 was presented. It read in part, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. A policy discussing fluid restricted residents, documentation of fluid, division of fluids between departments, or analyzation of meeting or exceeding the Physician fluid orders was not presented at the time of the survey.

Based on interview and record review, the facility failed to ensure follow-up to a change in condition according to professional standards of practice for two Residents (#11 and #75) of three resident's reviewed for change in condition. This deficient practice resulted in the potential for complications and worsening of condition.Findings include:Resident #11 (R11) Review of the Minimum Data Set (MDS) assessment, dated 3/24/2026, revealed R11 was admitted to the facility on 3/ 10/2024 and had diagnoses including Type 2 Diabetes Mellitus with hyperglycemia. Review of R11's April 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following physician's orders: Humalog KwikPen (rapid-acting insulin) Subcutaneous Solution Pen-Injector 100 unit/ML [milliliter]. Inject per sliding scale: If 0-199 = 0 units; 200-249 = 2 units; 250-299 = 4 units; 300-349 = 6 units; 350-399 = 8 units; 400+ = 10 units. If blood sugar is 400 or greater must contact provider . Start Date: 7/06/2025. Accucheck (point of care blood glucose test) – AC (before meals) & HS (at bedtime) . Notify provider if 70 or below or above 400. Start Date: 9/10/2025. Review of R6's point of care blood glucose results documented on the April 2026 MAR revealed the following readings: 4/03/2025 at 11:00 AM: 427 mg/dL (milligrams per deciliter). 4/05/2026 at 7:00 AM: 442 mg/dL. 4/10/2026 at 11:00 PM: 505 mg/dL. 4/12/2026 at 8:00 PM: 529 mg/dL. 4/13/2026 at 12:00 PM: 402 mg/dL. 4/13/2026 at 8:00 PM: 566 mg/dL. 4/14/2026 at 12:00 PM: 525 mg/dL. It was noted the April 2026 MAR and TAR did not include documentation of physician notification of R11's blood glucose readings greater than 400 mg/dL. Further review of the R11's electronic medication record (EMR), including progress notes and assessments, revealed no documentation of assessment for signs and symptoms of hyperglycemia or physician notification for the blood glucose results greater than 400 mg/dL on 4/03/2026 at 11:00 AM, 4/05/2026 at 7:00 AM, and 4/13/2026 at 8:00 PM. Review of the April 2026 MAR revealed R11 was administered 14 units of Humalog, additional to her regularly scheduled doses, in response to each of the glucose readings above 400 mg/dL on the following dates: 4/12/2026 at 8:30 p.m. 4/13/2026 at 9:00 p.m. 4/14/2026 at 6:12 p.m. Review of the EMR and April 2026 MAR and TAR revealed no documentation was noted in the EMR regarding R11's physical response (physical assessments or recheck of blood glucose levels) to the additional doses of insulin administered on 4/12/2026, 4/13/2026 and 4/14/2026. During an interview on 4/15/2026 at 9:51 AM, the Director of Nursing (DON) was queried about R11's high blood glucose readings and subsequent treatment. The DON reported R11's blood glucose tended to be high and her physician was reluctant to increase the dose of her scheduled inulin because, She [R11] has a tendency to bottom right out if given too much, if greater than 400 [mg/dL] staff should call physician but he is reluctant to increase her scheduled sliding scale dose so we seem to call him every day. The DON reported if the Resident's condition warranted physician notification all information, including assessment and discussion with the physician or provider should be documented in progress note. When asked when a recheck POC blood glucose is warranted, the DON reported she would not normally test the Resident's blood glucose level again until the next time scheduled on the MAR, even if extra insulin was administered. The DON stated that when she cared for residents she would usually go in and check on the residents. If extra insulin is given, I always go in and reassess. Resident #75 (R75): On 4/13/2026 1:35 PM Resident #75 (R75) was observed lying in bed with her spouse at bedside. R75 said she did not feel well. R75 was unable to explain the reason she did not feel well. The EMR of R75 was reviewed on 4/13/26 at approximately 2:00 PM. The EMR reflected R75 was admitted to the facility on [DATE]. An MDS dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of four, indicating R75 had severely impaired cognition. The MDS assessed R75 as continent of bowel. The MDS coded R75 as receiving hospice services. The EMR contained Certified Nurse Aide (CNA) task documentation for activities of daily living, including toileting and tracking of bowel and bladder elimination. The task record documented R75's last bowel movement as occurring on 4/8/26 at 4:44 AM. Physician's orders in the EMR included an order dated 4/12/26 for: Bisacodyl [a laxative medication] EC [enteric coated] oral tabled delayed release 5 mg give 1 tablet by mouth every 24 hours as needed for constipation. There were no administrations of bisacodyl documented in the month of April on the Medication Administration Record (MAR) or progress notes of R75. The EMR contained a document Evaluation of Bowel – V3 dated 1/19/26. The were no documented assessments of R75's abdomen or bowels after 1/19/26 contained in the EMR. The instructions on the document read, in part: Directions: Resident should be evaluated at admission and whenever there is a change in.bowel function. There was no documentation located in the EMR of R75 indicating the physician was notified of R75 not having a bowel movement since 4/8/26. A review of the hospice visit log revealed a documented date of the last hospice visit on 4/10/26 by the hospice Registered Nurse (RN). The hospice RN note dated 4/10/26 documented: Pt [patient] oriented to person only. She Believes [sic] she just arrived at [name of facility redacted]. She refuses shower or bed bath. 0 [No] BM [bowel movement] since 4/6/26. Afebrile [no fever] VSS [vital signs stable] Spouse at Bedside [sic]. There was no documented bowel/abdominal assessment documented by the hospice RN. The EMR did not contain a care plan for decreased GI motility or interventions for staff to follow if R75 experienced constipation. The most recent hospice care plan for R75, titled Hospice IDT Comprehensive Assessment and Plan of Care Update report dated 4/1/26, did not include a plan of care for constipation. On 4/14/26 at 9:30 AM, the Nursing Home Administrator (NHA) was asked to provide the facility bowel policy. The NHA said the facility did not have a bowel policy but had a bowel protocol. On 4/14/26 at approximately 9:45 AM, the NHA and corporate director of operations said they do not have bowel protocol or standing orders containing a bowel protocol. On 4/14/26 at 11:52 AM, Licensed Practical Nurse (LPN) D was queried regarding the process for bowel management. LPN D said if a resident does not have a bowel movement in three days, they are placed on the facility's bowel protocol. LPN D explained the facility's bowel protocol included administration of Milk of Magnesia (MOM – a laxative medication) on the third day without a bowel movement, then administration of Bisacodyl if the MOM was ineffective, then a fleets enema if the Bisacodyl was ineffective. LPN D said R75 was on the bowel tracking monitoring log for not having a bowel movement, but no laxative medications were documented as having been administered. When asked the last time R75 had moved her bowels, LPN D reviewed the EMR and said he did not know where to find the information. The DON was interviewed on 4/14/26 at 12:05 PM. The DON reiterated the bowel protocol of MOM, bisacodyl, and enema conveyed by LPN D. The DON said all residents had the bowel protocol entered into their order sets (a pre-defined group of medical instructions in the EMR), and the physician was to be notified if the bowel protocol was ineffective. The DON said if a resident has not had a bowel movement in three days, the resident is added to the bowel protocol list to commence the interventions in the protocol. The DON was asked the last time R75 had a bowel movement. After reviewing the EMR, the DON acknowledged the last documented bowel movement of R75 was six days prior, on 4/8/26. The DON said the physician should have been notified, and the goal was to keep R75 comfortable and pain-free. The DON agreed constipation was painful and added R75 had a history of constipation. When asked why constipation was not care planned if R75 had a history of constipation, the DON did not provide a response. When asked if an abdominal bowel assessment had been completed, the DON confirmed there was no documented bowel assessment in the EMR. The DON said a bowel assessment should have been completed and documented. RN G was interviewed on 4/14/26 at 1:31 PM. RN G said she was the nurse manager for the unit where R75 resided. RN G said she discussed the concerns with R75's lack of bowel movements with the hospice nurse but there was no documented response from hospice. RN G confirmed there was no documented bowel assessment in the EMR of R75. RN G said R75 had a poor appetite but agreed there should have been bowel movements despite the poor appetite and said a bowel assessment should have been documented. RN G said R75 should have the bowel protocol order set in the EMR. RN G said, I don't know why they [bowel protocol orders] weren't entered [in the EMR] for her [R75]. RN G said she would notify R75's physician immediately for further orders. On 4/14/26 at 2:34 PM, RN G said she completed a bowel assessment on R75 and notified the physician of R75 regarding lack of bowel movements. RN G said orders for laxatives were obtained from the physician of R75. CNA task documentation in the EMR of R75 was reviewed on 4/15/26 at 7:04 AM. The documentation revealed R75 had a bowel movement on 4/14/26 at 3:13 PM.

Based on observation, interview, and record review, the facility failed to obtain a physician's order for dialysis, monitor a dialysis access site, report dialysis concerns to the physician, care plan potential fluid volume overload, and adhere to physician-prescribed fluid restrictions for one Resident (#8) of one resident reviewed for dialysis.Findings include:Resident #8 (R8)R8 was admitted to the facility on [DATE] with a primary diagnosis of ESRD (End-Stage Renal Disease). A Minimum Data Set (MDS) assessment dated [DATE] documented R8 received hemodialysis treatments at an off-site dialysis facility.Multiple attempts were made to interview R8 on 4/13/26. Registered Nurse (RN) F, the nurse assigned to the unit where R8 resided, said R8 was at dialysis and would be available on 4/14/26.The electronic medical record (EMR) of R8 was reviewed on 4/13/26. The EMR did not contain a physician's order for dialysis. There was no physician's order for monitoring a dialysis vascular access site.Interviews were attempted with R8 on 4/14/26 but she was not in her room. On 4/14/26 at 10:19 AM, the Director of Nursing (DON) said R8 was unavailable due to attending an additional dialysis treatment. When asked the reason for another dialysis treatment, the DON said she did not know but thought it was a concern with excess fluid. When asked if the physician of R8 had been made aware of the additional dialysis treatment, the DON said she didn't know.The DON was asked about R8's vascular access site. The DON said R8 had an AV fistula (arteriovenous fistula - a surgically created connection between an artery and a vein, providing an access point for hemodialysis) and nurses were expected to monitor the AV fistula daily for bruit (an unusual sound produced by blood flow through an AV fistula) and thrill (a vibration that indicates the AV fistula is working).The DON was queried regarding physician's orders pertaining to dialysis. The DON reviewed the EMR of R8 and confirmed there was no physician's order for dialysis and no daily monitoring for thrill and bruit.The DON was asked where documentation was located regarding the reasoning behind the need for an additional dialysis treatment on 4/14/26. The DON reviewed the EMR of R8 and confirmed the absence of documentation providing the reason the additional dialysis treatment was indicated. The DON said she would obtain the documentation.On 4/14/26 at approximately 10:25 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON said a physician's order for dialysis was required and said there should be a physician's order for the location of the dialysis treatments, frequency of treatments, and monitoring requirements for the vascular access site. The ADON said the vascular access site for R8 should be monitored every shift for thrill, bruit, bleeding, signs and symptoms of infection or other complications.The ADON was asked if the physician had been notified regarding the need for R8 to attend an additional dialysis treatment. The ADON reviewed the EMR of R8 and confirmed that nothing was documented in the EMR.On 4/14/26 at 11:13 AM, the DON provided a Hemodialysis Nursing Home Communication Form dated 4/13/26. There was no documentation on the form indicating the reason for an additional dialysis treatment on 4/14/26.The progress notes in the EMR did not include the reason for the additional dialysis treatment nor did the progress notes include communication to R8's physician that an additional dialysis treatment was requiredRN G was interviewed on 4/14/26 at 1:59 PM. RN G said she was the nurse manager on the unit where R8 resided. RN G said the physician of R8 should have been notified of the need for an additional dialysis treatment, and the nurse should have called the dialysis unit to determine the reason an additional treatment was required. RN G said R8 attended an additional dialysis treatment on 4/14/26 due to fluid volume overload.An interview was conducted with R8 on 4/14/26 at 3:01 PM. R8 said she attended dialysis on Mondays, Wednesday, and Fridays each week but needed to have an additional dialysis treatment on 4/14/26. When asked the reason for an additional dialysis treatment, R8 said she had too much fluid build-up.R8 had a physician's order dated 3/22/26 for a 1,000 ml (milliliter) per day fluid restriction. 520 ml of fluid were to be provided by the dietary department with meals, and 480 ml per day were to be provided by nursing.A Registered Dietitian (RD) nutrition summary in the EMR dated 3/22/26 documented, in part: . Resident is agreeable to 1000 ml daily fluid restriction recommended by [name of off-site dialysis facility redacted] RD. 85-100% intake of meals since admission and 720 ml daily average fluid intake with meals [200 ml more than allotted in fluid restriction breakdown for dietary provision of fluids].The care plans of R8 did not contain a care plan or interventions pertaining to fluid volume overload to provide staff with interventions to implement if R8 was consuming an excess amount of fluids above her physician-ordered fluid restriction. The care plans did not indicate R8 was noncompliant with the fluid restrictions.The MDS dated [DATE] did not document any refusals of care or behaviors.A dialysis communication form dated 4/6/26 was reviewed. The dialysis RN documented R8 had a dietary concern fluid gain. The dialysis RN conveyed, 20.3 pound gain since last treatment. There was no documentation found in R8's EMR indicating the facility had addressed or responded to the fluid gain.On 4/15/26 at 9:28 AM, RN G said the certified nurse aides (CNA) document fluid intake through a point-of-care portal (in the Tasks portion of the EMR). RN G said the CNA's only document the amount of fluids consumed at meals.RN G was queried regarding monitoring additional fluids for R8 aside from just the amount consumed at meals, such as fluids at bedside, amount of fluids provided during medication administration, amount provided by nursing, and amount consumed during activities. RN G said nurses do not document fluid intake, and she was unaware of anywhere else fluid intake was documented.The RD was interviewed on 4/15/26 at 9:36 AM. The RD confirmed the CNAs documented the amount of fluids consumed during meals in point-of-care documentation. She said she did not know if, or where, staff documented additional fluids beyond what was offered on the meal trays of R8.The RD said excess fluid intake or noncompliance with fluid restrictions should be included in care plans. The RD said, Nursing needs to document how much fluid they are giving. Point-of-care fluid intake documentation for R8 was reviewed for the month of April to determine if R8 was maintaining the 520 ml of fluids provided by the dietary department as outlined in the physician's order for fluid restrictions. Point-of-care data revealed the following fluid intakes during meals each day:4/1/26: 720 ml4/2/26: 720 ml4/4/26: 960 ml4/7/26: 600 ml4/9/26: 760 ml4/11/26: 840 ml4/12/26: 720 ml4/14/26: 1,200 mlOn 4/15/2026 at 8:22 AM, R8 had a 480 ml Styrofoam cup of clear liquid that appeared to be water on the overbed table. The cup was almost empty. There was another 480 ml Styrofoam cup of dark fluid half empty at on the nightstand. R8 was unable to be interviewed regarding the fluids due to being out of the facility for dialysis.The policy Care Planning Special Needs - Dialysis dated as reviewed/revised 12/28/23 read, in part: . 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. Changes in condition following a dialysis treatment will be reported immediately to the physician.The policy Resident Hydration dated as reviewed/revised 7/1/25 read, in part: .Physician orders to limit fluids will take priority. Nursing will monitor and document fluid intake and the Dietitian will be kept informed of status. IDT [interdisciplinary team] will update care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved.

This deficiency pertains to intake #2661622Based on interview and record review, the facility failed to protect the right of one Resident (R1) to be free from physical and verbal abuse by a staff member of three residents reviewed for abuse. This deficient practice resulted in psychosocial harm including feelings of humiliation and fear based on the reasonable-person concept. Findings include:A facility-reported incident (FRI) investigation summary submitted to the state agency on 11/3/25 disclosed Certified Nurse Aide (CNA) A and CNA B witnessed CNA C abuse Resident #1 (R1) while rendering post-fall assistance to R1 on 10/26/25. The facility investigation substantiated the abuse. Review of the electronic medical record (EMR) of R1 revealed an admission date of 3/18/25 with a primary diagnosis of cerebral infarction (stroke). Additional diagnoses included but were not limited to: Alzheimer's disease, age-related cognitive decline, major depressive disorder, cognitive communication deficit, weakness, fatigue, and need for assistance with personal care. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] disclosed a Brief Interview for Mental Status (BIMS) score of three indicating R1 had severe cognitive impairment. A care plan documented R1 was not ambulatory and had an ADL self-care performance deficit. The care plan interventions indicated R1 required staff assistance with activities of daily living (ADL). An interview was attempted with R1 on 11/7/25 at 9:55 AM and 1:15 PM. R1 was confused and unable to answer questions appropriately or recall the incident with CNA C on 10/26/25. CNA A was interviewed on 11/7/25 at 11:01 AM regarding the event of 10/26/25. CNA A said at about 6:30AM - 7:00 AM she, CNA B, and CNA C were in R1's room because R1 fell from bed and was on the floor. CNA A alleged CNA C began kicking R1 and said, He [R1] got himself on the floor and he'll get himself back into bed! CNA A said, [CNA C] kicked [R1] at least three to five times along his left lateral lower extremity to get R1 moving toward the bed. CNA A said, I would describe the kicking as 'hard'. CNA A said R1 appeared startled, afraid, and in distress. CNA A said she exited the room and reported to Registered Nurse (RN) D that she [CNA A] was uncomfortable with the way CNA C was treating R1. RN D asked if R1 was being abused. CNA A said she shrugged her shoulders but did not answer. When asked why she did not respond to RN D's question, CNA A responded, I was taught that it's not my job to decide if something is abuse - my job is to report it. CNA A returned to R1's room and observed R1's disposable brief had fallen off. CNA A said, R1 was crawling around on the floor without anything on and fell forward onto his stomach. When R1 fell forward, CNA C struck R1 with an open hand on his buttocks and said loudly in an angry voice, You are so disgusting! to R1. CNA C said to CNA A, He is so disgusting - he doesn't listen! CNA A said CNA C grabbed R1's lower arm and began yanking hard on it to get R1 to grab the side rail to pull himself into the bed. CNA A described the action as pulling hard on [R1] arm five or six times. CNA A left the room again and reported to RN D that the Administrator (NHA) needed to be called due to the continued actions of CNA C toward R1. CNA A said she questioned if RN D reported her concerns to the NHA, so CNA A called the NHA on 10/26/25 at approximately 1:00 PM. CNA A said the NHA came to the facility within 15 minutes. CNA A witnessed CNA C obtain her personal belongings and exit the facility soon thereafter. CNA B was interviewed on 11/7/25 at 11:35 AM. CNA B confirmed she, CNA A, and CNA C were in R1's room on 10/26/25 to assist R1 back into bed after a fall. CNA B observed CNA C grab R1 by his wrist and start yanking him toward the bed rail telling him in a loud volume of voice, Get back into the bed! CNA B said she observed CNA C place her hands on the lateral torso of R1 while he was on the floor and began pushing the resident toward the bed. CNA B said the disposable brief of R1 had come off and his genitalia and buttocks were exposed. CNA C proceeded to slap R1 across the buttocks and tell him, Get going! CNA B said She [CNA C] slapped him hard but I don't think it left a mark that lasted. CNA B said CNA C appeared visibly irritated and aggressive and was speaking in a loud volume of voice. CNA B said R1 was able to get the top half of his body onto the bed before CNA C grabbed R1's legs and moved them onto the bed. CNA B said CNA A had exited the room, but RN D never came to the room. RN D was interviewed on 11/7/25 at 2:56 PM. RN D confirmed that on 10/26/25 at approximately 6:30 AM, CNA A reported she [CNA A] did not like how CNA C was treating R1. RN D asked CNA A if R1 was being abused and CNA A shrugged her shoulders. CNA A then went back into R1's room. Shortly thereafter, CNA A again approached RN D and asked her to call the NHA. RN D was asked if she went to the room of R1 when CNA A reported the concern with CNA C's treatment of R1. RN D said she did not go to R1's room on 10/26/25 until approximately 7:00 AM and none of the CNAs were in the room at that time. RN D said she called and reported CNA A's concerns to the NHA after she assessed R1. RN D confirmed she did not interview CNA A or CNA B, and did not talk with or suspend CNA C or stop CNA C from interacting with other residents in the facility. The surveyor was unable to reach CNA C via telephone on 11/7/25 despite two attempts to contact CNA C for an interview. The NHA was interviewed on 11/7/25 at 3:49 PM. The NHA said a text message was sent from RN D on 10/26/25 at 7:25 AM. The NHA read the text at approximately 8:00 AM. RN D told her CNA A reported CNA C had nudged R1 with her foot. The NHA said, Nudging someone with a foot is certainly inappropriate but didn't rise to the level of abuse from what I was told. The NHA said she received a call on 10/26/25 at 1:00 PM from CNA A who reported CNA C had kicked R1 and slapped him on the buttocks. The NHA said she immediately went to the facility, suspended CNA C, and commenced an investigation. The NHA said she notified the police on 10/27/25 at 8:00 AM. The NHA said the facility's abuse prevention protocol was not followed by the staff, and the employment of CNA C was terminated on 10/31/25. The NHA said she spoke with the Regional Director of Operations (RDO) and Regional Director of Clinical (RDC), and a past noncompliance (PNC) was developed and implemented. The policy Abuse, Neglect and Exploitation dated as revised 1/10/24 read, in part: . It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of the age, ability to comprehend, or disability . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting and kicking. It also includes controlling behavior through corporal punishment. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm. The Regional Director of Clinical (RDC) was interviewed on 11/7/25 at 1:53 PM. The RDC confirmed she was involved in developing and implementing a PNC when the facility investigation substantiated CNA C abused R1. The RDC presented a binder containing PNC supporting documents. The documents contained in the binder were determined to be sufficient to meet the requisite requirements for PNC. During the onsite survey, PNC was cited after the facility implemented actions to correct the noncompliance which included: Completed skin and pain assessments on R1 on 10/26/25 Initial and ongoing support visits from social services for R1 Contacted the physician and responsible party of R1 Interviewed residents with BIMS 12 or higher to identify additional situations of potential abuse Reviewed skin assessments and incident reports of residents with BIMS less than 12 to identify additional situations of potential abuse Re-educated staff on the Abuse, Neglect and Exploitation policy Suspended the employment of CNA C when the NHA became aware of the abuse allegation Terminated the employment of CNA C when the investigation substantiated abuse Reported the abuse to law enforcement Held a Quality Assurance Performance Improvement (QAPI) meeting to review the components of the PNC and elicit recommendations from the QAPI committee Developed and implemented ongoing audits to monitor for potential abuse situations The facility was able to demonstrate monitoring of the corrective action and has maintained substantial compliance.

Based on observation, interview, and record review, the facility failed to implement safe and effective infection prevention and control (IPC) practices for eight residents (#10, #30, #14, #59, #50, #67, #6, and #65) of ten residents reviewed for IPC to prevent the potential transmission of communicable diseases and infections as evidenced by failure to: 1. Maintain room doors closed for residents with COVID-19. 2. Appropriately sanitize and disinfect contaminated medical equipment. 3. Remove Personal Protective Equipment (PPE) prior to exiting the room of a resident with COVID-19 on Transmission-Based Precautions (TBP). 4. Prepare and handle medications in a manner to prevent contamination. 5. Ensure care plans were initiated for residents with COVID-19. 6. Ensure physicians' orders for were obtained before placing residents in TBP. This deficient practice resulted in the potential for the transmission of pathogens between residents and the spread of infectious organisms to all 67 residents in the facility. Findings include: Resident #10 (R10) R10, who was on hospice services, tested positive for COVID-19 on 1/6/25. On 1/14/25 the door to R10's room contained a posting indicating R10 was on TBP. There was no physician's order in R10's record to place R10 in TBP nor was there a care plan to provide staff with interventions for COVID-19 and TBP. The door to R10's room was open to the hallway on 1/14/25 at 1:22 PM, 1/14/25 at 1:34 PM, 1/14/25 at 2:41 PM, 1/14/25 at 3:45 PM, 1/15/25 at 8:14 AM, 1/15/25 at 10:19 AM, and 1/15/25 at 11:19 AM. On 1/15/25 at 10:19 AM, the hospice nurse, Registered Nurse (RN) N, was observed exiting R10's room wearing the face shield, N95 mask, gown, and gloves she was wearing in the room. RN N propelled a wheeled, portable vital sign device from the room. RN N obtained disinfectant wipes from an isolation cart down the hallway and began wiping down the vital sign device in the hallway wearing the PPE worn in R10's room. RN N was asked where disinfecting of contaminated medical equipment should occur. RN N responded, I usually do it right here (and indicted the hallway). No one has asked me to go anywhere else. After wiping down the vital sign device, RN N removed the face shield, N95 mask, gown, and gloves in the hallway and carried the PPE down the hall to dispose of in a refuse container. RN C was in the hallway when RN N exited R10's room wearing PPE and was wiping down the medical equipment from R10's room. RN C did not instruct RN N to remove PPE prior to exiting R10's room or to take potentially contaminated equipment to the soiled utility room for cleaning and disinfecting. Resident #30 (R30) R30 tested positive for COVID-19 on 1/10/25. On 1/14/24 at 11:18 AM, the door to R30's room was observed to have TBP signage posted. The door was open to the hallway. The door was observed to be open on the following dates and times: 1/14/25 at 1:22 PM, 1/14/25 at 1:34 PM, 1/14/25 at 2:41 PM, 1/14/25 at 3:45 PM, 1/15/25 at 8:14 AM, 1/15/25 at 10:19 AM, 1/15/25 at 11:19 AM, 1/15/25 at 11:50 AM, and 1/15/25 at 12:27 PM. On 1/15/25 at 11:50 AM, R30 was in a wheelchair in the hallway without a mask. RN C and Certified Nurse Aide (CNA) E were in the hallway but did not request R30 to return to his room or put on a mask. RN P approached and spoke with R10 about lunch but did not request he go to his room or wear a mask. R30's COVID-19 care plan contained an intervention that read, in part: .Redirect back to his room when opening door or sitting at doorway. If he insists, have him wear a mask . Resident #14 (R14) R14 tested positive for COVID-19 on 1/6/25. There was no physician's order in R14's record to place R14 in TBP nor was there a care plan to provide staff with interventions for COVID-19 and TBP. On 1/14/25 at 1:12 PM, the door to R14's room was observed with posted TBP signage. The door to the room was open. The door to the room was open on the following dates and times: 1/14/25 at 1:22 PM, 1/14/25 at 1:34 PM, 1/14/25 at 2:41 PM, 1/14/25 at 3:45 PM, 1/15/25 at 8:31 AM, 1/15/25 at 10:19 AM, and 01/15/25 at 11:19 AM. Resident #59 (R59) R59 tested positive for COVID-19 on 1/9/25. On 1/14/25 at 1:11 PM, the door to R59's room was observed with posted TBP signage. The door to the room was open. The door to the room was open on the following dates and times: 1/14/25 at 1:22 PM, 1/14/25 at 1:34 PM, 1/14/25 at 2:41 PM, 1/14/25 at 3:45 PM, 1/15/25 at 8:14 AM, 1/15/25 at 10:19 AM, and 1/15/25 at 11:19 AM. Resident #65 (R65) R65 was in TBP for COVID-19. A sanitized and disinfected face shield was hanging on a hook outside of R65's room for the next staff member who entered the room to apply as part of necessary PPE. On 1/15/25 at 1:17 PM, CNA F was walking in the hallway and bumped into the face shield resulting in the face shield falling to the floor. CNA F picked up the face shield from the floor and placed it back on the hook without cleaning or disinfecting the face shield. RN H was present and observed CNA F pick up the face shield and place it back on the hook without properly disinfecting it. RN H did not instruct CNA F to sanitize or disinfect the face shield. The Infection Preventionist (IP) G was interviewed on 1/15/25 at 4:57 PM. IP G said the doors to the rooms for residents who have COVID-19 were to remain closed. IP G said if residents leave their rooms they should be redirected back to their rooms if possible or encouraged to wear a mask and remain away from others. IP G said staff were educated on these endeavors, especially keeping the doors to the rooms closed. IP G said physicians' orders are required to place residents in TBP, and residents with COVID-19 should have care plans for the infection. IP G said PPE is expected to be removed prior to exiting the room of a resident on TBP, and it is not permissible to clean resident care equipment in the hallway. IP G said face shields are expected to be disinfected after being exposed to potential contamination. The policy Transmission-Based (Isolation) Precautions dated as last reviewed/revised on 12/27/23 read, in part: .It is our policy to take appropriate precautions to prevent transmission of pathogens . Residents on transmission-based precautions should remain in their rooms . An order for transmission-based precautions/isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively .Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens . Residents on Droplet Precautions who must be transported outside of the room should wear a facemask if tolerated . The policy COVID-19 Prevention, Response and Reporting dated as last reviewed/revised on 5/26/24 read, in part: .It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 .Residents with suspected or confirmed SARS-CoV-2 infection should be placed in a single-person room when possible and available with the door kept closed . All non-dedicated, non-disposable medical equipment used for that resident should be cleaned and disinfected . Resident #50 (R50) During medication preparation for R50 on 1/16/25 at 7:31 AM, RN D opened a bottle of vitamins and dropped one on top of the medication cart. After picking up the vitamin and disposing of it in the biohazard container on the side of the medication cart, RN D placed her ungloved finger in the medication cup and moved the medications around to count and identify the pills in the med cup. Resident #67 (R67) When preparing medications for R67 on 1/16/25 at 7:31 AM, RN D poured an incorrect amount of Vitamin D capsules into the medication cup. RN D used her ungloved finger to scoop out the extra capsules from the medication cup and place the extra capsules back into the bottle, contaminating the remainder of the capsules in the container. Resident #6 (R6) R6 was prescribed Vitamin C 1,000 milligrams (mg). On 1/16/25 at 7:31 AM, RN D opened a bottle of Vitamin C 500 mg and dispensed one tablet from the bottle into a medication cup. RN D reached into the bottle of Vitamin C with her ungloved finger to remove an additional tablet to add to the medication cup, contaminating the inside of the bottle and therefore the remainder of the tablets in the bottle. On 1/16/25 at 7:31 AM, RN D picked up a stack of blister packs (resident-specific card-type package containing a supply of medication) that were stacked atop the medication cart and held them against her uniform while she reviewed the Medication Administration Record (MAR). After reviewing the MAR, RN D placed the blister packs back into the medication cart. Nurse manager, RN I, was interviewed on 1/16/25 at 1:42 p.m. RN I was asked the process if a nurse places an incorrect amount of medication into a medication cup. RN I said the nurse should dispose of all the medications in the cup and start preparation over or perform hand hygiene and put on a glove to remove the incorrect amount. RN I was asked about holding blister packs of medications against a uniform. RN I answered, I saw [RN D] do that. That's not the way meds (medications) should be handled - they should be put in the drawer without touching the body. It's infection control. The policy Medication Administration dated as reviewed/revised on 1/17/23 read, in part: . Medications are administered . in accordance with professional standards of practice, in a manner to prevent contamination or infection . 13. Remove medication from source, taking care not to touch medication with bare hand .

Based on observation, interview, and record review, the facility failed to ensure respectful treatment and a dignified dining experience for three Residents (#18, #20, and #58) of five residents reviewed for residents' rights. This deficient practice resulted in the potential for feelings of frustration, embarrassment, and humiliation. Findings include: Resident #18 (R18) R18 was admitted to the facility on hospice services on 9/9/24. The most recent Minimum Data Set (MDS) assessment dated [DATE] documented R18 was dependent on staff for eating. On 1/14/25 at 11:22 a.m., R18 was observed awaiting the lunch meal in the dining room in a high-back mobile reclining chair seated at a table next to the hospice Social Worker (SW). The SW was using a cell phone and laptop computer. The SW was not speaking with or interacting with R18. The SW was drinking from a Styrofoam cup. R18 was not provided or offered fluids while waiting for his meal. R18 sat and watched the SW drinking from the cup and using the cell phone and laptop computer. On 1/14/25 at 11:43 a.m., the SW remained typing on the cell phone and still had not interacted with R18. The lunch meal had not yet been provided nor were fluids offered to R18. At 11:48 a.m. on 1/14/25, a meal tray was placed in front of R18. The SW answered a phone call and started talking on the phone while the meal tray sat in front of R18. Nurse Aide (NA) B approached the table and turned R18 around in the high-back mobile reclining chair so R18's back was to the table where two other residents were awaiting their meals. NA B put on gloves and began feeding R18 with R18 facing away from the two other residents at the table. Resident #20 (R20) On 1/14/25 at approximately 11:45 a.m., an uncovered lunch meal was placed on a table in the dining room with no resident present at the table. The meal consisted of beef stew, mixed vegetables, and a dinner roll. At 11:56 a.m., R20 propelled his wheelchair into the dining room to the table and began eating the meal that had been sitting uncovered for approximately 11 minutes. R20 was asked regarding temperature and palatability of the meal. R20 responded, it's cold - very cold. A staff member was told R20's meal was cold. The staff member left the original meal on the table and went to obtain another meal. R20 was provided with a fresh meal of beef stew and soup but not a new roll or vegetables. R20 started eating the vegetables from the original lunch meal and said, Now it's really cold. Resident #58 (R58) R58 was admitted [DATE]. A quarterly MDS completed 12/13/24 documented R58 was dependent on staff for all activities of daily living, including eating. On 1/14/25 at 12:02 p.m., R58 was observed in the dining room sitting at a table with a lunch meal in front of him without being assisted with eating. R58 watched two other residents at the table being fed by staff. At 12:07 p.m., the two residents at the table with R58 had finished eating. The staff members who had been feeding the residents left the table while R58 continued to wait to be fed. At 12:17 p.m., Regional Nurse K entered the dining room and began feeding R28 without reheating R58's meal or ensuring an appropriate temperature of the food. On 1/14/24 at 1:26 p.m., hospice CNA O was observed pulling R18 backward down the hall in his high-back mobile reclining chair. Registered Nurse (RN) A and NA B were in the hallway and did not stop or correct CNA O. When CNA O was stopped by the surveyor midway down the hall and asked the reason R18 was being propelled backward, CNA O responded, I only go backward to move these and indicated R18's high-back mobile reclining chair. CNA O continued to pull R18 backward in the high-back mobile reclining chair down the hallway to his room at the end of the hall. The Nursing Home Administrator (NHA) was interviewed on 1/16/25 at 10:10 a.m. The NHA agreed the expectation was for anyone in the facility, including contracted staff, to treat all residents with dignity and respect. The NHA said propelling residents in a chair backward down the hallway or being on the phone and not paying attention to residents are a big no-no. The policy Promoting/Maintaining Resident Dignity dated as reviewed/revised on 10/26/23 read, in part: .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality . When interacting with a resident, pay attention to the resident as an individual . Conversation should be resident focused, and resident centered .

Based on observation, interview, and record review, the facility failed to appropriately dispose of contaminated medications for three Residents (#61, #50, and #47) of eight residents reviewed for medication administration. Findings include: Resident #61 (R61) During medication preparation for R61 on 1/15/25 at 1:07 p.m., Registered Nurse (RN) H opened a bottle of acetaminophen and dispensed two tablets directly from the bottle into the palm of her hand. RN H said, Oh, I don't want to touch those. RN H disposed of the acetaminophen tablets into the garbage container on the side of the medication cart. Resident #50 (R50) During medication preparation for R50 on 1/16/25 at 7:31 a.m., RN D opened a bottle of vitamins and dropped one on top of the medication cart. RN D picked up the vitamin and disposed of it in the biohazard container on the side of the medication cart. Resident #47 (R47) R47 was prescribed 10 milliequivalents (mEq) of potassium daily. While preparing medication for R47 on 1/16/25 at 7:31 a.m., RN D placed 20 mEq of Potassium in a medication cup for administration to R47. The dosage discrepancy was pointed out after medication preparation was completed and RN D was ready to administer the medications to R47. RN D removed the 20 mEq tablet of potassium from the medication cup and disposed of it in the garbage container on the side of the medication cart. Nurse manager, Registered Nurse (RN) I, was interviewed on 1/16/25 at 1:42 p.m. RN I was asked the expectation and facility process for disposing of medications. RN I said medications were wasted by placing the medications in a drug destroyer (a medication solution intended to dissolve and deactivate medication). RN I confirmed the facility had drug destroyer solutions available for medication disposal. The policy Medication-Destruction of Unused Drugs dated 1/18/24 read, in part: . Drugs will be destroyed in a manner that renders the drugs unfit for human consumption . combine tablets, capsules, liquids, and contents of vials and ampules in container with Kitty Litter or other agent such as a drug destroyer .

Based on observation, interview, and record review, the facility failed to ensure medications were administered as prescribed for two Residents (R224 and R47) of eight residents reviewed for medication administration. This deficient practice resulted in R224 experiencing excruciating pain and the potential for R47 to experience increased anxiety. Findings include: Resident #224 (R224) R224 was prescribed meloxicam 15 milligrams (mg) daily for pain. During medication administration observation on 1/15/25 at 1:07 p.m., the meloxicam order for R224 was read on the Medication Administration Record (MAR), indicating the medication was overdue to be administered. On 1/15/25 at 1:20 p.m., Registered Nurse (RN) H asked R224 if she was experiencing pain. R224 indicated she had pain in her back and neck. RN H asked R224 to rate the pain on a scale of one to ten with one being no pain and ten being excruciating pain. R224 said her pain was ten out of ten. When asked why the meloxicam had not been administered as scheduled at 8:00 a.m., RN H said the meloxicam was not in the facility emergency supply of medications, and pharmacy had not yet delivered the medication. RN H said the medication was ordered on 1/14/25 at 6:10 p.m. which was after the pharmacy cut-off time for faxing medications so it would not have been delivered when pharmacy delivered medications the morning of 1/15/25. RN H said the meloxicam for R224 would arrive in the evening delivery of medications from pharmacy on 1/15/25. RN H admitted the pharmacy should have been contacted via phone call on 1/14/25 instead of by fax. RN H confirmed the pharmacy delivered medications stat (immediately) when requested by the facility. On 1/16/25 at 9:15 a.m., the MAR of R224 revealed the dose of meloxicam was signed out by RN H as administered on 1/15/25 at 8:00 a.m. Regional Nurse K was asked to provide a record of medication administration times on 1/15/25 for R224 and pharmacy delivery time and receipt for the meloxicam. On 1/16/25 at 1:05 p.m., a report Medication Admin Audit Report was presented by Regional Nurse K. The report disclosed the meloxicam signed out by RN H as administered at 8:00 a.m. on 1/15/25 was administered at 2:37 p.m. on 1/15/25. There were no medication notes or progress notes found in R224's record documenting the late administration of the medication. There was no documentation in the record indicating R224's physician had been notified of the medication being unavailable or administered late on 1/15/25 at 8:00 a.m. A pharmacy delivery manifest provided by Regional Nurse K on 1/16/25 at 1:05 p.m. documented the meloxicam for R224 was delivered on 1/16/25 at 1:08 a.m. Regional Nurse K was asked how the meloxicam was signed out as administered on 1/15/24 if the medication was not in the facility. Regional Nurse K said R224's family brought in the medication from home and RN H used the home supply of meloxicam for medication administration. Regional Nurse K confirmed there were no medication notes or progress notes regarding the delayed administration of the meloxicam or notification of R224's physician regarding medication unavailability or delayed administration. On 1/16/25 at 1:22 p.m., nurse manager (RN J) was asked the process if a medication is withheld or not available for administration. RN J said the physician should be notified. On 1/16/25 at 1:42 p.m., nurse manager (RN I) was asked the expectation if a medication is withheld or not available for administration. RN I said the nurse would be expected to call the physician and inform him, and the nurse should document in progress notes and follow-up with any new or revised orders implemented by the physician. Resident #47 (R47) R47 was prescribed Ativan 1 mg three times daily for diagnosed anxiety. On 01/16/25 at 7:31 a.m., RN D retrieved R47's blister pack (resident-specific card-type package containing a supply of medication) of Ativan labeled lorazepam (generic for Ativan) 0.5 mg. The instructions on the blister pack read Take 2 tablets by mouth three times daily for Anxiety. RN D placed one tablet in the medication cup and signed out one tablet on the medication record titled Control Substance Record. RN D was directed to the dosage discrepancy between the physician's dosage order for Ativan and the dosage contained in the blister pack. RN D said, She was supposed to get new pills. I ordered those. The order changed months ago. It was verified there were no blister packs of Ativan 1mg tablets available for dispensing to R47. Only 0.5 mg tablets were verified present in the controlled substance locked drawer. R47's medical record identified Ativan 1 mg three times daily was originally ordered on 11/22/23. A review of R47's Control Substance Record for lorazepam for 12/21/24 through 12/26/24 revealed R47 received only one tablet of lorazepam 0.5 mg instead of the two required to meet the prescribed dosage order on 12/21/24 at 1:38 p.m., 12/21/24 at 7:15 p.m., 12/22/24 at 8:50 a.m., and 12/22/24 at 1:15 p.m. The lorazepam Control Substance Record for 12/27/24 through 1/5/25 revealed R47 received 1 mg of Ativan on 1/4/25 with no other Ativan documented as administered on 1/4/25. Ativan 1 mg was documented on the Control Substance Record on 1/5/25 as being removed from R47's Ativan inventory five times: 1/5/25 at 2:10 p.m., 1/5/25 at 7:49 p.m., 1/5/25 at 8:00 a.m., 1/5/25 at 1:46 p.m., and 1/5/25 at 7:00 p.m. There were no orders in the record amending the three times daily frequency of Ativan administration. The Control Substance Record for R47's lorazepam for 1/6/25 through 1/15/25 were requested but not provided by the end of survey. RN I was interviewed on 1/16/25 at 1:42 p.m. RN I said administering the correct dosages of medications is one of the rights of medication administration. RN I said, Nurses absolutely need to adhere to the rights of medication administration. The policy Medication Errors dated as reviewed/revised on 1/24/24 read, in part: Policy: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors .Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety . The facility shall ensure medications will be administered as follows: a. According to physician's orders .c. In accordance with accepted standards and principles which apply to professionals providing services. 2. The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: i. Incorrect dose, route of administration, dosage form, or time of administration .5. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right resident, right medication, right dose, right route and right time of administration. 6. If a significant medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the prescriber of the medication as soon as possible. b. Monitor and document the resident's condition, including response to any provider orders. c. Document actions taken in the medical record .

Based on observation, interview, and record review, the facility failed to ensure two Residents (#47, & #224) of eight residents reviewed for medication administration received the correct dosages of prescribed medications. This deficient practice resulted in a medication error rate of 9.38 % with 3 medication errors detected in 32 opportunities. Findings include: Resident #47 (R47) R47 was prescribed 10 milliequivalents (mEq) of potassium daily. While preparing medication for R47 on 1/16/25 at 7:31 a.m., Registered Nurse (RN) D placed 20 mEq of potassium in a medication cup for administration to R47. The dosage discrepancy was mentioned by the surveyor after medication preparation was completed but before RN D administered the medications to R47. Upon inspection of the blister pack (resident-specific card-type package containing a supply of medication), it was noted RN D had dispensed the 20 mEq of potassium from a blister pack of another resident whose blister pack had been placed in R47's section of the medication cart. RN D said, Someone put the card [blister pack] in the wrong place. I should have checked the name and dose before I popped the pill out. R47 was prescribed Ativan 1 milligram (mg) three times daily for Anxiety. On 1/16/25 at 7:31 a.m., RN D retrieved R47's blister pack of Ativan labeled lorazepam (generic for Ativan) 0.5 mg. The instructions on the blister pack read Take 2 tablets by mouth three times daily for Anxiety. RN D placed one tablet in the medication cup and signed out one tablet on the medication record titled Control Substance Record. RN D was directed to the dosage discrepancy between the physician's dosage order for Ativan and the dosage contained in the blister pack. RN D said, They were supposed to get new ones. I ordered those. The order changed months ago. The Nurse Manager, Registered Nurse (RN) I, was interviewed on 1/16/25 at 1:42 p.m. RN I confirmed nurses are expected to verify the correct resident and the correct dosages when administering medications. RN I said, Nurses absolutely need to adhere to the rights of medication administration. Resident #224 (R224) R224 was prescribed meloxicam 15 milligrams (mg) daily for pain. During medication administration observation on 1/15/25 at 1:07 p.m., the meloxicam order for R224 was read on the Medication Administration Record (MAR), indicating the medication was overdue to be administered. On 1/15/25 at 1:20 p.m., Registered Nurse (RN) H asked R224 if she was experiencing pain. R224 indicated she had pain in her back and neck. RN H asked R224 to rate the pain on a scale of one to ten with one being no pain and ten being excruciating pain. R224 said her pain was ten out of ten. When asked why the meloxicam had not been administered as scheduled at 8:00 a.m., RN H said the meloxicam was not in the facility emergency supply of medications, and pharmacy had not yet delivered the medication. RN H said the medication was ordered on 1/14/25 at 6:10 p.m. which was after the pharmacy cut-off time for faxing medications so it would not have been delivered when pharmacy delivered medications the morning of 1/15/25. RN H said the meloxicam for R224 would arrive in the evening delivery of medications from pharmacy on 1/15/25. RN H admitted the pharmacy should have been contacted via phone call on 1/14/25 instead of by fax. RN H confirmed the pharmacy delivered medications stat (immediately) when requested by the facility. On 1/16/25 at 9:15 a.m., the MAR of R224 revealed the dose of meloxicam was signed out by RN H as administered on 1/15/25 at 8:00 a.m. Regional Nurse K was asked to provide a record of medication administration times on 1/15/25 for R224 and pharmacy delivery time and receipt for the meloxicam. On 1/16/25 at 1:05 p.m., a report Medication Admin Audit Report was presented by Regional Nurse K. The report disclosed the meloxicam signed out by RN H as administered at 8:00 a.m. on 1/15/25 was administered at 2:37 p.m. on 1/15/25. There were no medication notes or progress notes found in R224's record documenting the late administration of the medication. There was no documentation in the record indicating R224's physician had been notified of the medication being unavailable or administered late on 1/15/25 at 8:00 a.m. A pharmacy delivery manifest provided by Regional Nurse K on 1/16/25 at 1:05 p.m. documented the meloxicam for R224 was delivered on 1/16/25 at 1:08 a.m. Regional Nurse K was asked how the meloxicam was signed out as administered on 1/15/24 if the medication was not in the facility. Regional Nurse K said R224's family brought in the medication from home and RN H used the home supply of meloxicam for medication administration. Regional Nurse K confirmed there were no medication notes or progress notes regarding the delayed administration of the meloxicam or notification of R224's physician regarding medication unavailability or delayed administration. On 1/16/25 at 1:22 p.m., nurse manager (RN J) was asked the process if a medication is withheld or not available for administration. RN J said the physician should be notified. On 1/16/25 at 1:42 p.m., nurse manager (RN I) was asked the expectation if a medication is withheld or not available for administration. RN I said the nurse would be expected to call the physician and inform him, and the nurse should document in progress notes and follow-up with any new or revised orders implemented by the physician. The policy Medication Errors dated as reviewed/revised on 1/24/24 read, in part: .'Medication error' means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order . The facility shall ensure medications will be administered as follows: a. According to physician's orders . Medication administered not in accordance with the prescriber's order. Examples include, but not limited to i. Incorrect dose .

This citation pertains to intakes MI00147076 and MI00147197. Based on observation, interview and record review, the facility failed to ensure appropriate assessments and communication for change in condition for one Resident (#2) of three residents reviewed for change in condition, resulting in harm when Resident #2 was transferred to the hospital for mental status changes, found to have a severe wound infection and underwent subsequent intravenous antibiotic administration and surgical intervention. Findings include: Resident #2 (R2) Review of R2's Minimum Data Set (MDS) admission assessment, dated 6/24/2024, revealed the Resident was admitted to the facility on [DATE] and had diagnoses including lumbar fracture, diabetes, anxiety and dementia. Further review of the MDS assessment revealed R2 scored six out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Further review of R2's MDS data revealed R2 was discharged to a short-term stay, acute-care hospital on 9/03/2024. Review of R2's electronic medication record (EMR) revealed the following: 9/3/2024, 10:33 [a.m.] Nurses Notes . Resident confused and not making sense. Wife notified agree to transfer to the hospital. [Physician C] notified agree to transfer to hospital. Review of R2's hospital Discharge Summary, signed and dated 10/01/2024 at 12:08 p.m., revealed the following, in part: Hospital Course: . Prior to admission, he lived at [facility name] where he sustained a fall with a subsequent skin tear . Per the reports, it progressed into cellulitis, and he was started on Keflex [antibiotic]. Unfortunately, it did not improve. He started developing [acute mental status change] and was therefore sent to the ER [emergency room ]. He was noted to have inflammatory markers . was started on empiric antibiotics . Impression: Extensive cellulitis. Further review of the hospital Discharge Summary, revealed, On 9/4/24, [R2] was taken to surgery for a left forearm volar [palmar side] and dorsal [back side] fasciotomy [incisions to relieve pressure from compressed blood vessels due to swelling]. Purulent fluid was found about the [back of] the forearm and [back of] the elbow . Repeat debridement [surgical procedure to remove dead tissue] was undertaken on 9/7/24 and a third on 9/10/24. He was continued on [antibiotics] for left arm cellulitis with necrotizing fasciitis [serious bacterial infection that destroys the tissue under the skin] . On 9/16 [2024] he returned to the [operating room] once again for debridement of left forearm including skin, subcutaneous tissue and some fascia [connective tissue] . plan for flap procedure [transfer of health tissue from one area of the body to another are of significant tissue loss] after allowing more healing with wound vac in place . Further review of the EMR revealed, 8/24/2024, 23:30 [11:30 p.m.] Pertinent Charting-Skin . left forearm . Description: Noted quarter size skin tear to left forearm . 8/30/2024, 09:03 [9:03 a.m.] resident is found to have skin tear on left forearm, mechanism of injury unknown. Resident was agitated and combative for a lot of the night, attempting repeatedly to stand on his own and climb out of bed. Area cleaned and non-adherent dressing applied with a silicone bandage. It was noted in review of R2's progress notes, the Resident was noted to have an increase in confusion on 8/29/24 and was placed on behavior monitoring. R2 was placed on one-to-one supervision on 8/30/2024 due to increased confusion and behavior. During an interview on 9/25/2024 at 7:52 a.m., Registered Nurse (RN) B reported she was working on when R2 was observed to have a second skin tear to his left forearm. RN B stated there was no evidence of infection at that time. RN B reported R2 had one small quarter-sized tear near left medial (closer to the body) elbow and a new larger, linear tear on his dorsal (back side) forearm. RN B stated she phoned the wound care nurse to obtain wound care orders. Review of R1's Nurses Note, dated 9/01/2024 at 4:44 p.m. revealed the following: Bandages on left arm are saturated. Bandages removed and non-adherent dressings placed over open areas, ABDs [large, highly absorbent dressing] placed for moisture management . It was noted in review of the EMR there were no assessments of R2's left forearm wounds, notification to the facility wound care nurse or physician, or wound cultures completed in response to the increased drainage from R2's wounds documented on 9/01/2024. Further review of R2's EMR, including progress notes, assessments/evaluation and skin/wound documentation, revealed no wound evaluations of the skin tears were observed on 8/24/2024 or 8/30/2024, to include a description of the wound, including the wound bed and peri-wound area until 9/03/2024. During an interview on 9/25/2025 at 3:25 p.m., Certified Wound Care Nurse, RN A reported she was unaware of the extent of R2's injury until 9/03/2024 when she was asked to assess the wound by nursing staff that day. RN A stated she did not remember being alerted of the need to use an ABD pad to contain the increased drainage from the wound on 8/30/2024. Upon assessment of the wound, RN A reported she found the wound to appear infected with severe swelling, so she phoned Physician C. RN A stated Physician C gave the order for R2 to begin Keflex (antibiotic) but was transferred to the ER for evaluation prior to beginning the medication. Review of R2's Wound Evaluation, dated 9/03/2024 at 10:30 a.m., revealed the following: Area: 154.73 [cubic centimeters]. Length: 29.83 cm [centimeters]. Width: 8/83 cm. Deepest Point: 0.1 cm. Location: Left Outer Forearm . Slough [dead tissue within the wound] 50% . Evidence of Infection: Redness/Inflammation . Exudate [drainage] . Moderate . Surrounding Tissue: Fragile . Crepitus [crackling sensation felt when palpating cause by gas pushed through the tissue] . pitting edema extends [greater than] 4 cm around wound . Resident delirious . Review of R2's August 2024 and September 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following orders: Keflex Oral Capsule 500 MG (milligram) . Give 2 capsules by mouth two times a day for cellulitis to left arm for 10 days. Start Date: 09/03/2024 [10:00 a.m.] . It was noted no doses of the medication were administered. Left arm skin tear: cleanse, apply abx ointment, cover with silicone [daily] . Start Date: 8/28/2024. It was noted the wound care was performed daily from 8/28/2024 through 9/02/2024, with no corresponding wound assessments documented in the EMR. Apply oil emulsion to left posterior forearm wound, cover with ABD pad secure with [sleeve] change daily and [as needed] for soiled or removed dressing . Start Date: 9/01/2024. It was noted the wound care was performed on 9/01/2024 and 9/02/2024 with no corresponding wound assessments documented in the EMR. During an interview on 9/25/2024 at 3:43 p.m., the Director of Nursing (DON) reported she was notified of the R2's left forearm skin tears on 8/28/2024 when RN B phoned to inform her of R2's new injury and increased drainage from the injury noted as obtained from R2's fall on 8/24/2024. During an interview on 9/25/2024 at 4:20 p.m., Physician C confirmed he was not notified of R2's left forearm skin tears or the status of the wounds until phoned by RN A on 9/03/2024. Physician C reported necrotizing fasciitis can develop rapidly, within days or hours of injury. Review of the facility policy titled, Notification of Changes, last reviewed 8/29/2024, revealed the following, in part: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include . Accidents: resulting in injury, potential to require physician intervention . Circumstances that require a need to alter treatment. This may include: new treatment .

This citation pertains to intake MI00146968. Based on interview and record review, the facility failed to provide written notification for a facility-initiated discharge, including the reason, effective dates and right to appeal to the resident's representative and the Office of the State Long-Term Care (LTC) Ombudsman for one Resident (#1) of three residents reviewed for transfer or discharge, resulting in the resident and resident's representative being uninformed of their rights, an unnecessarily extended hospital stay and the potential for inappropriate discharge. Findings include: Resident #1 (R1) Review of the Minimum Data Set (MDS) assessment, dated 7/30/2024, revealed R1 was admitted to the facility on [DATE] with a primary diagnosis of schizophrenia (mental health disorder affecting the ability to think, feel and behave clearly). Review of R1's electronic medical record (EMR) revealed R1 was transferred to the emergency department (ED) for psychological evaluation on 7/30/2024 at 5:01 p.m. with no return as of 9/26/2024. Review of R1's Transfer Notice - Resident Expected to Return, dated 7/30/2024, revealed the following, in part: . It is anticipated that the Resident will return to the facility after the circumstances requiring transfer are resolved. Transfer Location: ED . The notice was signed as received by R1's court appointed guardian on 8/03/2024. Further review of R1's EMR revealed R1 did not return to the facility following transfer to the ED on 7/30/2024. Review of the R1's mental health Emergency Screening, dated 8/01/2024, provided by Social Services Director, Staff D, revealed following evaluation in the ED, R1 was admitted to a psychiatric facility for treatment. During an interview on 9/26/2024 at 11:56 a.m., hospital Case Manager, Registered Nurse (RN) I reported R1 was discharged , with no return expected, from the psychiatric hospital to the acute care for treatment of a urinary tract infection on 8/22/2024. RN I stated she was in contact with the facility to initiate discharge back as early as 8/26/2024. RN I reported she was informed the facility required further evaluation of R1's psychiatric condition prior to his return to the facility, specifically a Level II PASSAR (Preadmission Screening and Resident Review). RN I stated they initiated the assessment and were awaiting completion when R1's legal guardian, Family Member (FM) H called on 9/8/2024, stating the facility would not allow R1 to return. RN I stated no communication was received from the facility stating R1 was discharged . RN I reported R1's Level II PASSAR was completed on 9/11/2024 per the facility's request, but R1 remained hospitalized until 9/13/2024 awaiting placement in a new facility. During an interview on 9/26/2024 at 1:10 p.m., the Nursing Home Administrator (NHA) and Staff D reported when they did not hear from the hospital after the request for the Level II PASSAR, they considered R1 discharged from the facility. When asked if any further contact was initiated by the facility to determine the status of the Level II PASSAR, Staff D stated she did not reach out to the hospital to determine R1's status or anticipated return. When asked if R1 or his legal representative, FM H was provided a written notice of discharge, including information on how to appeal the facility-initiated discharge, the NHA reported no written notice was provided due to R1's extended leave from the facility. When asked if the Office of State Long-Term Care Ombudsman was notified of the discharge, the NHA and Staff D reported no notification was sent to the ombudsman as they considered R1 a resident-initiated discharge due to the length of his absence. Review of the email correspondence provided by the NHA revealed communication regarding R1's return to the facility began on 8/26/2024. It was noted that transfer back to the facility was initiated on 8/26/2024, less that 30 days after R1 was initially transferred to the emergency department on 7/30/2024. During an interview on 10/02/2024 at 11:34 a.m., FM H confirmed she did not receive written notification of R1's facility-initiated discharge, or information on how to appeal the decision. FM H stated she did not know the facility was not accepting R1 back until she received a phone call from a facility staff member on 9/08/2024 informing her of the need to pick up R1's belongings. FM H reported R1 was looking forward to being back at the facility and in the community where his family lived. Review of the facility policy titled, Transfer and Discharge, last reviewed 10/20/2023, revealed the following, in part: Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or location in the community, when return to the original facility in not expected . Non-Emergency Transfers or Discharges: At least 30 days before the resident id transferred or discharged , the Social Services Director will notify the resident and the resident's representative in writing in a language and manner they can understand (this time frame does not apply if the resident has not resided in the facility for 30 days) . A copy of the notice shall be provided to a representative of the Office of the State Long-Term Care Ombudsman . Emergency Transfers/Discharges: In case of discharge, notice requirements and procedures for facility-initiated discharge shall be followed.

Intake #MI00143052 Based on interview and record review the facility failed to assess, monitor, document, and provide treatment per professional standards of practice for one (resident #3) of one resident reviewed for diabetes management, resulting in diabetic ketoacidosis (emergent condition resulting from prolonged elevated blood sugar levels), hospitalization and death. Findings include: Resident #3 (R3) Review of the Electronic Medical Record (EMR) for R3, revealed the most recent admission to the facility was on 10/20/23 post fall at home with diagnoses including wedge compression fracture T5-T6, pelvis fracture, stage 4 sacral pressure ulcer, severe protein-calorie malnutrition, diabetes type II, peripheral vascular disease, colostomy, chronic kidney disease stage 3 and prior history of neoplasm of large intestine and cervix. R3 was previously admitted from 4/5/23 to 5/20/23 and was familiar to the facility. Review of the discharge summary for admission to the facility from (Regional Acute Care Hospital) from 10/20/23, read in part, R3 had orders of Novolog low dose scale 70 kilograms or more dose 0-12 units sliding scale four times a day (QID) with meals while in the hospital. Review of discharge instructions from hospital have no indications for blood glucose monitoring. In the discharge medications from hospital to facility, no insulin is listed. However, the facility failed to recognize R3 was on insulin during the hospital stay and failed to monitored for continued diabetic support. On 3/11/12 at 12:35 PM, during an interview regarding the use of insulin by R3 prior to admission to the facility, Resident Representative (RR) A stated resident had long standing home use of insulin for her diabetes that kept her diabetes under control. Review of R3's medical record revealed an order dated 10/20/23: Regular diet, Regular texture, Regular fluid, thin consistency. Review of an order for R3 dated 10/26/24: If blood sugar less than (X) administer OJ, Food or glucose gel per manufacturer recommendation. Recheck in 15 minutes if no improvement notify physician. Every 12 hours for hypoglycemia. There is no glucose value given in this order in which staff could notify physician, and nothing is indicated to do every 12 hours for hypoglycemia. No other orders were in in the EMR pertaining to blood glucose since admission on 10/20/23. The last blood glucose check performed and documented by the facility for R3 located in the EMR was charted on 5/20/23 during a prior admission to the facility and was 90 milligrams per deciliter (mg/dL). On 3/11/24 at 3:24 PM, an interview was conducted with Physician Assistant (PA) F, who was asked what process the facility should follow with a known diabetic admitted to the facility without orders for insulin. PA F stated the facility made it a practice to perform blood glucose checks for three days of before meals (AC) and at bedtime (HS) and then PA F would evaluate what the resident needs. PA F indicated the providers would expect a nursing notification If the blood glucose checks are out of the norm before the three days to evaluate a treatment plan quicker. PA F stated the physician providers are in the facility three times a week to assess residents so they are available to be sure resident needs are monitored appropriately. PA F stated that the facility does not have diabetic diet offerings, so he often provided council to residents that they need the higher calories to heal and that residents would have to modify their diets back to their normal diabetic diet upon returning home. On 3/11/24 at 4:00 PM, an interview was conducted with the Director of Nursing (DON), who was asked if there was a policy in place that addressed the blood glucose process PA F mentioned during their interview. The DON stated the facility did not have such a policy, it was just something the physician provider group did as necessary when diabetic residents were admitted . The DON stated even if a diabetic resident was previously admitted and treated with insulin, the treatment would be dependent on the physician assessment for readmission and there was no guarantee the facility would treat the resident with the same orders upon readmission. On 3/7/24 at 2:39 PM, a follow-up interview was conducted with RR A, who stated she felt the facility should have offered a diabetic diet. RR A stated R3 enjoyed pop and she often had to bring in diet pop because the facility was providing R3 regular pop. RRA stated on 12/17/23 she visited R3 and noticed R3 was not acting her normal self, was barely responsive, and her meal tray on her bedside table was untouched. On 3/7/24 at 3:47 PM, an interview was conducted with RR B, who stated on 12/17/24, he asked staff to alert the doctor R3 was not acting normal and was told by staff the physician would see her tomorrow. RR B stated the facility had not communicated to the family of R3's change in condition until the day of the visit on 12/17/23, even though R3 had not been eating or drinking for the past few days prior to the visit. Review of R3's progress notes from 12/20/17 at 10:24 AM, physician provider note read in part: Central Nervous System (CNS): able to make needs known, confusion consistent with dementia. Review of the facility transfer paperwork revealed on 12/21/23 at 10:40 AM, R3 was taken to an Acute Care Hospital emergency department via EMS (Emergency Medical Services) for altered mental status. Review of Emergency Documentation on 12/21/23, R3 arrived in the emergency department (ED) with chief complaint of possible failure to thrive, not taking medications or food, altered mental status for two days. Upon arrival to ED, R3's Glasgow Coma Scale for was 9 out of 15 with verbal responses noted as inappropriate words, and responsive only to localized painful stimulation. R3 was then admitted to the intensive care unit of the hospital, with diagnoses including diabetic ketoacidosis (DKA), altered mental status, and sacral decubitus ulcer. Review of the hospital course summary showed that R3 was admitted from nursing home. R3 had profound wound issues with a sacral decubitus. R3 was unresponsive and in DKA with positive blood cultures. R3 was treated aggressively per DKA protocol and covered with antibiotics. Her heart function deteriorated, and she required medications to maintain her blood pressure. Surgery had seen R3 in consultation for her wounds and felt there was nothing further to offer. The family after much discussion, elected not to proceed any further with intubation, mechanical ventilation or help with heart function. After discussion with the family, it was felt that further interventions would be against R3 wishes. R3 was made a code status of do not resuscitate and hospice was consulted. She was released to in patient hospice services the afternoon of 12/22/23. Review of [NAME] hospital documentation on 12/29/23 7:16 AM, R3 was pronounced dead of multi-system organ failure.

Intake #MI00143052 Based on observation, interview, and record review the facility failed to notify a physician of pressure ulcer condition worsening for one resident (Resident #3) of three residents reviewed for pressure ulcers. This deficient practice resulted in the potential for wound infection and worsening of pressure ulcer. Findings include: Resident #3 (R3) Review of the medical record revealed R3 was admitted to the facility on [DATE] after a fall at home with diagnoses including wedge compression fracture T5-T6, pelvis fracture, stage 4 sacral pressure ulcer (PU), severe protein-calorie malnutrition, diabetes type II, peripheral vascular disease, colostomy, chronic kidney disease stage 3, and prior history of cancer of large intestine and cervix. R3 was admitted for rehabilitation. Review of nurse note from 12/17/23 at 3:29 PM, states Wound was done on coccyx. Area has a strong foul odor. There was no indication the provider was notified of strong odor from pressure ulcer on sacrum. On 3/11/24 at 4:00 PM, an interview was conducted with the Director of Nursing (DON), who was asked when a wound has a foul odor what the expectations were of the nursing staff. The DON stated she expected staff to alert the physician immediately. A review of a wound care which was completed on 12/19/23 was reviewed, with photo updated by wound nurse C. Photos of the pressure ulcer located on sacrum dated 10/21/23 showed an approximate size of 0.5 centimeters (cm) x 0.5 cm in size and when compared to the photo measurements performed on 12/19/24, showed an increase in size to approximately 2.2 cm x 2.0 cm. On 3/7/24 at 2:39 PM, an interview was conducted with Resident Representative (RR) A via phone, who stated R3's pressure ulcer was only about the size of a quarter upon admission to facility and when seen at the hospital it was the size of a fist. A review of the physician progress note dated 12/20/23 at 10:24 AM, read in part Patient is seen for evaluation of wound; staff notes foul odor at this time. All questions and concerns addressed as posed .Plan: Patient is counseled and encouraged. Practitioner gives orders for keflex for ten days related to infection of sacral wound, acidophilus twice daily (BID) for twenty-one days. *Note: This assessment was three days after the foul odor was detected coming from the wound on the coccyx originally identified by wound nurse C. A review of a hospital note dated 12/21/23 revealed R3 was sent to a regional acute care hospital on 12/21/23 for assessment due to altered mental status for two days where she was treated for septic shock due to urinary tract infection, diabetic ketoacidosis, and sacral wound. Review of the emergency physician notes from 12/21/23 read in part: . large sacral decubitus is seen, the skin is necrotic and there appears to be some tunneling, there is similar skin breakdown on the left heel and the start of this on the right heel as well. (R3) was treated with two (cefepime and vancomycin) broad spectrum antibiotics in the emergency department. R3 was then admitted to the intensive care unit of the hospital, with diagnoses including diabetic ketoacidosis (DKA), altered mental status, and sacral decubitus ulcer. An order was placed for surgery consult for wounds on 12/21/23, but due to the instability of her condition it was not conducted until 12/25/23. Review of the hospital general surgery consultation notes dated 12/25/23 at 10:08 PM read in part: .when I logroll her, she has a very large 2 cm by 2 cm full thickness with minimal lining over the sacral region. Minimal thick slough. No purulent drainage. Skin color changes are concerning for ischemia (lack of blood flow). These wounds are comparable with end-of-life wounds. Offloading (not bearing weight) is not easy. This has been long and ongoing. She is acutely ill. Sepsis of unknown source at this time.

Based on observation, interview and record review, the facility failed to ensure dignified and respectful treatment for one Resident (R11) of three residents reviewed for dignity. This deficient practice resulted in an undignified shower experience and disrespectful treatment. Findings include: Resident #11 (R11) was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and anxiety disorder. R11 was identified in the care plan as having a deficit with the ability to perform Activities of Daily Living (ADL) due to weakness and a stroke that left R11 with paralysis on the left side of the body. The care plan documented the resident requires the use of a mechanical lift for transfers. Shower documentation revealed R11 is dependent on staff for showering and getting to and from the shower. On 2/6/24 at approximately 3:20 p.m. Certified Nursing Assistant M (CNA M) was observed pushing a shower gurney on the 600 hall. The surveyor entered the hall behind CNA M. R11 was lying on the gurney with towels laying atop her from the neck to the ankles with R11's bare body exposed on both sides beneath the towels. The shower room was located near the top of the 600 hall and R11 resided at the end of the 600 hall. There were residents in their wheelchairs or ambulating on the 600 hall but no other staff members were present. CNA M said to R11 in a stern voice, That's the way it is - deal with it! If you don't like it, you can go to [Nurse Manager, Registered Nurse D (RN D)]. CNA M turned around and noticed the surveyor was directly behind her. CNA M's conduct changed immediately, and CNA M said to the surveyor in an apologetic tone, [R11] doesn't like how I give a shower, so I offered to get [RN D] for [R11]. CNA M stopped the shower gurney in the doorway of R11's room and exited the area. Other employees arrived to assist R11 into bed. On 2/6/24 at approximately 3:35 p.m., the observation was reported to the facility Administrator (NHA). The NHA said conduct displayed by CNA M was unacceptable and stated, I expect all staff to treat residents with respect. At 4:00 p.m., the NHA conveyed that CNA M had been suspended pending investigation and a report was submitted to the State agency. R11 was interviewed on 2/7/24 at 10:25 a.m. R11 said, They (staff) push me down the hall on that bed (shower gurney) naked! I've never liked to be naked in front of people. I told them I don't like it! When asked how R11 feels when being propelled down the hall without clothing, R11 responded embarrassed. R11 was unable to recall who she had voiced concerns to about the showering process. When asked if staff treated her with dignity and respect, R11 said, most of the time but not always. R11 did not provide specific details or staff names or descriptions. A facility policy dated 1/1/22 titled Resident Rights read in part: Employees shall treat all residents with kindness, respect, and dignity . 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. A facility policy dated 10/30/23 titled Promoting/Maintaining Resident Self-Determination read in part: Policy: It is the practice of this facility to protect and promote resident rights by promoting and facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interests and preferences. 1. All staff members involved in providing care to resident will promote and facilitate resident self-determination. 4. Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on observation, interview, and record review, the facility failed to ensure care plans were updated and revised appropriately for two Residents (R3 and R45) out of 15 Resident care plans reviewed. This deficient practice resulted in care plans which did not reflect resident needs. Findings include: Resident #3 (R3) During an interview on 2/5/24 at 3:41 PM, Resident #3 (R3) stated her bandaged heel hurt. R3 was in her room in her wheelchair. The Electronic Medical Record (EMR) revealed the physician had ordered a treatment for this area on R3's left heal which read: Left heel abrasion; cleanse, apply silicone dressing, qd (every day). During an interview on 2/6/24 at 9:30 AM, Registered Nurse (RN) D wound care specialist performed the wound treatment, and this Surveyor observed the circular pink heal wound. R3 stated it hurt and she believed it was caused from her shoe. RN D suggested to R3 that she not wear shoes but instead grippy socks and continue to wear the soft puffy boots for foot protection when in bed. (The boots were observed on R3's dresser.) No other compromised skin issues were present. Review of R3's care plan accessed on 2/6/24 the EMR care plan was reviewed and included a focus for impaired skin integrity which read in part: Resident has impaired skin integrity as evidenced by: (right great toe bruising; abrasion to left heel; left thigh open lesion) related to muscle weakness Date Initiated: 10/27/2023 Revision on: 12/27/2023. The interventions for this care plan included: Administer medications as ordered, Administer treatment(s) per orders, Labs as ordered, Notify Physician . of signs/symptoms of infection (new or change in type/amount/color of drainage, bleeding, foul odor). There were no interventions of foot protection or offloading to improve or prevent further compromise. The skin integrity issues of toe bruising and open thigh lesion were past issues and were without update or intervention for further prevention. On 2/5/24 at 3:41 PM, R3 was observed to have water on her bedside table. The current physician orders for R3 did not include a fluid restriction and on further review revealed on 1/24/24 a fluid restriction had been discontinued. The care plan for R3 included a focus: Resident is at risk for fluid volume deficit related to diuretic use . On fluid restriction. Date initiated:10/27/2023 Revision on: 11/6/2023. Interventions included: .Ensure all beverages offered comply with diet/fluid restrictions . R3 no longer had orders for a fluid restriction. During an interview on 2/6/24 at 2:54 PM, RN Clinical Consultant A stated, she had reviewed the care plan and did not see skin interventions. RN A said she would expect interventions to be current and to be on the care plan. Resident #45 (R45) R45 was admitted to the facility on [DATE] with a hospitalization on [DATE] and readmission to the facility with a physician order for Total Parenteral Nutrition (TPN) [TPN is feeding a person intravenously rather than the usual process of eating and digesting]. The physician orders for TPN were discontinued on 1/30/24. During an interview on 2/5/24 at approximately 1:00 PM, Family members K and L stated R45 was now eating and drinking food again. RN N stated the TPN was discontinued last Thursday and R45 had returned to eating food. R45 had two beverages in front of her and was sipping one beverage with assistance. The care plan for R45 was reviewed on 2/7/24 and continued to include: Resident has an IV (intravenous) Peripherally Inserted Central Catheter (PICC) line Right Upper Extremity (RUE) related to parenteral nutrition (TPN) Date Initiated: 01/19/2024 Revision on: 01/19/2024 The care plan included a goal of: Resident will have no signs/symptoms of IV related complications (e.g., infection, pain, redness, swelling, drainage, fever, etc.) through next review. There were interventions of: Ensure that IV attachments are tight fitting . IV catheter care, maintenance, and dressing changes per orders. During an interview on 2/7/24 at 05:30 PM, the Nursing Home Administrator (NHA) confirmed there was no policy to address revised care plan interventions for updates to care or physician orders between assessments.

This citation pertains to Intake #MI 783. Based on interview and record review, the facility failed to identify, assess and treat a sutured wound, following admission, for one Resident (#1) of one reviewed for wounds. This deficient practice resulted in a re-hospitalization , infection, and prolonged healing. Findings include: According to the Admission Record, printed on 6/13/22, Resident #1 was admitted to the facility, from an acute care hospital, on 4/13/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was discharged on [DATE], to an acute care hospital. The Nursing Admission Evaluation, dated 4/13/22 (part one), and 4/14/22 (parts two and three), revealed Resident #1 was able to follow commands and cooperate. The Resident was unable to lift his limbs off the mattress. The Evaluation noted one fall prior to admission, with no behaviors, no cognitive changes within the prior 90 days and adequate sight. The Evaluation noted an orthopedic condition or risk, but did not specify a condition. The Evaluation noted no identified skin conditions or wounds. The Skin Related Care Plans section was checked for generic care plan interventions with no specific identified issues or interventions. The Evaluation Summary section for Part 1 noted transfer from acute care, alert and oriented with no pain, up with assistance of two people, vital signs stable and call light was within reach. There was no mention of the right arm fracture or a sutured laceration, dressing, or sling. Part 2 of the Evaluation noted that Resident #1 had a hospital stay of two days prior to admission. The discharge plan was home with home health services. The cognitive section noted the Resident was cognitively intact and made his own decisions. The Musculoskeletal section noted no limitations to range of motion, no casts or immobilizers. Resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Note, dated 4/13/22, authored by Registered Nurse (RN) F, indicated that Resident #1 had a fractured Humerus and that the sling was present. However, there was no nursing interventions and the Care Plan was to be determined. During a phone interview on 6/9/22 at 1:42 p.m., Family Member (FM) G said she was present at Resident #1's admission. FM G said three nurses were helping with the admission and they did not have adequate information from the hospital. So, she tried to tell the nurses all the details of the Resident's needs and care from the hospital, but they wouldn't listen to her. They told her they would call the hospital for clarification. FM G said no one ever changed the Resident's dressing to the laceration on the right elbow until four days after the admission on 4/17/22. On that day, the dressing was removed by a nurse to find copious purulent drainage from the wound, which had come apart (dehisced) from the sutures. FM G said the nurse cleansed the wound, and then cultured it (took a sample of the drainage for laboratory tests), which she said was backwards. FM G said no nurse ever measured or evaluated the wound. A new dressing was applied, and then Resident #1 was sent to the hospital, where the wound was diagnosed with an infection. Resident #1's medical record was absent any wound assessment, until 4/17/22. The hospital Patient Transfer Form, dated 4/13/22, was blank, except for the Resident name, date of birth, sex, address, facility name, daughter name and phone number and physician and nurse signatures. No information related to the Resident's medical condition/status was marked. The hospital discharge summary, dated 4/12/22 and printed on 4/13/22, had no appreciable information. The Final Report (hospital physician note), dated 4/12/22 and printed on 4/13/22, from the emergency department, revealed, .fall, Orders: Sling to Affected Side .a fall yesterday .majority of pain in right shoulder .worse with movement .right humerus tenderness with some swelling as well, holding arm in adduction (against torso), pain with any movement of the shoulder .IMPRESSION: Comminuted impacted fracture of the right humeral head and neck .Procedure Laceration repair 2 [centimeters] laceration over right posterior elbow .repaired with 4 .simple interrupted sutures covered with [MEDICATION(S)] and sterile gauze .placement [sling] for fracture .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment, dated 4/14/22, noted no skin or wound issues and no surgical wound care. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The emergency room Report, dated 4/17/22, revealed [CONDITION(S)] in the right elbow with increased induration, swelling and an open wound to the right elbow. Intravenous (IV) antibiotics were given and the wound was noted to have dehisced. During an interview on 6/13/22 at 2:29 p.m., RN H was asked about Resident #1's admission. RN H confirmed she was the admitting nurse, but was new and the Resident's admission was her first, so she had RN F helping her. RN H said RN F did the full skin assessment with a Certified Nurse Aide (CNA). RN H said she noticed the wound to the right elbow on admission but could not say why she did not document it. RN H also said she thought she remembered wound care orders on admission. RN H said the unit managers entered all the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN H said she did not assess the wound on admission but just lifted the dressing and replaced it. RN H said it was about the size of a quarter and looked like a pressure injury, with no approximated wound edges (it was an open wound). RN H said she could not recall any sutures. When documenting the initial nursing assessment, RN H said RN F just told her what to click on as she wasn't sure of the electronic medical record navigation. During an interview on 6/13/22 at 2:47 p.m., RN C was asked about Resident #1's admission. RN C confirmed she was the certified wound nurse and the unit manager and assisted with the admission. RN C confirmed the discharge summary from the hospital was inadequate and she would expect the admitting nurse to call for clarification. RN C could not explain why there was no documented clarification call to the hospital. When asked if FM G told her about a laceration to Resident #1's right elbow, RN C said she didn't remember being told that, and she didn't asses a wound for the Resident on admission. RN C said, There was something going on there and I didn't take careful note of it. RN C said the policy was changed so that all unit managers see all new admissions first hand. RN C said she went on vacation after the admission until 4/25/22. RN C said Resident #1 went to the hospital and was diagnosed with [CONDITION(S)] in the right elbow and put on IV antibiotics. RN C said that's when the facility realized something got missed and the policy changed. RN C confirmed the admission process and said the paper initial skin assessment was kept but did not get scanned into the medical record. RN C reconfirmed Resident #1 had a skin wound on admission that was missed. During an interview on 6/13/22 at 3:10 p.m., the Director of Nursing (DON) confirmed she called RN C on vacation with the concern about Resident #1's admission and skin/wounds issues. The DON stated that the process changed after that, but the policy did not change. The DON confirmed Resident #1 was in the hospital and would probably return with long term IV antibiotics through a PICC (peripherally inserted central catheter) line. An unsuccessful attempt was made by phone to reach RN F on 6/13/22 at 3:32 p.m. During an interview on 6/13/22 at 3:40 p.m., Social Service Designee (Staff) I confirmed many care conferences were had with Resident #1 and his family, due to many family concerns with care. Staff I confirmed Resident #1 saw the infectious disease specialist and that currently the infection was in the bone. During an interview on 6/14/22 at 8:09 a.m., the DON was asked about the admission process and expectation of the admitting nurse when information was insufficient. The DON said Resident #1 came from the emergency room and it's harder than when a resident was admitted to the hospital and had full records. When asked why there was no documented follow up phone call to the emergency room for order clarification, the DON said the emergency room was too busy and there was no one to call. The DON confirmed Resident #1 went to the emergency roiagnom on [DATE] and was diagnosed with [CONDITION(S)], received IV antibiotics, and had the dehisced sutures removed. During an interview on 6/14/22 at 9:06 a.m., RN A confirmed she was the nurse who discovered the dehisced sutures on 4/17/22 and sent Resident #1 to the hospital after notifying the physician. RN A said she peaked at the Resident's wound the day prior and dressed it. When asked how she knew what to dress it with, RN A confirmed there were no orders, but there was a wound so she needed to dress it. When asked why there were no progress notes regarding the care provided, RN A said family was aggressive and she just couldn't think straight. Resident #1's wound care orders were as follows: 4/17/22: [MEDICATION(S)] .1 gram intramuscularly 4/18/22: Wound care nurse to assess [bilateral] arms and set up daily wound and dressing care 4/18/22: [MEDICATION(S)] .1 gram intramuscularly 4/18/22: [[MEDICATION(S)]] one gram IV .[every] 24 hours times three days . From the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 4/20/22: [MEDICATION(S)]-Pot Clavulanate .one tablet by mouth every 12 hours for bacterial infection for 10 days 4/19/22: [right] mid upper arm incision; Cleanse area with wound cleanser, apply oil emulsion, 4X4 and cover with kerlix 4/21/22: [right] mid upper arm incision; Cleanse area with wound cleanser, apply [MEDICATION(S)], 4X4 and cover with kerlix 4/24/22: [right] upper arm incision; Cleanse area with wound cleanser, apply oil emulsion, 4X4 and cover with kerlix 5/11/22: Right elbow wound: cleanse with wound spray, apply iodosorb gel, cover with bordered gauze dressing, daily one time a day for daily wound care 6/7/22: [wound nurse] to use silver [MEDICATION(S)] to right elbow wound edges twice a week one time a day every Tue, Fri for wound edge treatment 6/9/22: Right elbow wound: cleanse with wound spray, apply iodosorb gel, tuck gauze tape into undermining, cover with bordered gauze dressing, daily one time a day for daily wound care Skilled Daily progress notes for 4/14/22, 4/15/22, 4/16/22 and 4/17/22 all noted an abnormal skin condition with no further details. The first notation in a nursing progress note regarding Resident #1's right elbow was on 4/17/22 authored by RN A and revealed, This nurse assessed R elbow area where sutures were present. Upon assessment it was noted that purulent drainage was present by opening from sutures . Resident #1's care plan included no specific recognition of the right elbow laceration until 4/15/22, and no specific interventions or care for the laceration until 5/10/22. One skin intervention, dated 4/13/22 revealed, Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1 skin assessments revealed the following: 4/22/22: right elbow abrasion 2.2 X 1.2 X 0.3 centimeters (cm) moderate exudate (drainage), slough 4/28/22: right elbow abrasion 0.8 X 0.9 X 0.1 cm 5/6/22: noted as abrasion and improving with no measurements 5/13/22: noted as dehisced surgical wound 1.2 X 0.8 X 0.1 cm noted to be improving 5/19/22: noted as abrasion 1.2 X 0.9 X 0.1 cm noted as stable 5/26/22: noted as abrasion, improving 0.8 X 1.2 cm 6/3/22: noted as abrasion, improving 1.3 X 0.8 X 0.1 cm 6/9/22: noted as abrasion, improving 1.1 X 0.5 X 0.2 cm Resident #1's admission skin assessment (paper form not scanned into the medical record) revealed a right humerus fracture with sling and multiple bruises to bilateral arms and redness to coccyx, but no dressings, wounds or sutures. Interdisciplinary skin meeting reviewed notes provided no further information. The policy Wound Treatment Management, dated 1/1/22, revealed, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent the development of new stage II, facility acquired pressure ulcers for two Residents (#52 & #45) of three residents reviewed for pressure injuries. This deficient practice resulted in harm to Resident #52 with the development two new stage II facility acquired pressure ulcers, the potential for further skin breakdown and deterioration of condition. Findings include: Resident #52 Review of Resident #52's Minimum Data Set (MDS) assessment, dated 9/23/21, revealed Resident #52 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #52 scored 11 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderately impaired cognition and required extensive to dependent two-person assistance with bed mobility, transfers, and toilet use. Resident #52 did not ambulate and was dependent on one-person assistance for locomotion. Resident #52 was at risk for the development of a pressure ulcer, but none were documented on the 9/23/21 MDS. During an observation on 10/18/21 at 7:25 p.m., Resident #52 was positioned on her back, with bare feet slightly elevated on a pillow. During an observation/interview on 10/19/21 at 9:21 a.m., Registered Nurse (RN)/Wound Care Nurse S performed wound care on Resident #52. Resident #52 was found positioned on her back, with bare feet elevated on a pillow. Upon inspection of Resident #52's buttocks, RN S said there were two pressure areas, and stated, I will be adding one (new pressure ulcer) today. RN S measured the two pressure areas, one on the right buttock, and one on the sacrum, and applied [Name Brand] ointment to the two, stage two pressure areas. Review of Resident #52's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Verbal Active Order Date: 10/07/2021 Start Date: 10/07/2021. Review of Resident #52's Skin and Wound Evaluations revealed the following, in part: 10/5/21: New, In-House Acquired Stage 2 Right Ischial Tuberosity Pressure injury. Measurements: 1.4 cm (centimeters) x 1.5 cm x 1.2 cm, depth of 0.1 cm, with intermittent pain. 10/12/21: Acquired Stage 2 Right Ischial Tuberosity Pressure injury. 0.6 cm x 1.0 cm x 0.8 cm x 0.1 cm. Progress: Stalled. 10/19/21: Acquired Stage 2 Right Ischial Tuberosity Pressure injury, 0.5 cm x 0.8 cm x 0.7 cm x 0.1 cm. Progress: Stable 10/19/21: New, In-House Acquired Stage 2 Sacrum Pressure injury, Measurements 1.3 cm x 1.7 cm x 1.3 cm x 0.1 cm, Intermittent Pain. During an interview on 10/20/21 at 9:50 a.m., the Director of Nursing (DON) was asked to observed Resident #52, who was positioned on her back on the bed. Resident #52's feet were covered by a sheet, which the DON removed to find Resident #52's bare feet positioned directly on the bed. A pillow was positioned between her legs but did not elevate her feet off the bed. When asked if Resident #52 had boots for skin protection in bed the DON said she was not 100% sure if Resident #52 had boots to wear. The DON looked in Resident #52's closet and stated, Yes, she does have boot in the closet. Review of Resident #52's Skin Integrity care plan, revised on 10/7/21, revealed the following interventions, in part: Bilat (Bilateral) heel lift boots on when in bed, Revision on: 1/28/2020 YELLOW DOT: Turn and reposition q 2 h (every two hours). Revision on 3/24/2019. 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. Date Initiated: 10/07/2021. No additional skin integrity interventions were added following the development of two new pressure ulcers for Resident #52 in the month of October 2021. Review of the Pressure Injury Prevention and Management policy, implemented 1/1/2021, revealed the following, in part: Modifications of Interventions: . b. Interventions on a resident's plan of care will be modified as needed. considerations for needed modifications include: 1. Changes in resident's degree of risk for developing a pressure injury. ii. New onset or recurrent pressure injury development. iii. Lack of progress towards healing. iv. Resident non-compliance. During an interview on 10/21/21 at approximately 12:15 p.m., when asked if there was any documentation showing Resident #52 had refused care, as previously requested, the DON acknowledged there was no documentation to show Resident #52 had refused repositioning by facility staff. Resident #45 Review of Resident #45's Electronic Medical Record (EMR) revealed Resident #45 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] revealed Resident #45 required one-person assistance for transfers and toileting, and supervision for bed mobility. The assessment revealed no pressure ulcers upon admission, and one surgical wound. The BIMS assessment revealed a score of 7/15, which indicated Resident #45 had moderate cognitive impairment. During an observation on 10/20/21 at 8:33 a.m., Registered Nurse (RN) S performed wound care for a surgical wound on Resident #45's right foot near the lateral malleolus (ankle bone). During the observation, Resident #45's right medial ankle had a small square beige band-aide, about 2.5 cm x 2.5 cm, placed over the medial malleolus. RN S described it was a skin tear, but reported they had not documented this during the last wound treatment. RN S removed the bandage, and an open blister was visualized. RN S measured the wound as .7 cm x .06 cm x .05 cm. The wound appeared to be a pressure ulcer, with no signs of infection; RN S concurred upon further observation. RN S explained Resident #45 wore an offloading boot over his right lower leg and foot when up in his wheelchair. RN S and Surveyor observed the offloading boot, for signs of potential pressure. A piece of Velcro was observed in the medial foot portion of the boot, about where the medial malleolus would set in the boot. RN S quickly removed the Velcro from the inside of the boot, and reported they indeed believed this likely caused the pressure area, and subsequent pressure ulcer. During an interview on 10/20/21 following the wound care observation, RN S reported they planned to document this as a new Stage 2 pressure ulcer, caused from a medical device, and stated, Last week it looked like a skin tear; now that I've seen the boot it is from friction, and could be classified as a pressure injury from the Velcro over the left malleolus. I guess if we had evaluated the boot more closely . RN S reported Resident #45 came to the facility with the boot. RN S reported the Velcro piece they removed was about 1 x 2, and Resident #45 did not have any alternate protective footwear device to protect the right foot from pressure while in bed. They reported Resident #45 often wore the offloading boot into bed, as he frequently transferred in and out of bed per his discretion. Review of Resident #45's wound care progress notes on 10/20/21 showed no documentation related to a skin tear or any skin altercation of the right foot/ankle following the same wound care observation, when RN S and Surveyor discovered the Stage 2 new pressure injury. Review of Resident #45's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date: 10/22/21. During an interview on 10/21/21 at 10:43 a.m., the DON was asked about the new Stage 2 pressure ulcer over/near Resident #45's medial malleolus of his right leg at the ankle. The DON responded, I was made aware of it (the new pressure injury) right away. Yes, there should have been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . We would not expect a pressure ulcer to develop . The DON reported this was an isolated incident, and Resident #45 came into the facility with the offloading boot. The DON explained RN S was putting in orders to check Resident #48's skin every shift. The DON added Resident #45 moved (transferred) quickly, and they were planning to talk with the physician to see if there was anything else (other device/interventions) they could put in place to address. Surveyor asked if the skin checks could have prevented the new Stage 2 pressure ulcer of the right medial malleolus. The DON responded, Yes, we could probably monitor it more closely with the skin checks. Preventative care should be for everybody. Review of Resident #45's Care Plan, accessed 10/21/21, revealed, The resident has actual impairment to skin integrity of the following location [R - right] foot lateral surgical wound and medial malleolus. Date initiated: 9/13/2021, Revision on: 10/20/21 .Interventions: .Resident to wear socks when wearing boots. Date initiated: 10/20/2021. Revision on 10/20/21 .The resident has a pressure ulcer development to the following areas: right medial malleolus, revision on : 10/20/2021 . There was no documentation found in the Care Plan regarding any non-compliance related to the wear of the offloading boot, or for skin inspection related to this medical device. Review of the policy, Pressure Injury Prevention and Management, revised 10/30/2020, revealed, The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries .Pressure injury refers to localized damage in the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device .The facility shall establish and utilize a systemic 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 interventions, and modifying the intervention as appropriate .Assessments of pressure injuries will be performed by a licensed nurse, and documented in the medical record .pressure injuries will be differentiated from non-pressure injuries .Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: .iv. Resident noncompliance .

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ESTABLISH AND IMPLEMENT A SYSTEM TO ENSURE SAFE MEDICATION ADMINISTRATION FOR ONE RESIDENT (#1) WHO WAS RECEIVING ANTI-PSYCHOTIC, ANTI-ANXIETY, MUSCLE RELAXANT AND NARCOTIC MEDICATIONS OF FIVE RESIDENTS REVIEWED FOR MEDICATION ADMINISTRATION FROM A TOTAL FACILITY POPULATION OF 78 RESIDENTS. THIS FACILITY DEFICIENT PRACTICE RESULTED IN RESIDENT #1 REQUIRING EMERGENCY MEDICAL TREATMENT PLACING HIM IN IMMEDIATE JEOPARDY TO HIS HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 10/30/12 AT 5:00 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 10/25/12, WHEN REGISTERED NURSE (RN) "A" TELEPHONED RESIDENT #1'S PHYSICIAN WITH THE RESULTS OF A LABORATORY SPECIMEN REFLECTING A GROWTH OF YEAST IN THE URINE AND THEN WROTE A TELEPHONE ORDER FOR RESIDENT #1 TO RECEIVE [MEDICATION NAME] 150 MILLIGRAMS ONE P.O. (ONE TIME) DAILY TIMES 7 DAYS FOR THE [DIAGNOSES REDACTED]. RN "B" ADMINISTERED THE FIRST DOSE OF THE [MEDICATION NAME] AT 8:00 P.M. ON 10/26/12 TO RESIDENT #1 ALONG WITH 30 MG OF [MEDICATION NAME] SULFATE, 1 MG [MEDICATION NAME] AND 1 MG [MEDICATION NAME] WITHOUT CONSULTING RESIDENT #1'S PHYSICIAN REGARDING THE POSSIBLE DRUG INTERACTIONS/SIDE EFFECTS AND THE USE OF THE [MEDICATION NAME] IN THE EXCESSIVE DOSE OF 150 MG. ON 10/27/12 AT APPROXIMATELY 9:00 A.M., RN "C" ATTEMPTED TO WAKE RESIDENT #1 AND FOUND HIM WITH "HUGE PUPILS", LETHARGIC, INCOHERENT AND "STARING OFF INTO SPACE..." RESIDENT #1 WAS SENT TO THE HOSPITAL AND WAS admitted INTO INTENSIVE CARE WITH A [DIAGNOSES REDACTED]. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 10/31/12 AT 10:00 A.M. AND A WRITTEN PLAN FOR REMOVAL OF THE IMMEDIATE JEOPARDY WAS REQUESTED. ON 10/31/12 AT 3:30 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED AFTER THIS SURVEYOR VERIFIED THE FOLLOWING: -ALL LICENSED NURSES WERE RE-EDUCATED BEFORE WORKING THEIR NEXT SHIFT ON THE PROPER PROTOCOL FOR TRANSCRIBING OF PHYSICIAN ORDERS INCLUDING BOTH VERBAL AND TELEPHONE ORDERS, SAFE AND PROPER MEDICATION ADMINISTRATION, WHEN TO CLARIFY ORDERS, RESIDENT MEDICATION RIGHTS, AND THE RED FLAGS CONCERNING PROPER DOSAGE AND PROPER USAGE. -PHARMACY CONSULTANT "E" PROVIDED A TRAINING FOR LICENSED NURSES RE-EMPHASIZING MEDICATION ADMINISTRATION, AND THE "DO'S AND DON'TS" AND PROCEDURE OF VERBAL ORDERS. THIS RE-EDUCATION AND TRAINING INFORMATION WAS VERIFIED BY REVIEW OF THE RE-EDUCATION AGENDA, NURSE SIGN-IN SHEETS AND THE FOLLOWING INTERVIEWS: ADMINISTRATOR ON 10/30/12 AT 2:15 P.M.; NURSE TRAINER "F" ON 10/31/12 AT 9 A.M.; RN "A" ON 10/30/12 AT 2:45 P.M.; PHONE INTERVIEWS WITH RN "C" ON 10/30/12 AT 3:30 P.M. AND RN "B" ON 10/30/12 AT 3:55 P.M. -THE FACILITY MANAGEMENT STAFF CONDUCTED CHART AUDITS ON ALL VERBAL ORDERS RECEIVED FROM PHYSICIANS IN THE PAST 30 DAYS TO ENSURE MEDICATION AND DOSAGE WAS APPROPRIATE FOR [DIAGNOSES REDACTED]. A REVIEW WAS CONDUCTED OF THE FACILITY'S CHART AUDIT REPORT TITLED "ALL VERBAL ORDERS AUDITED-ALL HAVE PROPER DX FOR ORDERS" (10/29/12). THE REPORT IDENTIFIED WHICH RESIDENTS HAD RECEIVED VERBAL ORDERS AND THE REVIEW FOUND NO CONCERNS. RESIDENT #2 AND RESIDENT #4'S VERBAL ORDERS WERE REVIEWED AND SHOWED REVIEW BY PHYSICIAN SIGNATURES AFTER THE VERBAL ORDER HAD BEEN TAKEN. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WILL CONTINUE AT AN ISOLATED LEVEL WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM, PENDING VERIFICATION BY THE STATE AGENCY OF THE FOLLOWING QUALITY IMPROVEMENT ACTIONS TO BE MADE BY THE FACILITY: -THE CONSULTING PHARMACY'S INSERVICE TO THE FACILITY'S CONSULTING PHARMACISTS REGARDING MAXIMUM DOSAGE, PROPER [DIAGNOSES REDACTED]. -THE FACILITY'S QUALITY PERFORMANCE IMPROVEMENT PLAN THAT WILL INCLUDE REVIEW/REVISION OF THE FACILITY'S POLICIES/PROCEDURES FOR MEDICATION ADMINISTRATION, PHARMACY, VERBAL ORDERS AND RESIDENT MEDICATION RIGHTS. -ADDITIONAL TRAINING IS TO OCCUR WITH ALL LICENSED NURSING STAFF EMPHASIZING SUCH AREAS AS; IF THE NURSE IS EVER UNSURE ABOUT THE DOSE OR MEDICATION, THE NURSE IS TO CONTACT THE NURSE ON-CALL AND LOOK UP THE MEDICATION IN THE "LIPPINCOTT, NURSING DRUG GUIDE" (2013). IF THE DOSE OR INDICATION FOR USE IS CONTRARY TO THE DRUG GUIDE, THE NURSE WILL CONSULT WITH THE PHYSICIAN OR PHARMACIST. THE TRAINING WILL ALSO INCLUDE WHAT TO DO WHEN MEDICATIONS ARE GIVEN TOGETHER AS WELL AS MONITORING NEW MEDICATION FOR SIDE EFFECTS. THE EMPHASIS OF THE EDUCATION INCLUDED THE CRITICAL THINKING STEP REGARDING BEST TIME FOR ADMINISTRATION OF NEWLY PRESCRIBED MEDICATION AND THE NECESSARY MONITORING FOR SAFETY. -A REVIEW OF ALL CURRENT RESIDENT MEDICATIONS TO ENSURE MEDICATION DOSAGE IS ACCURATE AND APPROPRIATE, AND MEDICATIONS WITH POTENTIAL SAME-TYPE SIDE EFFECTS ARE REVIEWED WITH ACTIONS TAKEN IF NECESSARY. -THE DIRECTOR OF NURSING (DON) OR HER DESIGNEE WILL CONDUCT DAILY AUDITS TO ENSURE ALL MEDICATIONS ORDERED ARE AT THE APPROPRIATE DOSAGE AND FOR treatment of [REDACTED]. FINDINGS INCLUDE: RESIDENT #1'S 9/21/12 MINIMUM DATA SET (MDS) ASSESSMENT SHOWED HE ENTERED THE FACILITY ON 8/23/12 AND IS [AGE] years OLD. THE MDS DOCUMENTED HIS [DIAGNOSES REDACTED]. THE 8/12 CARE PLAN DOCUMENTED RESIDENT #1 WAS IN THE FACILITY FOR SHORT TERM REHABILITATION STRENGTH TRAINING AFTER HAVING SPINAL CORD SURGERY. THE MDS ASSESSMENT SHOWED RESIDENT #1'S COGNITION WAS INTACT AND HE MADE HIS OWN MEDICAL DECISIONS. A REVIEW OF RESIDENT #1'S Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., [MEDICATION NAME] 1 MG (MILLIGRAM), [MEDICATION NAME] 1 MG, [MEDICATION NAME] SULFATE 30 MG, AND [MEDICATION NAME] 150 MG WERE GIVEN TO RESIDENT #1. A REVIEW OF LEXI-COMP'S DRUG REFERENCE HANDBOOK 12TH EDITION TITLED "GERIATRIC DOSAGE HANDBOOK INCLUDING CLINICAL RECOMMENDATIONS AND MONITORING GUIDELINES" REFLECTS THE DRUG [MEDICATION NAME] IS USED FOR treatment of [REDACTED]. THE MONITORING PARAMETERS INCLUDE RESPIRATORY, CARDIOVASCULAR AND MENTAL STATUS. THE DRUG [MEDICATION NAME] IS USED FOR treatment of [REDACTED]. THE DRUG [MEDICATION NAME] SULFATE (MS CONTIN) IS A NARCOTIC/OPIOID [MEDICATION NAME] USED FOR treatment of [REDACTED]. THE MONITORING PARAMETERS INCLUDE PAIN RELIEF, RESPIRATORY AND MENTAL STATUS. THE DRUG [MEDICATION NAME] IS USED FOR treatment of [REDACTED]. THIS DRUG INTERACTS WITH OPIATES CAUSING AN INCREASED EFFECT. THE MONITORING PARAMETERS INCLUDE SYMPTOMS, BLOOD PRESSURE AND MENTAL STATUS. THE RECOMMENDED GERIATRIC DOSAGE OF [MEDICATION NAME] READS, "INITIAL: 5 MG, 2-3 TIMES/DAY, INCREASING GRADUALLY...SPECIAL GERIATRIC CONSIDERATION, OLDER ADULTS ARE MORE SENSITIVE TO THE EFFECT OF [MEDICATION NAME] AND ARE MORE LIKELY TO EXPERIENCE ADVERSE CNS (CENTRAL NERVE SYSTEM) EFFECTS AT HIGHER DOSES. TWO CASES OF [MEDICAL CONDITION] WERE REPORTED AFTER INADVERTENT HIGH DOSES (50 MG/DAY AND 90 MG/DAY) WERE GIVEN TO OLDER ADULT PATIENTS...)." A PHYSICIAN ORDER SHEET DATED 10/25/12, SHOWED RN "A" TRANSCRIBED A TELEPHONED PHYSICIan order for [REDACTED].' [MEDICATION NAME](PHYSICIAN'S INITIALS)". AN INTERVIEW WAS CONDUCTED WITH RN "A" ON 10/30/12 AT 2:45 P.M. RN "A" EXPLAINED SHE HAD TAKEN THE PHONE ORDER FROM RESIDENT #1'S PHYSICIAN ON THE EVENING OF 10/25/12. RN "A" SAID SHE QUESTIONED THE ORDER AND SPELLED [MEDICATION NAME] BACK TO THE PHYSICIAN TO MAKE SURE IT WAS CORRECT BECAUSE SHE BELIEVED [MEDICATION NAME] WAS NOT USED FOR THE [DIAGNOSES REDACTED]. SHE SAID SHE WOULD NEXT TIME. DURING AN INTERVIEW WITH RN "B" ON 10/30/12 AT 3:55 P.M., SHE STATED THE FACILITY'S CONSULTING PHARMACIST CALLED THE PHYSICIAN'S ORDER INTO A LOCAL PHARMACY IN THE COMMUNITY. RN "B" EXPLAINED WHEN SHE WENT TO PICK UP THE [MEDICATION NAME] PRESCRIPTION, SHE QUESTIONED THE [MEDICATION NAME] DRUG ORDER WITH THE LOCAL PHARMACIST. RN "B" SAID THE PHARMACIST STILL FILLED THE ORDER, SAYING 150 MILLIGRAMS WAS AT THE "TOP END" FOR A DOSE GIVEN. RN "B" SAID SHE GAVE 150 MG OF [MEDICATION NAME] ON 10/26/12 TO RESIDENT #1 ALONG WITH THE OTHER ORDERED MEDICATIONS ([MEDICATION NAME] SULFATE) SCHEDULED AT 8:00 P.M. DURING AN INTERVIEW WITH RN "C" ON 10/30/12 AT 3:30 P.M., RN "C" STATED SHE TRIED TO AWAKEN RESIDENT #1 AROUND 9:00 A.M. ON 10/27/12. RN "C" EXPLAINED, "HE WAS LETHARGIC, INCOHERENT AND DID JUST STARE AHEAD...HIS GIRLFRIEND TRIED TO TALK TO HIM AND HE JUST DIDN'T RESPOND OR IF HE DID, IT DIDN'T MAKE SENSE...". RN "C" STATED SHE WAS INFORMED RESIDENT #1 HAD RECEIVED A NEW MEDICATION THE PREVIOUS NIGHT. RN "C" SAID WHEN SHE SAW THE MEDICATION ([MEDICATION NAME]) AND DOSAGE (150 MG), SHE KNEW THERE WAS A PROBLEM. SHE SAID, "...WHEN I CALLED (THE PHYSICIAN) HE SAID THAT HE DID NOT ORDER [MEDICATION NAME] CALLED THE AMBULANCE AND (RESIDENT #1) WAS TAKEN TO THE HOSPITAL..." A REVIEW OF A HOSPITAL REPORT TITLED "HISTORY AND PHYSICAL" OF RESIDENT #1 DATED 10/27/12 READS IN PART, "...REASON FOR ADMISSION: OVERDOSE AND OBTUNDATION...APPARENTLY, A MISTAKE WAS MADE...LAST NIGHT AND HE WAS GIVEN THE WRONG MEDICATION. INSTEAD OF 150 MG OF [MEDICATION NAME], HE RECEIVED 150 MG OF [MEDICATION NAME] WHICH IS NOT A MEDICATION HE REGULARLY TAKES. IN ADDITION, LAST NIGHT HE HAD [MEDICATION NAME] WHICH ARE HIS REGULAR MEDICATIONS...THIS MORNING...HE WAS BASICALLY UNRESPONSIVE. THE MISTAKE WAS DISCOVERED THIS MORNING AND HE WAS SENT TO THE ...EMERGENCY DEPARTMENT. FROM THERE, HE WAS TRANSFERRED HERE FOR ICU (INTENSIVE CARE UNIT) ADMISSION. APPARENTLY, THE PATIENT HAS BEEN BASICALLY UNRESPONSIVE ALL MORNING. HE DID RECEIVE [MEDICATION NAME] TWICE...AND WAS A LITTLE BIT MORE ALERT AND AWAKE AFTER THIS BUT NOWHERE NEAR HIS BASELINE. HE IS CURRENTLY SNORING AND DOES NOT EVEN WAKE UP TO A STERNAL RUB..." AN INTERVIEW WAS CONDUCTED WITH RESIDENT #1'S PHYSICIAN ON 10/31/12 AT 10:35 A.M. THE PHYSICIAN EXPLAINED THE NURSE HEARD HIM WRONG AND WROTE DOWN [MEDICATION NAME] INSTEAD OF [MEDICATION NAME]. THE PHYSICIAN SAID WHEN THE FACILITY CALLED HIM THE MORNING OF 10/27/12 WITH RESIDENT #1'S SYMPTOMS, HE EXPLAINED HE WANTED RESIDENT #1 SENT TO THE HOSPITAL FOR OBSERVATION AND TREATMENT DUE TO THE [MEDICATION NAME] BEING GIVEN WITH THE OTHER 8:00 P.M. MEDICATIONS. DURING A TELEPHONE INTERVIEW WITH THE FACILITY'S CONSULTING PHARMACY'S GENERAL MANAGER ON 10/31/12 AT 8:30 A.M., HE SAID THE PHARMACIST "...SHOULD 'NEVER' HAVE FILLED THE [MEDICATION NAME] ORDER AS IT WAS WRITTEN AND FOR THAT DIAGNOSES... THE DOSAGE COULD HAVE BEEN FOR 150 MILLIGRAMS BUT NEVER IN ONE DOSE FOR 7 DAYS... THE PHARMACY PROTOCOL IS TO CALL THE FACILITY FIRST TO VERIFY THE ORDER AND IF THERE IS STILL A QUESTION, THEN THE PHYSICIAN IS CALLED TO CLARIFY THE ORDER AND/OR DOSE..." RESIDENT #1 WAS REadmitted to the facility on [DATE] WITH NO PHYSICIAN ORDERS FOR [MEDICATION NAME]. A NEW PHYSICIAN ORDER SHOWED "[MEDICATION NAME] 150 MG PO DAILY X 7 DAYS LAST DOSE 11-6-12, DX [MEDICAL CONDITION][MEDICATION NAME]" RESIDENT #1 WAS INTERVIEWED ON 10/31/12 AT 5 P.M., AS HE WAS OBSERVED SITTING UPRIGHT IN HIS WHEELCHAIR. RESIDENT #1 SAID HE WAS TOLD WHAT HAD HAPPENED. HE STATED HE DOES NOT REMEMBER ANYTHING EXCEPT WAKING UP AT THE HOSPITAL AND HE IS NOT SURE WHEN THAT WAS. HE EXPLAINED HE WAS GOING TO CONTINUE HIS THERAPY AND RETURN HOME AS SOON AS POSSIBLE. THE ADMINISTRATOR WAS INTERVIEWED ON 10/31/12 AT 4:00 P.M. THE INCIDENT, THE SURVEYOR RECORD REVIEWS AND STAFF INTERVIEWS WERE DISCUSSED. THE ADMINISTRATOR SAID SHE BELIEVED THE FACILITY AND THE PHARMACY HAD MADE THE MEDICATION ERROR. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT AN UNSAFE ELOPEMENT FOR ONE COGNITIVELY IMPAIRED AND PHYSICALLY IMPAIRED RESIDENT (#1) OF FIVE SAMPLED RESIDENTS REVIEWED AND IDENTIFIED AS AT RISK FOR ELOPEMENT FROM THE TOTAL FACILITY POPULATION OF EIGHTY-FOUR RESIDENTS. RESIDENT #1 ELOPED THROUGH A WINDOW AND PROCEEDED 1.4 MILES FROM THE FACILITY UN-SUPERVISED TO HER HOME. THIS FAILURE RESULTED IN RESIDENT #1 BEING PLACED IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 9/13/12 AT 4:50 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 9/12/12 AT APPROXIMATELY 8:55 P.M., WHEN RESIDENT #1, WHO WAS KNOWN BY THE FACILITY TO BE AT RISK FOR ELOPEMENT, EFFECTIVELY EXITED THE FACILITY THROUGH A WINDOW IN HER ROOM. RESIDENT #1 THEN AMBULATED 1.4 MILES IN THE DARK THROUGH 5 ROAD/TRAFFIC INTERSECTIONS TO HER HOME WITHOUT AN ASSISTIVE DEVICE OR SUPERVISION. THE FACILITY WAS UNAWARE OF RESIDENT #1'S WHEREABOUTS/SAFETY UNTIL 9:40P.M., WHEN THE FACILITY ADMINISTRATOR FOUND RESIDENT #1 IN HER HOME STANDING IN THE LIVING ROOM. RESIDENT #1'S HUSBAND RETURNED HER TO THE FACILITY AT APPROXIMATELY 10:00 P.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 9/13/12 AT 5:05 P.M. AND A WRITTEN PLAN FOR REMOVAL OF THE IMMEDIATE JEOPARDY WAS REQUESTED. ON 9/13/12 AT 6:30 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THE FOLLOWING: - ONE ON ONE SUPERVISION BEING PROVIDED TO RESIDENT #1 - REVISION OF RESIDENT #1'S CARE PLAN AND CARE DELIVERY GUIDE TO REFLECT CURRENT STATUS AND NEEDS - ALL CURRENT RESIDENTS HAD BEEN REVIEWED FOR ELOPEMENT RISKS AND APPROPRIATE PLAN OF CARES AND CARE DELIVERY GUIDES WERE VERIFIED - MODIFICATIONS WERE MADE TO ALL WINDOWS LIMITING THE OPENING TO SIX INCHES - A PLAN TO EDUCATE ALL STAFF REGARDING ELOPEMENT PREVENTION AND MANAGEMENT POLICY WHICH NOW INCLUDES MONITORING OF WINDOW EGRESS AND CENTER EXIT DOORS - A SCHEDULED QUALITY PERFORMANCE IMPROVEMENT MEETING FOR SEPTEMBER 14, 2012 TO ADDRESS DEVELOPMENT OF A PLAN FOR THE MONITORING OF EGRESS, DOOR ALARM FUNCTIONALITY, IDENTIFICATION OF RESIDENTS AT RISK FOR ELOPEMENT AND RESULTS OF ELOPEMENT AUDITS ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT A PATTERN LEVEL WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM FOR 5 SAMPLED RESIDENT'S (#1, #2, #3, #4 AND #5) AT ELOPEMENT RISK AND 15 SUPPLEMENTAL SAMPLED RESIDENTS (#6 THRU #20) IDENTIFIED BY THE FACILITY AT RISK FOR ELOPEMENT. THE DEFICIENT PRACTICE WILL CONTINUE, PENDING VERIFICATION BY THE STATE AGENCY OF THE FOLLOWING ACTIONS NEEDED TO BE MADE BY THE FACILITY. - VALIDATION BY THE STATE AGENCY OF THE REVISED ELOPEMENT PREVENTION AND MANAGEMENT POLICY/PROCEDURE THAT INCLUDES THE MONITORING OF ALL AREAS OF EGRESS AND COMPETENCY OF FACILITY STAFF REGARDING THE REVISED POLICY/PROCEDURE. - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH PROVIDING ADEQUATE SUPERVISION TO RESIDENTS IDENTIFIED AS ELOPEMENT RISK. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET, RESIDENT #1 IS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE "ELOPEMENT PLAN OF CARE: ASSESSMENT, PREVENTION AND MANAGEMENT" DATED 6/1/12, INDICATED RESIDENT #1 WAS AT RISK FOR ELOPEMENT BECAUSE SHE WAS INDEPENDENT IN AMBULATION AND VOICED THE DESIRE TO GO HOME. A REVIEW OF THE NURSES NOTES FOR RESIDENT #1 SINCE HER ADMISSION ON 5/30/12, SHOWED SHE ATTEMPTED TO ELOPE FROM THE FACILITY ON 6/5/12, 6/19/12, 7/9/12, 8/5/12, 8/19/12 AND 9/8/12 WITHOUT SUCCESS. A NURSES NOTE WRITTEN AT 10:45 P.M. ON 9/12/12, READ "RESIDENT NOT IN ROOM-SCREEN FRAME BROKE OUT OF WINDOW-RESIDENT (#1) ESCAPED- CALL TO 911 TO REPORT MISSING PERSON-CALL TO DIRECTOR OF NURSING (DON)-CERTIFIED NURSE AIDES (CNA) SENT OUT OF FACILITY FOR SEARCH AROUND OUTSIDE FACILITY-9:00 P.M., POLICE ARRIVE-GIVEN DESCRIPTION PHOTO-POLICE CALL TO RECEIVE SEARCH DOGS- ADMINISTRATOR AND DON SEARCHING FOR RESIDENT-HUSBAND .... AWARE WIFE IS MISSING- 9:30 P.M. CNA'S STILL SEARCHING-9:45 P.M. CALL FROM ADMINISTRATOR THAT RESIDENT FOUND-9:50 P.M., 911 CALLED TO NOTIFY RESIDENT FOUND-10:00 P.M. RESIDENT BACK AT FACILITY WITH POLICE-HUSBAND-DON-ADMINISTRATOR ARE WITH RESIDENT-RESIDENT IS TIRED-fell A FEW TIMES-DOCTOR .... AWARE-RESIDENT TO HAVE ONE ON ONE OBSERVATION-BP 116/62-HEART FATE 72- RESPIRATIONS 19-OXYGEN SATURATION 99 % ROOM AIR"...... A NURSES NOTED DATED 9/12/12 AT 11:30 P.M., READ "RESIDENT (#1) AWAKE ALERT AND VERBAL, RESTING IN BED WITH 1:1 WITH HER. NOTED TO HAVE PURPLE BRUISING 35 CENTIMETERS ( CM)-15 CM LEFT HIP AND LEG. 12.5 CM BY 0.6 CM LEFT BUTTOCK PAIN TO LEFT HIP WHEN PRESS ON. UP TO BATHROOM WITH ASSIST. DENIES PAIN WHEN STANDING. ASSISTED BACK TO BED". UPON INTERVIEW WITH THE FACILITY ADMINISTRATOR ON 9/13 /12 AT APPROXIMATELY 10:00 A.M., SHE CONFIRMED THE ABOVE NURSES NOTES WRITTEN ON 9/12/12 TO BE FACTUAL. UPON INTERVIEW WITH RESIDENT #1'S HUSBAND ON 9/13/12 AT APPROXIMATELY 10:45A.M., HE GAVE THE SAME ACCOUNT AS WRITTEN IN THE NURSES NOTES DATED 9/12/12. HE FURTHER INDICATED IT WOULD HAVE TAKEN HIS WIFE (RESIDENT #1) AT LEAST AN HOUR TO WALK THE 1.4 MILES TO THEIR HOME AND RESIDENT #1 HAD TOLD HIM THE ROUTE SHE HAD WALKED TO GET TO THE HOUSE. ON 9/13/12 AT APPROXIMATELY 11:30A.M., RESIDENT #1'S HUSBAND GAVE THIS SURVEYOR (# ) A RIDE FROM THE FACILITY TO THE HOUSE THAT IS LOCATED IN A CITY WITH A POPULATION OF 4,868. THE ROUTE TAKEN, AS TOLD TO HIM BY HIS WIFE, INCLUDED A DOWN HILL GRADE BEHIND THE HOSPITAL ON HURON STREET, THEN CROSSING 3 INTERSECTIONS WITH STOP SIGNS AND TAKING A LEFT ONTO COURT STREET AT THE FOURTH STOP SIGN. RESIDENT #1 THEN CONTINUED DOWN COURT STREET CROSSING ANOTHER INTERSECTION WITH A STOP SIGN. RESIDENT #1 THEN MADE A RIGHT ON PALMYRA, THEN A LEFT ON STANLEY STREET AND THEN TAKING A LEFT ACROSS THE LAWN TO THEIR HOUSE. THIS ROUTE WAS WALKED BY RESIDENT #1 IN THE DARK WITH INTERMITTENT STREET LIGHTS ON SOME STREETS. AN INTERVIEW WITH RESIDENT #1 TOOK PLACE ON 9/13/12 AT 10:45 A.M., SHE WAS ASKED ABOUT HER ELOPEMENT INCIDENT ON THE EVENING OF 9/12/12. SHE STATED "I WAS JUST GOING HOME." DURING AN INTERVIEW WITH THE PHYSICAL THERAPY ASSISTANT (PTA) ON 9/13/12 AT APPROXIMATELY 2:00 P.M., SHE INDICATED RESIDENT #1 NEEDED CONTACT GUARD ASSIST WITH A WHEELED WALKER FOR AMBULATION BECAUSE OF SLIGHT FOOT DROP AND INTERNAL ROTATION OF HER LEFT FOOT, CAUSING THE LEFT FOOT CATCHING ON THE RIGHT FOOT. SHE FURTHER INDICATED, WHILE AMBULATING RESIDENT #1 LAST WEEK OUTSIDE THE FACILITY (AROUND THE BUILDING), RESIDENT #1 NEEDED TO HAVE ONE REST PERIOD DURING THE WALK. THE CARE PLAN FOR ACTIVITIES OF DAILY LIVING DATED 6/1/12, INDICATED RESIDENT #1 NEEDED ASSIST OF ONE STAFF FOR AMBULATION. UPON INTERVIEW WITH THE DIRECTOR OF NURSING ON 9/13/12 AT APPROXIMATELY 2:30 P.M., SHE SAID THE FACILITY CONSIDERED ANY RESIDENT WITH COGNITIVE IMPAIRMENT AND THE ABILITY TO BE INDEPENDENT WITH MOBILITY EITHER BY WHEELCHAIR OR AMBULATION, WITH OR WITHOUT AN ASSISTIVE DEVICE, AT RISK FOR ELOPEMENT. SHE ALSO CONFIRMED RESIDENT #1 HAD BEEN AN ELOPEMENT RISK. THE FACILITY POLICY FOR "ELOPEMENT PREVENTION AND MANAGEMENT PROGRAM" UPDATED 7/12, UNDER PROCEDURE READ "ASSESS THE SECURITY OF POTENTIAL INTERNAL ENVIRONMENTAL HAZARDS INCLUDING, BUT NOT LIMITED TO, THE FOLLOWING: "SCREENS" AND "WINDOWS". ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION FOR ONE COGNITIVELY IMPAIRED RESIDENT (#101), WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK, OF FIVE SAMPLED RESIDENTS IDENTIFIED AS COGNITIVELY IMPAIRED AND INDEPENDENT WITH MOBILITY, FROM A TOTAL FACILITY POPULATION OF 65 RESIDENTS. THE FACILITY'S DEFICIENT PRACTICE RESULTED IN RESIDENT #101 ELOPING FROM THE FACILITY, IN THE WINTER TIME, PLACING HIM IN IMMEDIATE JEOPARDY TO HIS HEALTH AND SAFETY. FINDINGS INCLUDE: THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 1/5/12 AT 11:30 A.M. THE IMMEDIATE JEOPARDY BEGAN ON 1/3/12 AT 6:08 P.M., WHEN RESIDENT #101, WHO HAD BEEN ASSESSED TO BE AT RISK FOR ELOPEMENT WITHOUT A DEVELOPED PLAN OF CARE TO ADDRESS THIS SAFETY PROBLEM, AND, WHO HAD MADE AN ELOPEMENT ATTEMPT EARLIER ON THE DAY OF 1/3/12, EFFECTIVELY LEFT THE FACILITY IN A WHEELCHAIR, UNDETECTED BY FACILITY STAFF, THROUGH THE FRONT EXIT DOOR, ON A COLD NIGHT. ACCORDING TO WWW.W(WEATHER)UNDERGROUND.COM, THE AREA TEMPERATURE ON 1/3/12 AT APPROXIMATELY 6:14 P.M., WAS RECORDED AS 16.7 DEGREES FAHRENHEIT (?F) WITH A WIND CHILL OF 6.2?F. WHEN RESIDENT #101 WAS DISCOVERED BY CERTIFIED NURSE AIDE (CNA) "E", HE WAS OUTSIDE KNOCKING ON THE 500 HALL EXIT DOOR AT APPROXIMATELY 6:15 P.M. HE WAS SITTING IN A WHEELCHAIR, DRESSED ONLY IN FLANNEL PAJAMA TYPE PANTS, A SWEATSHIRT, SHOES AND SOCKS. THE NURSING "PROGRESS NOTES" DATED 1/3/12 AT 1815 (6:15 P.M.) READ, "CNA BROUGHT RESIDENT (#101) TO ME STATES FOUND OUTSIDE-FACE AND HANDS COLD BUT BLANCHABLE SKIN. (RESIDENT #101) AGITATED STATES (IT) IS COLD OUTSIDE...". THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 1/5/12 AT 1:40 P.M. ON 1/5/12 AT 4:05 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE SURVEYOR VERIFIED THE FOLLOWING: - ON 1/5/12 AT 10:20 A.M. TO APPROXIMATELY 10:45 A.M., THE MAINTENANCE DIRECTOR AND THIS SURVEYOR OBSERVED THE FOUR EMERGENCY EXIT DOORS (ON HALLS 500, 600, 700 AND DINING ROOM DOOR) AND THEY WERE DETERMINED TO BE SECURED BY VISUAL (RED FLASHING BUTTON) AND AUDIBLE ALARMS. THESE ALARMS NEED A DOUBLE RESET, AT THE EXIT DOOR AND AT THE ALARM BASE AT THE NURSING STATION. THE 800 HALL DOOR ALARM WAS OBSERVED TO HAVE A 15 SECOND DELAY. THE AUDIBLE ALARM SETS OFF IMMEDIATELY; HOWEVER, THE DOOR WILL NOT OPEN FOR 15 SECONDS. IN ADDITION, THE 800 DOOR ALARM HAS A DOUBLE RESET ALARM SYSTEM IN PLACE. THE FRONT EXIT DOOR WAS OBSERVED TO HAVE A KEY PAD CODE BEFORE THE LOCK WILL BE RELEASED AND THE ALARM RESETS IN 8 SECONDS. - ON 1/3/12 AT 6:15 P.M., THE ADMINISTRATOR IMMEDIATELY INITIATED A 1:1 DOOR SITTER TO MONITOR THE FRONT DOOR ENTRANCE UNTIL A SECONDARY ALARM COULD BE INITIATED. - ON 1/3/12 AT 2120 (9:20 P.M.) THE CENTER INITIATED A SECONDARY ALARM SYSTEM IN ADDITION TO THE KEY PAD ALARM AND THE EXISTING WANDERGUARD SYSTEM. - ON 1/4/12 AT 1:00 P.M., THE FRONT DOOR ALARM DELAY (WHICH WAS AT 15 SECONDS AT THE TIME OF THE ELOPEMENT) WAS DECREASED TO AN 8 SECOND DELAY. - ON 1/5/12 AT 10:20 A.M., THIS SURVEYOR ATTEMPTED TO EXIT/ENTER THE FACILITY THROUGH THE FRONT DOOR, WHILE IN A WHEELCHAIR, WITHIN THE 8 SECOND DELAY PERIOD AND WAS UNABLE TO DO SO WITHOUT THE ALARM BEING INITIATED. - INITIATION OF A BRACELET WANDERGUARD DEVICE TO THE INVOLVED RESIDENT (#101) WITH CARE PLAN, CARE DELIVERY GUIDE AND ELOPEMENT MANUAL UPDATES. - ON 1/4/12, A RE-EVALUATION OF ALL FACILITY'S RESIDENTS TO DETERMINE THE FLIGHT RISK POTENTIAL. - IMMEDIATE INITIATION OF STAFF EDUCATION ON THE ELOPEMENT PREVENTION AND MANAGEMENT POLICY AND PROCEDURE. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL, WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM, DUE TO: - AWAITING COMPLETION OF RE-ASSESSMENTS OF ALL RESIDENTS AND ANY NEEDED CARE PLAN ADJUSTMENTS REGARDING COGNITIVELY IMPAIRED AND INDEPENDENTLY MOBILE RESIDENTS. - ELOPEMENT DRILL MONTHLY TO DETERMINE COMPLIANCE. - VERIFICATION BY THE STATE AGENCY. FINDINGS INCLUDE: THE CLINICAL RECORD WAS REVIEWED AND THE FACE SHEET REVEALED RESIDENT #101 IS AN [AGE] year OLD MAN, admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. . THE MINIMUM DATA SET (MDS) assessment dated [DATE], REVEALED A "BRIEF INTERVIEW OF MENTAL STATUS" (BIMS) SCORE RECORDED AS AN 8 OF 15, INDICATING RESIDENT #101 HAS MODERATE IMPAIRMENT. THIS MDS ASSESSMENT REFLECTED THE MAIN MODE OF LOCOMOTION IS WALKER/WHEELCHAIR. THE "QUARTERLY NURSING DATA COLLECTION AND ASSESSMENT" DATED 10/20/11, REVEALED UNDER THE "ELOPEMENT" ASSESSMENT, THAT RESIDENT #101 WAS AN ELOPEMENT RISK DUE TO THE RESIDENT BEING INDEPENDENTLY MOBILE AND COGNITIVELY IMPAIRED. BASED ON THE ABOVE ELOPEMENT ASSESSMENT, THE "APPROPRIATE RESPONSE" READ, "COMPLETE / REVIEW / UPDATE ELOPEMENT PLAN OF CARE: ASSESSMENT, PREVENTION AND MANAGEMENT". THE "ELOPEMENT" PLAN OF CARE DATED 12/15/10 WAS REVIEWED. THERE WAS NO DOCUMENTATION OF ANY TYPE OF INTERVENTIONS, TO PREVENT ELOPEMENT UNTIL 1/4/12, AFTER THE ELOPEMENT INCIDENT. AN INTERVIEW TOOK PLACE, WITH THE DIRECTOR OF NURSING (DON) ON 1/5/12 AT 11:45 A.M., AND SHE CONFIRMED THAT THERE WAS NO CARE PLAN INTERVENTIONS IN PLACE PRIOR TO THE ELOPEMENT INCIDENT ON 1/3/12 FOR RESIDENT #101. THE DON STATED, "YES, WE ABSOLUTELY SHOULD HAVE HAD SOMETHING IN PLACE....ESPECIALLY AFTER HIS EARLIER ATTEMPT TO EXIT THE BUILDING THAT DAY...HE SHOULD HAVE BEEN REASSESSED." THE NURSING "PROGRESS NOTES" DATED 1/3/12 AT 3:00 P.M., REVEALED THAT RESIDENT #101 "TRIED TO GO OUT FRONT DOOR...". FURTHER REVIEW OF THE NURSING PROGRESS NOTES REVEALED TWO ELOPEMENT ATTEMPTS ON 12/8/11, SPECIFICALLY AT 10:00 P.M. AND 11:00 P.M. WHICH REVEALED, "(RESIDENT #101) TRIED TO LEAVE BUILDING WAS ATTEMPTING TO RUN AN ERRAND" AND "(RESIDENT #101) WANTING TO LEAVE & GET HIS CAR" RESPECTIVELY. IN ADDITION, THERE WAS ANOTHER DOCUMENTED ELOPEMENT ATTEMPT (IN THE NURSING PROGRESS NOTES) ON 12/31/12 AT 10:45 P.M. DOCUMENTATION REVEALED "...(RESIDENT #101) TRYING TO GET OUT THE DOOR, CURSING & INSISTING ON LEAVING TO GO TO WORK". THERE WAS NO EVIDENCE THAT THE ELOPEMENT CARE PLAN WAS ADDRESSED AT THE TIME OF ANY OF THESE ELOPEMENT ATTEMPTS. DURING AN INTERVIEW ON 1/5/12 AT 2:00 P.M. WITH LICENSED PRACTICAL NURSE (LPN) "C", SHE STATED "YES, (RESIDENT #101) ATTEMPTED TO LEAVE THE FACILITY THROUGH THE FRONT DOOR ON 1/3/12 AT 3:00 P.M. (I) REDIRECTED HIM, TOILETED AND ENCOURAGED (HIM) TO PLAY Wii AND I SAT WITH HIM 1:1 FOR 45 MINUTES. NO, A WANDERGUARD WAS NOT PUT ON (HIM) HONESTLY... I DIDN'T KNOW THAT HE DIDN'T HAVE ONE ON HIM...". LPN "C" ALSO CONFIRMED THAT SHE WAS AWARE OF RESIDENT #101 HAVING AT LEAST ONE OTHER ELOPEMENT ATTEMPT IN THE MONTH PRIOR. A REVIEW OF THE WRITTEN STATEMENT BY HOUSEKEEPER "F", COMPLETED ON 1/3/12 AND RECEIVED BY THE FACILITY ON 1/4/12, READ "ON TUESDAY EVENING I SAW (RESIDENT #101) SITTING IN HIS WHEELCHAIR FACING THE NURSES CIRCLE AROUND 6:08 P.M.." A REVIEW OF THE "ACCIDENT/INCIDENT REPORT" DATED 1/3/12, "TIME OF INCIDENT 1815 (6:15 PM.)" READ, "RESIDENT (#101) FOUND OUTSIDE 500 HALL DOOR.... RES (RESIDENT #101) STATES HE WENT OUT FRONT DOOR AND WHEELED AROUND THERE - RES IMMEDIATELY ASSESSED ...KNOWS IT IS WINTER. WARM BEVERAGES (COFFEE) OFFERED & TAKEN. RES LAUGHING AT EXTRA ATTENTION "AM I SPECIAL?" VSS (VITAL SIGNS STABLE) 1:1 OBSERVATION. PRESSURE ALARMS ON FUNCTIONING. SKIN BLANCHABLE." "IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS" READ, "WANDERGUARD BRACELET APPLIED TAB ALARM ATTACHED TO FRONT DOOR WITH EVERY 15 CHECKS FOR PLACEMENT; 1:1 RES OBSERVATION BY FACILITY STAFF & HOSPICE, DIVERSION INTERVENTIONS, FOOD & DRINK, MULTIPLE REORIENTATION ATTEMPTS." THE NURSING "PROGRESS NOTES" DATED 1/3/12 AT 1815 (6:15 P.M.), READ, "VS (VITAL SIGNS) (BLOOD PRESSURE) 112/84 - P (PULSE) 76 - R (RESPIRATORY RATE) 20 - T (TEMPERATURE) 97.8 - O2 (OXYGEN SATURATION 97% RA (ROOM AIR)". DURING AN INTERVIEW ON 1/5/12 AT 9:15 A.M. WITH RESIDENT #101, HE STATED, "YEAH (I REMEMBER GOING OUTSIDE). THE GIRL PASSED OUT... AND I FOLLOWED THEM OUT AND WENT AROUND THE HOSPITAL - WENT TO THE BACK STOPPED AT THE FIRST DOOR AND THEY WOULDN'T LET US IN SO WE WENT TO THE SECOND DOOR. YEAH, SOMEONE LET ME IN THERE." WHEN ASKED IF HE WAS COLD, HE STATED "WELL, IT WAS NOT HOT OUT, I'LL TELL YOU THAT." WHEN HE WAS ASKED IF HE WOULD ATTEMPT TO LEAVE THE FACILITY AGAIN, HE STATED "WELL, I WANT TO GET BACK HOME." RESIDENT #101 APPEARED TO BE PLEASANT, RELAXED AND CALM THROUGHOUT THE INTERVIEW. THERE WAS NO EVIDENCE OF COLD WEATHER EFFECTS TO THE SKIN SPECIFICALLY, TO THE RESIDENT'S EARS, NOSE, FACE OR FINGERS. THESE AREAS WERE PINK AND WARM TO THE TOUCH WITH NO VISIBLE SKIN IRRITATION. DURING AN INTERVIEW WITH RESPONSIBLE FAMILY MEMBER "D" ON 1/5/12 AT 3:20 P.M., SHE STATED SHE WAS UNAWARE OF ANY ELOPEMENT ATTEMPTS PRIOR TO 1/3/12. FAMILY MEMBER "D" STATED, "IT DOESN'T SURPRISE ME THAT HE WANTS TO GET OUT OF THERE...HE THINKS HE CAN DO WHAT HE WAS ABLE TO DO YEARS AGO...BECAUSE OF HIS DEMENTIA HE HAS NO REALITY OF HIS REAL CAPABILITIES." DURING TWO INTERVIEWS ON 1/5/12 AT 8:45 A.M. AND 11:35 A.M., WITH THE ADMINISTRATOR (ADMIN), SHE STATED "I WAS INFORMED OF THE ELOPEMENT AT ABOUT 6:18 P.M....WE IMMEDIATELY DID A HEAD COUNT, A VISUAL CHECK OF ALL RESIDENTS, A PARAMETER CHECK AND WE CHECKED ALL DOORS TO ENSURE THAT DOOR ALARMS WERE WORKING. RESIDENT (#101) STATED THAT HE WENT THROUGH THE FRONT DOORS...HE WHEELED HIMSELF UP TO THE FRONT DOOR AND POINTED TO IT AND SAID THAT HE WENT THROUGH THOSE DOORS. WE IMMEDIATELY PUT SOMEONE AT THE FRONT DOOR - LITERALLY FOR ABOUT 3 HOURS UNTIL THE TAB ALARMS WAS IN PLACE." THE ADMIN STATED RESIDENT #101 WAS WEARING FLANNEL PAJAMA TYPE PANTS, A SWEAT SHIRT, SHOES AND SOCKS AT THE TIME OF THE ELOPEMENT. THE ADMIN STATED THE FACILITY BELIEVES RESIDENT #101 FOLLOWED A VISITOR OUT THE FRONT DOOR. THE ADMIN ADDED, "THANK GOD NO PHYSICAL OR MENTAL HARM OCCURRED WITH THIS INCIDENT." ON 1/5/12 AT 10:20 A.M., THIS SURVEYOR, THE MAINTENANCE DIRECTOR "A" AND THE ADMIN WENT OUTSIDE OF THE FACILITY FOR A TOUR, RETRACING RESIDENT #101'S PRESUMED ROUTE THE NIGHT OF THE ELOPEMENT (1/3/12). THIS SURVEYOR WAS IN A WHEELCHAIR AND PROPELLED SELF WITHOUT MUCH DIFFICULTLY UNTIL THE LAST RIGHT TURN TOWARD THE 500 EXIT DOOR. THE FACILITY INVESTIGATION, AS REPORTED BY THE ADMIN, DETERMINED RESIDENT #101 WENT OFF THE SIDEWALK AT THIS CORNER, AND ONTO THE GRASSY/MUDDY AREA. THE TERRAIN WAS UNEVEN AND THIS SURVEYOR COULD NOT PHYSICALLY PROPEL FORWARD FROM THE GRASSY/MUDDY AREA BACK ONTO THE SIDEWALK, AFTER SEVERAL ATTEMPTS TO DO SO. THIS SURVEYOR HAD TO BACKUP UNTIL THE WHEELCHAIR WAS COMPLETELY ON THE SIDEWALK AND PROPEL FORWARD, WHILE MAINTAINING THE WHEELCHAIR ON THE SIDEWALK. THIS SURVEYOR CONTINUED TO SELF PROPEL TOWARD THE 500 HALL EXIT DOOR ,WHICH AT THIS POINT WAS AT AN INCLINE. THIS SURVEYOR APPROACHED THE 500 EXIT DOOR WITH GREAT EFFORT. DURING AN INTERVIEW ON 1/5/12 AT 2:30 P.M., THE ADMIN STATED "HE (RESIDENT #101) MADE SEVERAL ATTEMPTS TO GET UP THIS INCLINE (INDICATING THE INCLINE TO THE 500 EXIT DOOR) THE NIGHT OF THE ELOPEMENT (1/3/12)." ON 1/5/12 AT 6:10 P.M., THIS SURVEYOR AND ADMIN WALKED OUTSIDE TO ASSESS THE PHYSICAL AND ENVIRONMENTAL CONDITIONS RESIDENT #101 WOULD HAVE ACQUIRED THE NIGHT OF 1/3/12. THERE WAS A BRIGHT LIGHT AT THE ENTRANCE DOOR, ANOTHER FLOOD LIGHT MOUNTED ON THE CORNER OF THE BUILDING AND A THIRD FLOOD LIGHT AT THE 500 EXIT DOOR. ONCE ON THE SIDEWALK (AWAY FROM THE ENTRANCE DOOR), LIGHTING ON THE , WHERE THE FLOOD LIGHT (MOUNTED ON THE CORNER OF THE BUILDING) LIT UP THE SIDEWALK. FROM THAT POINT ON, VISIBILITY WAS ADEQUATE, EVEN THOUGH THE PARKING LOT ITSELF HAD NO FIXED LIGHTING. IN ADDITION, THERE WAS AN AREA OF THE SIDEWALK WHERE THERE WAS A PIECE OF MISSING CEMENT, MEASURING APPROXIMATELY 4-5 INCHES IN DIAMETER, WHICH MADE THE SURFACE UNEVEN. A REVIEW OF THE FACILITY'S POLICY TITLED, "ELOPEMENT PREVENTION: RESIDENT" DATED 10/08, READ, "(FACILITY) RECOGNIZES THAT ELOPEMENT PREVENTION IS AN INTERDISCIPLINARY PROCESS THAT MUST INCLUDE THE COGNITIVELY IMPAIRED RESIDENT AND FAMILY... (THE FACILITY STRIVES TO) PROVIDE SUPERVISION AND ASSISTANCE DEVICES TO EACH RESIDENT TO PREVENT AVOIDABLE ACCIDENTS. MECHANISMS AND PROCEDURES ARE USED TO HELP MITIGATE THE RISK OF A RESIDENT LEAVING A SAFE AREA WITHOUT SUPERVISION." A REVIEW THE THE FACILITY'S POLICY TITLED "ELOPEMENT - MANAGEMENT" DATED 10/08, READ "THE INTERDISCIPLINARY TEAM (ITD) WILL RE-EVALUATE COGNITIVELY IMPAIRED RESIDENTS WHO HAVE ATTEMPTED, UNSUCCESSFULLY OR SUCCESSFULLY, TO LEAVE THE CENTER WITHOUT SUPERVISION. WITH ASSISTANCE OF THE RESIDENT AND FAMILY, INDIVIDUALIZED INTERVENTIONS WILL BE DEVELOPED AND INITIATED TO MANAGE THE ELOPEMENT BEHAVIOR." ( )