Every finding on record at Medilodge of East Lansing

Based on observations, interviews, and record reviews, the facility failed to effectively maintain the physical plant effecting 69 residents resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 01/07/2026 at 3:44 P.M., The restroom commode drain, located in resident room [ROOM NUMBER], was observed partially obstructed. The commode basin water level was also observed slowly receding and refilling upon flushing. An interview was conducted with Resident #39 regarding the slow flushing restroom commode. Resident #39 stated: The toilet has been clogging since I arrived last August. Resident #39 also stated: Maintenance has been here, but the toilet continues to clog. On 01/07/2026 at 3:52 P.M., The restroom commode seat, located in resident room [ROOM NUMBER], was observed severely loose-to-mount. The commode seat could be moved from side-to-side approximately 12-18 inches. An interview was conducted with Resident #82 regarding the loose commode seat. Resident #82 stated: The seat has pinched my skin more than once. Resident #82 also stated: I hope I don't fall off of the seat before they fix it. On 01/07/2026 at 4:00 P.M., An interview was conducted with Director of Maintenance (DOM) O regarding the facility maintenance work order system. (DOM) O stated: We have the TELS software system. On 01/07/2026 at 4:05 P.M., An interview was conducted with Director of Maintenance (DOM) O regarding Resident #39 's clogged restroom commode drain. (DOM) O stated: I will have to contact our rodding vendor. On 01/08/2026 at 10:25 A.M., An environmental tour of the facility Laundry Service was conducted with Environmental Services (EVS) District Manager P and Environmental Services (EVS) Account Manager Q. The following items were noted: Clean Laundry Room: 2 of 2 overhead clear plastic light lens covers were observed (chipped, broken), adjacent to the entrance door. Ten 12-inch-wide by 12-inch-long vinyl flooring tiles were also observed (etched, scored, chipped, missing), adjacent to commercial washing machine #1. (EVS) District Manager P stated: I'll enter a work order into TELS. Soiled Laundry Room: The 12-inch-wide by 12-inch-long vinyl flooring tiles were observed (etched, scored, stained, chipped). The damaged flooring tile measured approximately 10-feet-wide by 15-feet-long totaling 150 square feet. (EVS) District Manager P stated: I'll enter a work order into TELS. On 01/08/2026 at 10:44 A.M., One 24-inch-wide by 24-inch-long acoustic ceiling tile was observed (stained, particulate) from a previous moisture leak, within the South Unit Biohazard Room. (EVS) District Manager P stated: I'll enter a replacement request into TELS. On 01/08/2026 at 03:15 P.M., Record review of the Policy/Procedure entitled: Maintenance Inspection dated 3/12/2022 revealed under Policy: It is the policy of this facility to utilize a maintenance inspection program in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. On 01/08/2026 at 03:30 P.M., Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 3/12/2022 revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. On 01/08/2026 at 03:45 P.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on interview and record review, the facility failed to ensure one resident (R9) of three reviewed was able to understand and consent to the binding arbitration agreement.Findings include: Review of the medical record reflected R9 admitted to the facility on [DATE], with diagnoses that included cerebral infarction (stroke) due to thrombosis (blood clot) of other precerebral artery (8/26/26), persistent vegetative state (8/26/25) and tracheostomy status (surgical hole through the neck and into the windpipe). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/2/25, reflected R9 was coded as being in a persistent vegetative state/no discernible consciousness. The Quarterly MDS, with an ARD of 12/3/25, reflected R9 was coded as being in a persistent vegetative state/no discernible consciousness. An Alternative Dispute Resolution Agreement reflected R9's first and last initials were written with notation that R9 verbally consented to the Agreement on 11/19/25. The Agreement reflected, .YOU ACKNOWLEDGE AND AGREE; (I) THAT YOU HAVE FULLY READ, UNDERSTAND AND ARE VOLUNTARILY ENTERING INTO THIS AGREEMENT; AND (II) THAT, YOU HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS BEFORE SIGNING THIS AGREEMENT . Additionally, the Agreement reflected, .YOU ACKNOWLEDGE AND AGREE; (I) That you have been offered to, or have been able to view the audio/visual recorded video that details this agreement and what it includes . In an interview on 01/09/2026 at 9:47 AM, Admissions Coordinator (AC) N reported they had been responsible for Arbitration Agreements (Alternative Dispute Resolution Agreement) since October 2025. Their process was to review the agreement with the resident or their Responsible Party, including informing them if there were issues with care, finances or anything pertaining to the facility, they agreed to speak to an arbitrator/mediator. When asked how they ensured the resident or Responsible Party understood the Arbitration Agreement, AC N stated because they (resident or Responsible Party) agreed to check yes or no on the document and were notified that they could have a copy of the document. When asked how they ensured they were reviewing the document in terms that were understood, AC N stated they made sure to explain the concepts of arbitration and mediator. In an interview on 01/09/2026 at 11:05 AM, AC N reported being unaware of any audio and/or visual recording the facility had which detailed the Arbitration Agreement. AC N was unaware the facility's Arbitration Agreement included language pertaining to offering an audio/visual recording. R9's medical record included a Physician Progress Note for 8/27/25, which reflected, .Today, he remains unresponsive on the vent [ventilator/machine that helps with breathing or breathes for a person] . A Physician Progress Note for 10/1/25 reflected R9 was unresponsive on exam. A Physician Progress Note for 11/12/25 reflected R9 did not follow commands. R9's Social Service Progress Review, dated 12/3/25, reflected R9 was marked as rarely/never understood for their ability to express ideas and wants, considering both verbal and non-verbal expression. R9 was marked as rarely/never understands for understanding verbal content and their ability to understand others. The same Progress Review reflected R9 was unable respond nor showed signs of understanding. In an interview on 01/09/2026 at 12:10 PM, AC N recalled being in R9's room at the time the Arbitration Agreement was reviewed with them (11/19/25). AC N reported R9 was trying to sign the document but could not, so they asked R9 if they were verbally consenting. AC N reported R9's eyes were open and they were alert at the time. When asked if they believed R9 was able to understand what they were going over, AC N reported they would not have had R9 sign the agreement if they did not know what she was saying.

Based on interview and record review, the facility failed to ensure the accuracy of advance directives for one (R13) of two reviewed.Findings include:Review of the medical record reflected R13 admitted to the facility on [DATE], with diagnoses that included neurocognitive disorder with Lewy Bodies and Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R13 was unable to complete the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had long-term and short-term memory impairments. R13's medical record reflected a Do-Not-Resuscitate (DNR-no cardiopulmonary resuscitation/CPR) form was signed by a Representative (on the Patient Advocate line), the Physician and two witnesses on [DATE]. A Physician's Order, with a revision date of [DATE], reflected Full Resuscitate (CPR to be initiated in the event of cardiac and/or respiratory arrest). On [DATE] at 2:57 PM, Registered Nurse (RN) D reported that a resident's code status could be viewed by selecting the Medication Administration Record (MAR). RN D demonstrated selection of a MAR, which then populated the Electronic Medical Record (EMR) banner, which listed code status. RN D reported there was also a folder at the nurse's station, which included resident code status information. On [DATE] at 3:01 PM, the Resident Face Sheets & Code Status binder, located at the nurse's station, reflected R13's face sheet, with DNR written in black ink, at the top of the page. The signed DNR form for [DATE] and Advance Directives/Medical Treatment Decisions Acknowledgement of Receipt form, also signed [DATE], were noted behind the face sheet. On [DATE] at 3:06 PM, RN E acknowledged being R13's nurse that day. Regarding how they would know the code status of a resident, RN E stated they would go into the chart, under the profile. RN E reported the large bar (banner) had the code status, or it was in the Orders tab of the EMR. In a phone interview on [DATE] at 3:15 PM, Regional Social Service Consultant (SSC) F reported that on admission, nursing staff were to find out the resident's code status. If a resident was to be a DNR, the form had to be signed by the resident, their activated Power of Attorney (POA) or Guardian; the Physician and two witnesses. SSC F reported R13 was a full code, and their DNR was marked as not valid due to their POA being financial, not medical. According to SSC F, the individual that signed the DNR form on behalf of R13 did not have the authority to do so. SSC F reported R13's full resuscitate order was revised on [DATE], which she reported may have been when the facility caught that the DNR form was inaccurate. SSC F reported the binders at the nursing stations were in place in the event the EMR went down. SSC F indicated R13's code status in the binder should have been updated when their code status order was changed. In an interview on [DATE] at 10:32 AM, Director of Nursing (DON) B reported they went back through R13's paperwork and noted there was one sentence that designated R13's POA as having medical decision-making authority. Regarding if R13 had been deemed unable to make their own decisions, DON B stated there was hospital documentation for [DATE], stating R13 had a Durable Power of Attorney in place at that time. An email was sent to Nursing Home Administrator (NHA) A on [DATE] at 11:02 AM, requesting documentation reflecting that R13 had been deemed unable to make medical treatment decisions. The documentation was not received prior to the exit of the survey on [DATE].

Based on interview and record review, the facility failed to obtain informed consent for antidepressant medication use for one (R11) of five reviewed.Findings include:Review of the medical record reflected R11 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic respiratory failure with hypoxia (low oxygen level), depression and bipolar disorder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/3/25, reflected R11 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received antidepressant medication. According to the medical record, R11 had a Guardian in place. R11's Physician's Orders reflected Trazodone (antidepressant medication) was ordered to start on 6/30/25. The medical record did not reflect that R11's Guardian had provided consent for Trazodone use, nor that they had been informed of the medication risks and/or benefits. In an interview on 01/09/2026 at 10:32 AM, Director of Nursing (DON) B reported she did not see a consent for Trazodone in R11's medical record upon review on 1/8/26. DON B reported she contacted the Psychiatric Services Provider, who did not recall contacting R11's Guardian about the medication.

Based on observation, interview, and record review the facility failed to ensure one (Resident #35) out of three residents was up able to regularly attend activities.Findings Included:Per the facility's face sheet Resident #35 (R35) was admitted to the facility on [DATE]. Diagnoses included history of traumatic brain injury and persistent vegetative state. Review of a Brief Interview of Mental Status (BIMS) dated 11/10/2025, revealed R35's BIMS score was zero out of 15 which indicated R35 had no cognitive ability to respond to stimuli or voice his needs.In an observation on 1/07/2026 at 3:34 PM, R35 was observed in bed, but was never observed today to be out of bed and sitting in the Broda chair that was observed in R35's room. The Broda chair was observed to have several wedges and blankets laying on the seat.In an observation on 1/08/2026 at 8:39 AM, R35 remained in bed. The Broda chair remained unchanged from previous day with wedges and blankets laying in the seat. No music, no TV, no entertainment was observed to be on in R35's room. Just silence.In an observation on 1/08/2026 at 11:39 AM, Resident #35 was observed in bed. Broida chair remained untouched with all wedges and blankets as they were from 1/7/2026 observation.In an observation on 1/8/2026 at 2:18 PM, R35 was observed to still be in bed, and Broda chair was observed to still have the blankets and wedges laying on the seat of the chair.Review of a Preferences for Customary Routine and Activities dated 11/11/2025, revealed R35's family informed the facility that R35 would enjoy sports, jazz music, animals, and group activities.Review of R35's care plan with a focus of Resident (R35) at risk for altered activity patterns/pursuits related to.is dependent on staff for activities, cognitive stimulation, and social interactions, dated 4/21/2025.Review of the interventions on R35's care plan revealed R35 enjoyed watching basketball and football, one on one visits from staff and volunteers, staff were to provide periodic friendly visits for increased socialization, R35 enjoys jazz music, outside activities, and religious activities. All the interventions were dated 4/21/2025.In an interview on 1/08/2026 at 9:05 AM, Certified Nurse Aid (CNA) I stated that it was rare that R35 would go to activities. CNA I said R35 did go to church on Wednesdays but said she did not know why R35 did not go to activities. CNA I stated that she had not seen R35 up in his Broda chair daily.In an interview on 1/08/2026 at 11:06 AM, CNA J said R35 would go to church on Wednesdays and said Fridays on one of his shower days he would get up out of bed for a shower. CNA J said sometimes the Activities Director (AD) K would direct the CNAs to clip R35's nails.In an interview on 1/08/2026 at 11:20 AM, Activities Director K stated that the activities department offers music, hand messages, sometimes R35 would make it down to church. AD K said when R35 was not up in his Broda chair it made it harder for her to bring R35 to group activities. AD K said R35 was not up in his chair often. AD K said maybe one time per week R35 would be up in his Broda chair, and that was for Wednesday church. AD K said over the last month R35 had not had much activity with the department, because she only had enough staff for the activities in the dinner room and activity room. AD K said the dining room and activity room always had an activity going on and again stated that she did not have the staff for someone to sit with R35 for 30 minutes. However, AD K said if R35 was up in his Broda chair everyday then she could have him in the dining or activity room daily. AD K stated R35 was never up in his Broda chair for Wednesday church and said R35 was rarely up in his Broda chair at all. AD K said she had spoken to the CNAs about it and it had been mentioned at R35's care conferences but said that had no impact and nothing had changed.Record review of R35's activity log revealed for the last 30 days from 12/14/2025 through 1/1/2026 R35 was provided with only eight activities.

Based on observation, interview, and record review, the facility failed to consistently and timely address Monthly Medication Regimen Review recommendations for one (R37) of five reviewed. On 1/7/26 at 9:04 AM, R37 was observed sitting up in his bed with clear speech. He reported needing a swallow study and being thirsty.A review of the clinical record revealed R37 was admitted into the facility on 8/2/2025 with the most recent re-admission on [DATE], with diagnoses that included: tracheostomy, anxiety, and need for assistance with personal care. According to the Minimum Data Set (MDS) assessment dated [DATE], R37 scored 13/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).A review of R37's physician orders for his diet revealed an NPO order (nothing by mouth) dated 10/21/2025 through current.A review of R37's pharmacy progress notes revealed pharmacy made recommendations for July 2025, August 2025, October 2025, December 2025 and January 2026. A request was made for the facility to provide the above-mentioned recommendations. The facility failed to provide the recommendation for October 2025. A review of the pharmacy recommendation for 8/21/2025 revealed NURSING: Please correct the route of administration for the following medications; Milk of Mag, (magnesium), Furosemide, GuaiFENesin Liquid 100mg/5ML. Resident is NPO with a PEG (feeding tube placed directly through the skin into the stomach). Under the Follow-Through section of the form there was a hand-written triangle/Delta symbol indicating an agreement to the change. A review of R37's physician orders revealed the recommended changes from August were not made until 12/11/2025 for both the Milk of Magnesium and Furosemide and 10/21/2025 for the GuaiFENesin. In an interview on 1/9/26 at 10:32 AM, Director of Nursing (DON) acknowledged that the August recommendations were not changed timely, no rationale was provided. No rationale was provided for the omission of the October recommendation as well.Review of the facilities policy, titled Addressing Medication Regimen Review Irregularities, documented in part The facility will utilize a systematic approach for reviewing each resident's medication regimen which includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. The medication regimen of each resident must be reviewed by a licensed pharmacist at least once a month.The report should be submitt4ed to the DON within 10 working days of the review.

This citation pertains to intact 2655825Based on observation, interview, and record review the facility failed to follow physician orders for the administration of tube feeding solution for one resident (#12) out of three residents reviewed resulting in the harm of significant weight loss. Findings Included: Resident #12 (R12)Review of the medical record revealed R12 was admitted to the facility 05/24/2024 with diagnoses that included chronic respiratory failure with hypoxia, moderate protein calorie malnutrition, Angelman Syndrome (rare genetic disorder affecting the nervous system), gastrostomy, spastic quadriplegic (paralysis affecting both arms and both legs) cerebral palsy (brain damage during development), convulsion, dependence on respiratory ventilator, hypokalemia (low potassium), hypotension, esophagitis (inflammation esophagus), obstructive and reflux uropathy (blockage in urinary tract), pain, anxiety, anemia (low red blood cells) , and tracheostomy. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/31/2025, revealed R12 had a Brief Interview for Mental Status (BIMS) that could not be assessed as R12 is rarely/never understood.During observation and attempted interview on 12/03/2025 at 11:22 a.m. R12 was observed lying on a mattress on the floor. R12 did not respond to verbal questions. Review of R12's medical record revealed a Dietary Progress Note (dated 03/07/2025) that stated, Resident very active at night, crawls around on the floor and chewing on tubing, causing nursing to have to disconnect him from his TF (tube feeding). Wt (weight) change: triggered for sig (significant) wt. loss of 10.1% (13.7#) in six months.Review of R12's tubing feeding orders, with a start date of 2/14/2025, stated Two times per day. 2cal HN at 66ml(milliliters)/hr(hour) x 12 hr (hours), 792ml. Total volume 1583 Kcal. Review of March 2025 medication record revealed that R12's 04:00 a.m. dose of tube feeding was not given on dates of 03/04/2025 and 03/19/2025. The same March medication record revealed R12's 04:00 p.m. feeding tube was not given on 03/15/2025 and 3/16/2025. Review of the same March medication record revealed that R16's 04:00 a.m. dose only had 500ml out of 792ml of tube feeding solution on 03/04/2025, 03/05/2025, 03/06/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/10/2025, 03/11/2025, 03/12/2025, 03/13/2025, 03/14/2025, 03/15/2025, 03/16/2025, 03/17/2025, 03/18/2025, 03/20/2025, 03/21/2025, 03/22/2025, 03/23/2025, 03/24/2025, 03/25/2025, 03/26/2025, 03/27/2025, 03/28/2025, 03/29/2025, 03/30/2025, 03/31/2025. Review of April Medication record revealed R12 only received 500ml out of 792 ml of tube feeding solution, during 04:00 a.m. administration for the dates of 04/01/2025, 04/02/2025, 04/03/2025, and 04/04/2025.Review of R12's weight history revealed a weight of 142. 6 lbs (pounds) on 12/02/2024 and a weight of 111.5 lbs. on 04/24/2025. R12's weight had decreased by 31.1 lbs. in four months. During an interview 12/03/2025 at 01:58 p.m. Registered Dietician (RD) O explained that she had entered the progress note in R12's medical record that stated Resident very active at night, crawls around on the floor and chewing on tubing, causing nursing to have to disconnect him from his TF (tube feeding). Wt (weight) change: triggered for sig (significant) wt. loss of 10.1% (13.7#) in six months. RD O explained that she had reported this information to the Director of Nursing. RD O reviewed R12's medication record for March and April of 2025 and agreed that R12 had not received the prescribed caloric intact from his tube feeding. RD O explained the physician order, for the date of 04/04/2025 to 04/17/2025, was 2Cal HN @ 66mL(milliliters) /hr(hour) x 9hrs, 594mL total volume (1188kcal(kilocal), 49.5g protein, 416mL fluid) Auto flush @ 70mL/hr x 9hr, 630mL additional fluid run tube feed until total volume is given. RD O explained that a bolus order was supposed to be ordered also on 04/04/2025, so that R12 could receive his caloric needs of 1583 Kcal per day. RD O explained that from the date of 04/04/2025 until 04/17/2024 that R12 did not receive his required caloric intact. RD O could not explain why R12 did not received his caloric intact during the dates listed above. During an interview on 12/03/2025 at 03:22 p.m. Director of Nursing (DON) B explained that she had been made aware by RD O of the nursing staff not providing the appropriate tube feeding volume to R12 in March 2024. DON B could not provide any corrective action that had been taken following the incident for which R12 had not received the appropriate caloric intact.

This citation pertains to intact 2655825Based on observation, interview, and record review the facility failed to prevent significant weight loss in two residents (#12, #16) of three residents reviewed for weight loss. Findings Included: Resident #12 (R12)Review of the medical record revealed R12 was admitted to the facility 05/24/2024 with diagnoses that included chronic respiratory failure with hypoxia, moderate protein calorie malnutrition, Angelman Syndrome (rare genetic disorder affecting the nervous system), gastrostomy, spastic quadriplegic (paralysis affecting both arms and both legs) cerebral palsy (brain damage during development), convulsion, dependence on respiratory ventilator, hypokalemia (low potassium), hypotension, esophagitis (inflammation esophagus), obstructive and reflux uropathy (blockage in urinary tract), pain, anxiety, anemia (low red blood cells) , and tracheostomy. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/31/2025, revealed R12 had a Brief Interview for Mental Status (BIMS) that could not be assessed as R12 is rarely/never understood.During observation and attempted interview on 12/03/2025 at 11:22 a.m. R12 was observed lying on a mattress on the floor. R12 did not respond to verbal questions. Review of R12's medical record revealed a Dietary Progress Note (dated 03/07/2025) that stated, Resident very active at night, crawls around on the floor and chewing on tubing, causing nursing to have to disconnect him from his TF (tube feeding). Wt (weight) change: triggered for sig (significant) wt. loss of 10.1% (13.7#) in six months.Review of R12's tubing feeding orders, with a start date of 2/14/2025, stated Two times per day. 2cal HN at 66ml(milliliters)/hr(hour) x 12 hr (hours), 792ml. Total volume 1583 Kcal. Review of March 2025 medication record revealed that R12's 04:00 a.m. dose of tube feeding was not given on dates of 03/04/2025 and 03/19/2025. The same March medication record revealed R12's 04:00 p.m. feeding tube was not given on 03/15/2025 and 3/16/2025. Review of the same March medication record revealed that R16's 04:00 a.m. dose only had 500ml out of 792ml of tube feeding solution on 03/04/2025, 03/05/2025, 03/06/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/10/2025, 03/11/2025, 03/12/2025, 03/13/2025, 03/14/2025, 03/15/2025, 03/16/2025, 03/17/2025, 03/18/2025, 03/20/2025, 03/21/2025, 03/22/2025, 03/23/2025, 03/24/2025, 03/25/2025, 03/26/2025, 03/27/2025, 03/28/2025, 03/29/2025, 03/30/2025, 03/31/2025. Review of April Medication record revealed R12 only received 500ml out of 792 ml of tube feeding solution, during 04:00 a.m. administration for the dates of 04/01/2025, 04/02/2025, 04/03/2025, and 04/04/2025.Review of R12's weight history revealed a weight of 142. 6 lbs (pounds) on 12/02/2024 and a weight of 111.5 lbs. on 04/24/2025. R12's weight had decreased by 31.1 lbs. in four months. During an interview 12/03/2025 at 01:58 p.m. Registered Dietician (RD) O explained that she had entered the progress note in R12's medical record that stated Resident very active at night, crawls around on the floor and chewing on tubing, causing nursing to have to disconnect him from his TF (tube feeding). Wt (weight) change: triggered for sig (significant) wt. loss of 10.1% (13.7#) in six months. RD O explained that she had reported this information to the Director of Nursing. RD O reviewed R12's medication record for March and April of 2025 and agreed that R12 had not received the prescribed caloric intact from his tube feeding. RD O explained the physician order, for the date of 04/04/2025 to 04/17/2025, was 2Cal HN @ 66mL(milliliters) /hr(hour) x 9hrs, 594mL total volume (1188kcal(kilocal), 49.5g protein, 416mL fluid) Auto flush @ 70mL/hr x 9hr, 630mL additional fluid run tube feed until total volume is given. RD O explained that a bolus order was supposed to be ordered also on 04/04/2025, so that R12 could receive his caloric needs of 1583 Kcal per day. RD O explained that from the date of 04/04/2025 until 04/17/2024 that R12 did not receive his required caloric intact. RD O could not explain why R12 did not received his caloric intact during the dates listed above. During an interview on 12/03/2025 at 03:22 p.m. Director of Nursing (DON) B explained that she had been made aware by RD O of the nursing staff not providing the appropriate tube feeding volume to R12 in March 2024. DON B could not provide any corrective action that had been taken following the incident for which R12 had not received the appropriate caloric intact. Resident #16 (R16) Review of the medical record revealed R16 was admitted to the facility 08/25/2025 with diagnoses that included cerebral infarction (stroke), type 2 diabetes, atrial fibrillation, pain, congestive heart failure (CHF), hypertension, anemia (low red blood cells), dysphagia (difficulty swallowing), and hyperlipidemia (high fat content in blood). Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 99 (interview could not be completed) out of 15. During observation and attempted interview on 12/03/2025 at 08:20 a.m. R16 was observed lying down in bed. Resident did not respond to verbal questions. Review of R16's medical record revealed that her weight on 09/05/2025 was 113.2 lbs. (pounds) and that her weight on 12/01/2025 was 98.6 lbs. R16's medical record revealed a weight loss of 14.6 lbs. or 13% weight loss in 90 days. Review of R16's food acceptance record for the last 30 days revealed the following: 11/6/2025- no food acceptance for breakfast or dinner, 11/10/2025-no food acceptance for dinner, 11/16/2025- no food acceptance for dinner, 11/21/2025 - no food acceptance for dinner, 11/23/202- -no food acceptance for breakfast, 11/27/2025-no food acceptance for diner, and11/29/2025- no food acceptance for dinner.Review of current dietary orders, written 09/08/2025 revealed No salt packet diet mechanical soft texture, regular fluid, thin consistency. Review plan of care, written 09/03/2025, Eating 1:1 assist to initiate task and occasionally assist and eating: supervision-offer assistance with meal set up as needed.Review of Nutrition Data Collection/Evaluation-V2, dated 08/29/2025 revealed 1:1 assistance with meals. Encourage resident to be up in dining room for meals. Adaptive equipment: scoop plat to assist in self-feeding.During an interview on 12/03/2025 at 10:15 a.m. Registered Dietician (RD) O explained that she was responsible for monitoring residents' dietary needs. RD O explained that she is also responsible to monitor if residents were to have a significant weight loss and to make recommendations to assist in the prevention of weight loss. RD O explained that she also reviewed food acceptance of residents. RD O verified that R16 had lost 13% of her weight in the last 90 days. RD O was asked to verify R16's food acceptance for the last 30 days and verify that R16 had received a dietary tray for the dates that did not have food acceptance recorded. RD O could not verify that R16 had received a dietary tray for the missing dates and times of meals. During an interview on 12/03/2025 at 10:34 am. Director of Nursing (DON) B explained that it was the responsibility of the Certified Nursing Aides (CNA) to document food acceptance in resident's medical record. DON B was asked to review the charting for R16's food acceptance for the preceding 30 days. DON B confirmed that there were multiple dates and mealtimes that were not documented in R16's medical record, as listed above. DON B could not explain why all meals were not documented in R16's medical record for the preceding 30 days.

This Citation Pertains to Intake #2627443, 2634124, 2642694, 2662031, 2668275. Based on observation, interview and record review the facility failed to ensure sufficient nursing staff and call lights were responded to in a timely manner for 3 of 3 residents reviewed (Resident #2, Resident #4 and Resident #7). Resident #4 (R4): Review of the medical record revealed R4 was admitted to the facility 10/28/29 with diagnoses that included quadriplegia, chronic respiratory failure, neuromuscular dysfunction of bladder (nerve damage of the bladder), sever protein calorie malnutrition, tracheostomy, colostomy, iron deficiency, stage 3 pressure ulcer, asthma, and insomnia. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/27/2025, revealed R4 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. R4 was discharged to the hospital 11/30/2025 R4 was unable to be interviewed as he was admitted to the hospital. According to his complaint intake, the facility is not staffed adequately to provide sufficient care to meet the needs of the residents. During an interview on 12/02/2025 at 11:55 a.m. the Nursing Scheduler (NS) K explained that she was responsible for the daily Nurse staffing. She explained that she staffs each shift and unit according to a staffing grid, which is determined by the census in the facility. Staffing sheets were reviewed in cooperation with NS K and were found not to have enough nursing staff according to the facilities staffing grid: - 10/4/2025- (census 71) CNA-15 staffed. There should have been 18. 3 short on 1st shift . -10/11/2025-(census 74) CNA - 5 during the day shift. There should have been 6. -10/12/2025- (census 74) CNA-17 staffed. There should have been 19. 2 short on the 3rd shift. -10/17/2025- (census 70) CNA-15. Should have been 17.5. Short 1.5 on the 2nd shift and 1 short on the 3rd shift. -10/19/2025 (census 72) CNA-16. Should have been 19. Short 1 on the 1st shift and 2 short on the 3rd shift. -10/20/2025 (census 72) Nurses 8. should have been 9, 1 nurse short. CNA-17 should have been 18. Short 1 on 1st shift. - 10/21/2025 (census 74) CNA-16. Should have been 19. One short on 1st shift and two short on 2nd shift. -10/25/2025 (census 76) CNA-14. Should have been 19. 3 short on 1st shift, 2 short on 2nd shift. -10/26/2025 (census 76) CNAs-16. Should have been 18. 1 short on 1st shift, 1 short on 3rd shift. -11/01/2025 (census 76) CNA- 17. Should have been 19. 2 short on 1st shift. - 11/03/2025 (census 76) CNA 18. Should have been 19. 1 short on 2nd shift. -11/04/2025 (census 74) Nurses 8. Should have been 9. 1 nurse short on first shift. CNA 18. Should have been 19. 1 short on 2nd shift. -11/08/2025 (census 78) CNA- 15. Should have been 20. 3 short on 1st shift and 2 short on 3rd shift. -11/10/2025 (census 78) CNA 18. Should have been 20. 2 short 2nd shift. - 11/12/2025 (census 80) Nurses 9. Should have been 10. 1 short on 1st shift. Resident #2 (R2) According to the medical record, including The Minimum Data Set (MDS) dated [DATE], revealed R2 was [AGE] year-old female admitted to the facility on [DATE] diagnosis of chronic obstructive pulmonary disease and heart disease, bipolar and schizoaffective disorder. R2 scored 15 out of 15 (cognitively intact) on the Brief Interview Status for Mental (BIMS). On 12/01/2025 at 12:42 am, During an interview with R2 it was reported she has not had a shower since 11/20/25, does not get assistance timely she stated she often waits for an hour to have her call light answered and frequently staff will come in her room, turn the call light off and tell her they will be back momentarily but don't come back. R2 elaborated this was common occurrence, stating she had complained to nursing management staff many times, and it was brought up by others in Resident Council, but nobody takes the concern serious. Resident #7 (R7) R#7 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of quadriplegia. Review of the Minimum Data Set (MDS) dated [DATE], revealed R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 12/02/25 at 12:53 pm, during a bedside interview R7 reported the facility was perpetually understaffed. R7 stated he has filed multiple grievances with the facility about staffing and call light response time but nothing changes. R7 reported he was hungry a few evenings ago and requested a bowl of cereal but was told by his nursing assistant No when quired why he couldn't get cereal R7 stated he was told that because he requires staff to feed him, they did not have time. Review of Resident Council Meeting minutes dated 10/14/25 revealed a concern with call light response time under old business, however when the 09/02/25 Resident Council Meeting minutes were reviewed, the mention of call light response time was mentioned under old business. It was requested to review the concern form generated from the Resident Council meetings as it pertained to call light response times. On 12/03/25 at 2:15 pm, during an interview with Regional Nurse Consultant DD she reported the facility was unable to locate concern forms related to the Resident Councils concerns related to staffing levels or call light response time identified in the Resident Council Meeting minutes. In an observation on 12/8/2025 at 9:46 AM, it was observed that three call lights were going off in the long-term care hall. Four staff members were observed to not respond to the call light, two of the staff members were sitting at the nurse's station where the call light buzz was audible and did not respond. Director of Nursing (DON) B entered the hall, approached the nurse's medication cart, spoke with the nurse, but did not respond to the call lights that were buzzing. At 9:48 AM a nurse was observed to be sitting at the nurse's station but still did not respond to call light. By 9:49 AM only one call light was on, staff were observed in the hall and at the nurse's' station, however, no one responded to the call light. It was observed on 12/8/25 at 9:56 AM that two call lights were buzzing and two nurses, one at the desk and one at the cart, did not respond to the call lights. On 12/8/2025 at 10:12 AM, one call light was observed to be on, and four staff members were observed to be at the nurse's station. None of the four staff members responded to the call light. At 10:13 AM a staff member was observed to go to the room across from room [ROOM NUMBER], which was the room that had the call light on, the staff member spoke briefly with the resident and then left without responding to the call light that was going off in room [ROOM NUMBER]. At 10:14 AM the call light in room [ROOM NUMBER] continued to buzz. Three staff members were observed at the nurse's station and none of the three staff members responded to the call light. At 10:16 one staff member was observed to be in the hall but did not respond to the call light in room [ROOM NUMBER]. Another two staff members were observed to be standing at the nurse's station, did not respond to the call light, but rather walked away and out of the unit. At 10:18 AM the Unit Manager as observed to walk by the nurse's station where the call light was audible and did not address the call light. In an interview with Director of Nursing (DON) B on 12/8/2025 at 10:25 AM, DON B stated that her expectation was that all staff, anyone, was to answer a call light, and stated that if the person who answered the call light was not able to assist the resident then the call light was to be left on and the nurse was to be made aware of the resident's need. Review of the facility's policy and procedure titled, Call Lights: Accessibility and Timely Response dated 10/19/2020, revealed under Policy Explanation and Compliance Guidelines, 7. Any staff member who sees or hears an activated call light is responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on observation, interview, and record review the facility failed to ensure proper storage of medication, medications observed in hall unattended, for one resident (#18) out of a facility census of 68 residents. Findings Included:Resident #18 (R18)Review of the medical record revealed R18 was admitted to the facility 07/22/2024 with diagnoses that included stroke, hypertension, chronic pain, bradycardia, bilateral hearing loss, dementia, post-traumatic stress disorder, prostate cancer, gastro-esophageal reflux disease, adjustment disorder with depressed mood, constipation, and restless leg syndrome. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/25, revealed R18 had a Brief Interview for Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. During the initial tour of the facility on 12/01/2025 at 09:14 a.m. a medication cup, with medication, was observed sitting on top of an isolation care outside room [ROOM NUMBER]. No staff were in the vicinity of the medication, and no residents were in the vicinity of the medication. Regional Director of Respiratory Therapy T was observed collection the medication cup. The medication cup was observed to contain 3 round pills, 2 oblong pills, 1 capsule, and one bottle of nasal spray. Regional Director of Respiratory Therapy T explained that she would take the medication to the Director of Nursing B. The facility identified that the medication belonged to R18. The medication in the medication cup was identified as one tablet multivitamin with minerals, one tablet vitamin D 1000 units, one tablet donepezil HCL (hydrochloride) 10 mg (milligrams), one tablet memantine HLC 10 mg, one tablet proton 40mg, one capsule fluoxetine 20mg and one bottle of fluticasone propionate suspension 50 MCG (micrograms).During observation and interview on 12/01/2025 at11:27 a.m. R18 was observed sitting in his wheelchair in the dining room. R18 could not verify that the nursing staff had given him his medication this morning. During an interview on 12/08/2025 Director of Nursing (DON) B explained that it was facility policy that during medication administration, medication must be under the direct observation of the person administering the medications. DON B explained that on 12/01/2025 she was made aware of medication that was left unattended. DON B explained that she had identified that the medication belonged to R18. DON B explained the medication was destroyed. DON B explained that R18's medication was re-pulled from the medication cart and distributed to R18. Review of facility policy entitled Medication Storage, with an implementation date of 10/30/2020 and last review date of 01/03/2024 revealed Policy Explanation and Compliance Guidelines- 1. General Guidelines: c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

This Citation Pertains To Intake # 2631073, 2666145, 2655825, 2666019 and 267649Based on observation, interview and record review the facility failed to provide showers/bathing on a routine basis to maintain cleanliness and hygiene for 2 residents (Resident #2 and Resident #12) of four reviewed.Findings include: Resident #2 (R2) According to the medical record, including The Minimum Data Set (MDS) dated [DATE], revealed R2 was [AGE] year-old female admitted to the facility on [DATE] diagnosis of chronic obstructive pulmonary disease and heart disease, bipolar and schizoaffective disorder. R2 scored 15 out of 15 (cognitively intact) on the Brief Interview Status for Mental (BIMS). On 12/01/2025 at 12:42 am, During an interview with R2 she reported she has not had a shower since 11/20/25. R2 stated this was not uncommon and despite multiple complaints made to nursing management the issue is ongoing. Review of R2's Shower records for November 2025 revealed R2 received a total of 3 showers for the entire month of November (11/3, 11/6 and 11/20.) There was one documented refusal on 11/14. On 12/02/25 at 10:55 AM during an interview with Certified Nursing Assistant (CNA) W reported the facility did not have CNA's specifically for showers and each CNA was responsible to for their own assignment. CNA W stated residents should be receiving a shower twice a week, when asked to elaborate on should CNA W stated sometimes she is scheduled to give two showers which was doable and other days shed be scheduled 15 showers, which was not possible. Resident #12 (R12) Review of the clinical record revealed Resident #12 (R12) was admitted to the facility on [DATE] with a readmission date of 11/18/2025. R12 had diagnoses that included angel-man syndrome, cerebral palsy, chronic respiratory failure and constipation. Review of the Minimum Data Set (MDS) with an assessment reference date of 8/31/25 R12 was coded as having no speech, long and short-term memory impairment with severely impaired daily decision-making skills.On 12/03/25 at 10:24 am during a phone interview with R12's mother/legal guardian CC it was reported that she and other family members visit on a very regular basis and that she had requested meetings on multiple occasions with the facility interdisciplinary team regarding care concerns including but not limited R12 not receiving showers. Review of the facility concern log did reveal R12's mother/legal guardian CC did file a grievance form with the facility on 11/24/25 regarding care concerns including but not limited to R12 not getting his scheduled shower and family having to assist to ensure it was done. Of note, the grievance from had no documented response by facility staff. Review of R12's shower sheet in October reflected a shower was provided on 10/16 and not again until 10/26, with no refusal in between. Review of November shower sheets reflected R12 received a shower on 11/2 but not again until 11/9 with no refusal in between those dates. On 12/03/25 at 9:10am during an interview with ADON G she reported all residents were scheduled to have a shower at least twice a week. When queried about R12 and R2, ADON G stated there was a meeting with R12's mother/guardian CC yesterday and everything was resolved and she could not account for why R12 did not get regularly scheduled showers. ADON G stated in the case of R2, that R2 often refused or will tell staff she would like her shower later. It was requested at this time that documentation be provided to regarding these refusals /postponements. ADON G stated there was no documentation to support this.

This Citation Pertains to Intake #'s 2677649 and 2666019.Based on observation, interview and record review, the facility failed to monitor and treat constipation for two of three residents reviewed (Resident #12 and # 15) resulting in hospitalization for Resident #12.Findings include:Resident #15 (R15) Review of the medical record revealed R15 was admitted to the facility 02/07/2025 with diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), tracheostomy, type 2 diabetes, obesity, ventilator dependence, congestive heart failure (CHF), dysphagia (difficulty swallowing), hypoglycemia (low blood sugar, bilateral hearing loss, obstructive and reflux uropathy (blockage that hinders urine flow), and stage 3 kidney disease. R15's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/16/2025, revealed R15 did not have a Brief Interview for Mental Status (BIMS) completed during the MDS look back period. Review of R15's medical record revealed the following bowel pattern: 10/14/2025- no bowel movement, 10/15/2025-no bowel movement, 10/16/2025-no bowel movement, 10/17/2025- no bowel movement, 10/18/2025- no bowel movement, 10/19/2025-no bowel movement. Review of R15's Medication Administration Record (MAR) for October 2025, revealed R15 was given Milk of Magnesia Suspension 400mg (milligrams)/5ml (milliliters) Give 30ml as need for constipation, was given on 10/19/2025. R15's record revealed he had medium bowel movement on 10/20/2025. During an interview on 12/04/2025 at 10:04 a.m. Assistant Director of Nursing (ADON) G explained that resident bowel movements are monitored by the nursing staff, which are reported on the clinical dashboards on the computerized medical record. ADON G explained that when resident's do not have bowel movements in 3 days, the physician would be contacted to request mediation that would alleviate constipation. ADON G agreed that R15's medical record revealed he did not have a bowel movement between the dates of 10/16/2025 and 10/19/2025. ADON G could not explain why medication had not been given, prior to 10/19/2025, for R15's constipation. During observation and attempted interview on 12/8/2025 at 08:30 a.m. R15 was observed lying in bed. R15 was unable to answer questions regarding constipation. Review of the clinical record revealed Resident #12 (R12) was admitted to the facility on [DATE] with a readmission date of 11/18/2025. R12 had diagnoses that included angel-man syndrome, cerebral palsy, chronic respiratory failure and constipation. Review of the Minimum Data Set (MDS) with an assessment reference date of 8/31/25 revealed R12 was coded as having no speech, long and short-term memory impairment with severely impaired daily decision-making skills. Review of R12's bowel elimination record for October 2025 revealed R12 had no record of having a bowel movement (BM) from 10/08/25 to 10/18/25, no BM 10/21, 10/22, 10/23, 10/24 and 10/25/25. The October Medication Administration Record (MAR) revealed the only intervention was on 10/19/25 when a suppository was administered, of note, the October MAR further revealed the suppository was ineffective. There was no record of R12 having a BM 10/29, 10/30 10/31, 11/1, 11/2, 11/3 and 11/4. No BM documented 11/08, 11/09, 11/10, 11/12, 11/13/25. Review of the medication administration record revealed a suppository was administered to R12 on 11/11 with unknown results and again on 11/13/25, in which R12 was transferred to the hospital. Review of the Respiratory Therapy progress notes dated 11/13/25 at 06:50 AM revealed He was found to have dry vomit on his mouth/face to the left side of him, on his shirt and sheets underneath. There was a moderate amount of white, completely dry vomit. He was off the Ventilator. He had a HME (Heat Moisture Exchange) in place, on room air. HME had vomit in it. He appeared diaphoretic and pale with increased Work of Breathing (WOB.) He was non-responsive to all stimuli, including sternal rub. Extremities are cold. SpO2 (peripheral oxygen saturation- the percentage of oxygen carrying hemoglobin in the blood, indicating how well the lungs are oxygenating your body.) difficult to obtain. Once obtained SpO2 found to be 79%, HR (Heart Rate)110 bpm (Beats Per Minute). Immediately Resident was placed on Ventilator, cuff inflated to Micro laryngeal Tube (MLT.) No improvement in saturation or presentation. Oxygen bled into Ventilator. Titrated up to obtain saturation over 90%. Unable to obtain SpO2 of greater than 90% on Ventilator with 15 lpm (liters per minute) through Ventilator. IP (Inspiratory Pressure) increased to obtain better tidal volumes. No improvement. Began to bag with MVB (Mask Valve Bag). Able to achieve SpO2 of 95% with bagging at 15 lpm. Continued bagging for about 5 minutes to aide in recovery, then attempted to place back on the Ventilator. Placed on Ventilator with initially 15 lpm bled in, SpO2 was 94%. Attempted to wean oxygen to 12 lpm and SpO2 began to drop instantly. On call doctor contacted and EMS called. EMS arrived and began asking about Resident's code status. Review of Nursing progress notes dated 11/13/25 at 07:06 AM, desaturation 75% on Room Air (RA) old vomit on shirt. Record checked for BM, last one was 11/7. Res (sic) placed on 02(oxygen) and recovered The progress note further revealed the physician was notified, a suppository was administered, 911 called and R12 was transferred to the hospital. Nursing notes dated 11/13/25 at 10:53 revealed the Nurse received an update from R12's family member who was at the hospital with R12 and stated suppository was effective. Review of the hospital summary dated 11/13/25 revealed R12 . had a vomiting episode at the facility after which he was noted to have respiratory arrest and was bagged, EMS called and the patient was placed on a ventilator in the emergency department, a cat scan showed bilateral dense consolidation, possible 2 person witnessed aspiration event. Review of the Infectious Disease Physician hospital notes dated 11/13/25 reflected R12 was presented to the hospital via EMS Found covered in vomitus, likely had aspiration event' .Thick mucus with milky tube feed was appreciated throughout airway. Bronchial wash was performed. Review of hospital records 11/14/25 revealed R25 .for some reason removed from his vent around 3:00am and was found with emesis all over him this morning and respiratory arrest. Hospital progress notes dated 11/15/25 revealed constipation, a cat scan revealed an extended abdomen, and the plan was to increase bowel regimen and that R12 had aspiration pneumonia. Nutrition was administered via a nasal gastric tube opposed to the Percutaneous Endoscopic Gastrostomy (PEG) tube that R12 normally received nutrition due to R12's constipation. Review of the hospital Registered Dietician (RD) progress notes dated 11/17/25 revealed R12's had less than optimal enteral nutrition related to tube feeding was on hold due to aspiration event as evidenced by constipation with unknown adherence to bowel regimen. The note additionally reported upon admission imaging R12's abdomen had been distended. On 12/03/25 at 10:24 am during a phone interview with R12's mother/legal guardian CC it was reported that she and other family members visited on a very regular basis and that she had requested meeting on multiple occasions regarding care concerns including but not limited to R12's constipation. Review of the facility concern log reflected R12's mother/legal guardian filed a grievance with the facility dated 11/06/25 that she was concerned with R12's lack of BM's and she was informed by the nurse on 11/6 that R12's last BM was 10/28. The concern form was assigned to Assisted Director of Nursing (ADON) G. Of note, the concern form section Findings and Plan/actions were blank the section Resolved and Results reported to were all left blank. The sections for signatures were blank. On 12/03/25 at 9:10am during an interview with ADON G she reported she had a meeting with R12's mother/guardian CC yesterday and everything was resolved. When queried about R12's lack of bowel elimination and hospitalization for acute respiratory failure and aspiration pneumonia, ADON G reported R12's family was very involved and possibly changed R12 and didn't notify staff. When queried who was responsible for monitoring bowel records, ADON G stated it was the floor nurse's responsibility and the computer system will alert them if there is no BM for 3 days. When queried why there was no intervention, including the blank response to the grievance form filed on 11/6/25. ADON G stated the floor nurses may have cleared the alert without acting on it. On 12/03/25 at 3:30pm, during an interview with the Director of Nursing (DON) B she reported the facility has no policy or procedure of bowel elimination or constipation, and that it was up to the Physician to act upon individual episodes of constipation. When quired how the Physician would be informed for someone like R12 who was unable to communicate their needs, DON B stated the Unit Manager and ADON G was responsible for tracking BM and notifying the Physician when an issue arises. DON B stated she would expect Unit Managers and the ADON G to notify the Physician after 3 days of no bowel elimination. DON B stated the family was involved and may not have told staff if R12 had a BM. When queried if the nurses get an alert of no BM, and the family is actively involved and, in the facility, would the expectation be that the Nurse ask the family prior to clearing the computer-generated alert? DON B stated that ADON G was working with the family on some issues including bowel elimination.

This citation pertains to intake 2597662.Based on observation, interview and record review, the facility failed to ensure medications were administered per physician's orders for one (R1) of three reviewed.Findings include: Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic respiratory failure with hypoxia, asthma, tracheostomy status (surgical hole made through the front of the neck, into the windpipe/trachea, for placement of a tracheostomy tube for breathing) and spastic quadriplegic cerebral palsy. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/31/25, reflected R1 did not speak, was rarely/never understood and rarely/never understands.On 8/26/25 at 8:05 AM, R1 was observed seated in a wheelchair, in their room. A tracheostomy was observed, secured with tracheostomy ties. R1's hospital Discharge summary, dated [DATE], reflected discharge diagnoses that included tracheostomy dependence, pneumonia, septic shock and gram-positive bacteria. According to the discharge summary, R1 was to receive sulfamethoxazole-trimethoprim (Bactrim DS-an antibiotic) 800-160 milligrams (mg) by mouth two times daily until 8/13/25. R1's August 2025 Medication Administration Record (MAR) reflected their 8:00 PM dose of Bactrim DS, which was ordered for pneumonia, was not administered on 8/11/25. A correlating Progress Note for 8/11/25 at 11:18 PM reflected the medication was on order, and the pharmacy had been called.Review of the facility's back-up medication supply list, dated 5/28/25, reflected Bactrim DS 800-160 mg was available within the facility. A medication error Incident Report for 8/11/25 at 8:00 PM reflected the nurse did not pull Bactrim DS from the back-up supply for R1's evening dose of medication. The report reflected the on-call provider was notified. R1's medical record did not reflect documentation pertaining to consideration of changes to the Bactrim DS order to account for R1's missed dose of medication.R1's August 2025 MAR reflected their bedtime dose of Olanzapine (antipsychotic medication) 7.5 mg was not administered. A correlating Progress Note for 8/11/25 at 11:21 PM reflected the medication was on order, and the pharmacy had been called. A medication error Incident Report for 8/11/25 at 8:00 PM reflected the nurse did not pull Olanzapine from the facility's back-up medication supply for R1's 8:00 PM dose on 8/11/25. According to the August 2025 MAR, R1's 8:00 PM dose of Klonopin (medication to treat seizure disorder) 0.5 mg was not administered on 8/11/25. The MAR reflected the medication was ordered for a diagnosis of unspecified convulsions. A medication error Incident Report for 8/11/25 at 8:00 PM reflected the nurse did not pull Klonopin from the facility's back-up medication supply for R1. In an interview on 8/26/25 at 1:32 PM, Director of Nursing (DON) B confirmed Bactrim DS was included in the facility's back-up medication supply. DON B reported they would typically extend the order for the number of days (doses) missed, but that would be at the discretion of the provider. When asked if an extension of the order was discussed with the provider, DON B acknowledged she did not see Bactrim in the provider notes. DON B reported the nurse should have also pulled R1's Olanzapine and Klonopin doses from the facility's back-up medication supply for 8/11/25. According to the American Lung Association, Pneumonia Treatment and Recovery .Take any medications as prescribed by your doctor. If your pneumonia is caused by bacteria, you will be given an antibiotic. It is important to take all the antibiotics, even though you will probably start to feel better in a couple of days. If you stop before the prescription is gone, you risk having the infection return, and you increase the chances of the germs becoming resistant to treatment in the future . (https://www.lung.org/lung-health-diseases/lung-disease-lookup/pneumonia/treatment-and-recovery)

This citation pertains to intake 2597662.Based on observation, interview and record review, the facility failed to provide respiratory care according to physician's orders for one (R1) of three reviewed.Findings include:Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic respiratory failure with hypoxia, asthma, tracheostomy status (surgical hole made through the front of the neck, into the windpipe/trachea, for placement of a tracheostomy tube for breathing) and spastic quadriplegic cerebral palsy. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/31/25, reflected R1 did not speak, was rarely/never understood and rarely/never understands.On 8/26/25 at 10:51 AM, R1 was observed seated in a wheelchair, in their room. A tracheostomy was observed, secured with tracheostomy ties. A cough assist machine was observed on a table in R1's room. In an interview on 8/26/25 at 11:01 AM, Respiratory Therapist (RT) D reported R1 received their cough assist three to four times daily, and there was an order to sign off on. R1's July 2025 Respiratory Administration Record (RAR) reflected an order for cough assist therapy for assistance with airway clearance, three times daily, for airway patency, related to chronic respiratory failure with hypoxia. The scheduled times reflected 7:00 AM, 4:00 PM and 8:00 PM. According to the RAR, R1 missed 20 opportunities to receive their cough assist due to reasons including lack of tolerance, refusal or being asleep. R1's hospital Discharge summary, dated [DATE], reflected discharge diagnoses that included tracheostomy dependence, pneumonia, septic shock and gram-positive bacteria. According to the discharge summary, R1 was to receive cough assist three times daily. A readmission Physician Progress Note, dated 8/12/25, reflected R1 was recommended to continue the cough assist three times daily.Review of R1's August 2025 RAR reflected an order for ten cycles of their cough assist, three times daily, for lung inflation, related to chronic respiratory failure with hypoxia. The scheduled times reflected 7:00 AM, 3:00 PM and 10:00 PM. The first administration of the cough assist upon return from the hospital was documented for 10:00 PM on 8/12/25. The RAR reflected R1's cough assist as not being administered for their 7:00 AM scheduled time on 8/20/25, the scheduled 3:00 PM time on 8/24/25 or the scheduled 10:00 PM time on 8/16/25, 8/17/25 and 8/24/25 due to reasons including refusal, being asleep or being out of the facility.In a phone interview on 8/27/25 at 9:56 AM, RT E reported R1 did not tolerate the cough assist, and they could not recall the last time they attempted to administer R1's cough assist.

This citation pertains to intake number MI00151442 and MI00151852 Based on observation, interview, and record review the facility failed to provide for three out of three residents (Resident #105, #106, #111) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds, osteomyelitis, and hospitalization . Findings Included: Review of the facility Matrix, dated 4/8/25, the facility census was 69 and they had nine current residents with pressure ulcers and three had facility acquired pressure wounds. Review of two complaints received by the State Agency alleged the facility failed to prevent worsening of pressure ulcers for R105 and R106, who was known high risk for skin breakdown. Resident #106(R106) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R106 was a [AGE] year-old male admitted to the facility on [DATE], with re-admission 3/13/25 related to wound infection with other diagnoses that included traumatic brain dysfunction, cerebral vascular accident, acute respiratory failure with anoxic brain damage with tracheostomy, contracture of left knee and right knee, The MDS reflected R106 was dependent on staff for all care. Continued review of the MDS reflected R106 had one new stage 4 pressure ulcer(PU) (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) not present on admission. During a telephone interview on 4/9/25 at 9:43 a.m., R106 Responsible Party (RP) K reported R106 was currently in the hospital for several infected worsening facility acquired pressure wounds since 4/1/25. R106 RP K facility staff were not turning and repositioning R106 enough and on several occasions appeared to be unkept and ungroomed. Review of R106 Physician Progress Note, dated 10/25/24, reflected, Patient is a 38M[male], medical history of TBI[traumatic brain injury],trach and PEG [percutaneous endoscopic gastrostomy] placement, nonverbal, AOx0[alert and oriented times 0] at baseline, who resides at [named long term care facility]. His brain injury occurred in April 2022 when he was struck by a vehicle on his bicycle. He was admitted to [named hospital] for medical management. He required PEG tube and tracheostomy. Ultimately, he was admitted to [named long term care facility] on 8/1/2024. He has required multiple ED[emergency department] visits for PEG tube replacement after being dislodged. Additionally, his most recent hospitalization was due to aspiration PNA [pneumonia]. However, he was recently able to be decannulated and is now doing well on room air .consulted for rehab needs and evaluation of contracture's and bruxism [grinding of teeth] . Review of R106 Provide Note, dated 10/28/24, reflected, Primary Chief Complaint: Skin: Pressure Wound .History Present Illness : 38M with hx[history] TBI, chronic resp.[respiratory] failure, nonverbal, total care, developed a new Stage 2 pressure wound on his coccyx .This is an acute new problem . Review of R106 Pertinent Charting Skin Note, dated 2/2/25, reflected, Location of skin area being documented: Coccyx, bilateral ischial tuberosities Coccyx, wound is white around the edges but improving with the wound bed. Cleaned and dressing applied. Right Ischial tuberosity has a fluid filled blister that is intact. Skin prep applied, let dry, then applied non-adherent pad then comfort foam border. Left: hip is open . Review of R106 Pertinent Charting Skin Note, dated 2/14/25, reflected, Location of skin area being documented: Coccyx, bilateral hips Coccyx wounds still declining, with the rim of wound white, skin prepped the outside of wound before applying dressing. Right hip doing well, still flush with skin, dressing applied. Left hip declining, slightly deeper than last observed by myself with significant amount of drainage . Review of R106 Pertinent Charting Skin Note, dated 2/17/25, reflected, Location of skin area being documented: Coccyx, Left hip, right hip left outer foot. Coccyx wound no change, but still not doing well, left hip is worse, wound is draining more and has an odor to it. Right hip is almost completely healed. This area looks great. Left outer foot has a blister on it .risk management started Review of R106 Wound Notes, dated 10/29/24 through 3/4/25, reflected the following: 10/29/24-Coccyx NEW Facility Acquired(FA) Stage 4 pressure ulcer(PU)--1.07 x 0.6 x 0.1 cm Start date 10/28/24. 2/4/25--Coccyx FA stage 4 PU-3.6 x 2.3 x 0.3 cm -Left Trochanter(hip) New Facility Acquired-6.7 x 3.3 x 0.2 cm--NEW -Right Trochanter New Facility Acquired blister-4.8 x 3.3 x 0.1 cm-NEW 2/18/25-Coccyx FA stage 4 PU-4.2 x 3.3 x 0.4 cm-slough -Right Trochanter FA PU-RESOLVED -Left Trochanter FA blister-3.9 x 5 x 0.2 cm-slough, dark non-granulation -Left lateral foot NEW hematoma-2.4 x 1.3 x 0 cm--NEW 3/4/25--Coccyx FA unstageable PU-4.7 x 3.0 x 0.4 cm--slough -Left Trochanter FA unstageable pressure-6.2 x 2.2-slough -Left lateral foot FA deep tissue injury-2.4 x 1.5 x 0 cm Review of R106 Provider Notes, dated 3/13/25, reflected, Primary Chief Complaint: Readmission .Patient was sent to ED on 3/6 sepsis and sacral wound infection. Patient had a sacral decubital and it was debrided, and patient grew out Escherichia coli ESBL and Pseudomonas aeruginosa and staff. Patient was treated with Zyvox. And patient is requiring meropenem 500 mg every 6 hours and levofloxacin 750 every 24 hours for 6 weeks. Patient is being readmitted to the facility . Review of R106 Nursing Evaluation Summary Note, dated 3/13/25 at 9:21 p.m., reflected, Resident arrive via stretcher from [named] hospital after a hospital stay r/t[related to] infection . Review of R106 Physician History and Physical Note, dated 3/14/25, reflected, He is being seen for readmission to the facility after hospitalization at [named]. He was admitted for suspected sepsis with hypotension and tachycardia. Source was felt to be due to a sacral ulcer. He was taken for debridement on 3/8/25 with cultures showing ESBL E. coli and Pseudomonas. ID was consulted and recommended 6 weeks of meropenem and Levaquin .PICC[peripherally inserted central catheter] was placed on 3/13. Today, he was noted by nursing to have been grinding his teeth more, diaphoretic, and appearing more uncomfortable . Review of R106 Pertinent Charting-Infections/Signs Symptoms Note, dated 3/16/25, reflected, .Resident has had a difficult night tonight. Has been moaning and groaning, have given PR muscle relaxer and his scheduled medications and they do not appear to help. When dressing was completed, he did appear to settle down and is at this time quiet. Review of R106 Provider Wound Note, dated 3/18/25, reflected, Chief Complaint / Nature of Presenting Problem: Sacral and left hip pressure wounds History Of Present Illness:39yr old male requested by facility for evaluation of wounds and follow up related to coccyx, left lateral foot, and left hip pressure wounds .Coccyx stage 4 pressure Measurements- 5.1 x 3.7 x 1.5cm Tissue type- Pink non-granulation/slough .Infection- delayed healing/non-viable tissue .Wound Plan Of Care- Medihoney/lightly fluffed saline gauze/foam BID and prn .Wound Additional Orders- Caregiver staff to provide frequent turning and repositioning .Left lateral foot deep tissue injury Measurements- 3 x 1.7 x 0cm Tissue type- discolored epithelial .Left trochanter unstageable pressure Measurements- 6.6 x 7 x Unable to determine true depth Tissue type- pink non-granulation/slough .Wound Plan Of Care- Medihoney/lightly fluffed saline gauze/foam BID and prn . Review of R106 Provider Wound Note, dated 3/25/25, reflected, Coccyx stage 4 pressure Measurements- 5 x 3.8 x 1.2cm .Tissue type- Pink non-granulation/slough Peri Wound- fragile Drainage- Light serosanguineous Pain- none Infection- delayed healing/non-viable tissue Overall Wound Condition- stable Wound Plan Of Care- Medihoney/lightly fluffed saline gauze/foam BID and prn .Left lateral foot deep tissue injury Measurements- 2.8 x 1.7 x 0cm Tissue type- discolored epithelial Peri Wound- fragile .Left trochanter unstageable pressure Measurements- 7.7 x 7.6 x Unable to determine true depth Tissue type- pink non-granulation/slough Peri Wound- fragile Drainage- Light serosanguineous Pain- none Infection- non-viable tissue . Review of R106 Wound Provider Note, dated 4/1/25, reflected, Chief Complaint / Nature of Presenting Problem: Sacral and left hip pressure wounds History Of Present Illness: 39yr old male requested by facility for evaluation of wounds and follow up related to coccyx, left lateral foot, and left hip pressure wounds. Caregiver staff notes recent fevers and odor from buttocks wounds .Coccyx unstageable pressure Measurements- 5.8 x 5.2 x unable to determine true depth Tissue type- slough/dark avascular tissue Peri Wound- fragile Drainage- Light serosanguineous Pain- none Infection- delayed healing/non-viable tissue Overall Wound Condition- deterioration .Left lateral foot deep tissue injury Measurements- 2.8 x 2 x 0cmTissue type- discolored epithelial .Overall Wound Condition- stalled Wound Plan Of Care- skin prep and OTA daily .Left trochanter unstageable pressure Measurements- 7.8 x 7 x Unable to determine true depth Tissue type- pink non-granulation/slough Peri Wound- fragile Drainage- Light serosanguineous Pain- none Infection- non-viable tissue .Right trochanter blister Measurements- 1.5 x 2.5 x 0.1cm Tissue type- dermal Peri Wound- fragile .Overall Wound Condition- new .Right Upper arm blister lateral Measurements- 1.3 x 0.9 x 0cm Tissue type- fluid filled epithelial Peri Wound- fragile .Overall Wound Condition- new .Right Upper arm blister medial Measurements- 1.8 x 0.5 x 0cm Tissue type- fluid filled epithelial Peri Wound- fragile .Overall Wound Condition- new .Reclassified sacral wound as unstageable d/t increase in slough and appearance of avascular tissue. Concern as wound continues to deteriorate despite use of IV meropenem and levaquin. Pt now experiencing blisters in recurrent areas such as his right trochanter. Pt likely requires advanced imaging and diagnostics to assist in identifying underlying reason for sacral wound deterioration. Notified physician and she agreed pt should be transferred to [named] ER for further evaluation . Review of R106 Skin Care Plan, dated 8/1/24, reflected interventions that included, Assist resident with turning and repositioning per facility protocol and PRN. Resident utilizes pillows and wedges to assist with offloading boney prominence .Preventative treatment(s) per orders . Provide incontinence care as needed .Provide incontinence care as needed . Review of R106 Treatment Administration Record, dated 2/1/25 through 3/31/25, reflected R106 had 20 missed wound treatments, as evidenced by no documentation as completed, for facility acquired pressure wounds. Continued review of the TAR reflected Provider order for twice daily wound care to R106 Coccyx wound was completed daily (seven missed treatments). Review of R106 facility, Documentation Survey Report v2(Task Report), dated 2/1/25 through 3/31/25, reflected R106 had task, Assist/Remind to Turn and Reposition per Care Plan and PRN. The Report reflected R106 had 42 eight-hour shifts that R106 was not turned and repositioned, as evidenced by no documentation as completed. Resident #111(R111) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R111 was a [AGE] year-old female admitted to the facility on [DATE], with re-admission 4/5/25 related to wound infection with other diagnoses that included non-traumatic brain dysfunction, heart failure, and seizure disorder. The MDS reflected R111 was dependent on staff for all care. Continued review of the MDS reflected R111 had one unstageable pressure wound related to slough in wound bed and one unstageable pressure wound related to suspected deep tissue injury both on admission. During an observation on 4/9/25 at 3:15 p.m., Registered Nurse (RN) C entered R111 room with dressing supplies to complete wound care treatment. R111 was laying in bed and was nonverbal. CNA staff assisted with positioning. RN C removed old dressing dated 4/8/25 that was saturated over sacral area. R111 had large sacral wound the size of small football with about 50 % slough in base of wound. RN C cleaned would bed with normal saline and gauze, ointment, then place dry gauze pads loosely under border foam dressing. RN C reported R111 admitted with sacral wound and was recently readmitted to hospital related to osteomyelitis (bone infection). Review of R111 Physician order, dated 4/5/25, reflected, Monitor sacral wound, if saturated/ missing replace every day and night shift for WOUND CARE related to PRESSURE ULCER OF SACRAL REGION Review of R111 Provider Note, dated 2/27/25, reflected, [AGE] year old seen today for new admission. She is currently resting in bed. She was admitted to the hospital secondary to cardiac arrest .Her neurological status did not improve and neurology was consulted, EEG[brain activity scan] showed no seizure and did show diffuse encephalopathy. MRI[soft tissue scan] brain showed anoxic brain injury pattern. She had trach and peg placed on 2/11. She was also treated for Klebsiella UTI and moraxella and MSSA[type of bacteria] pneumonia and she did complete course of antibiotics. She then continued to have fevers and ID[infectious disease] rec to continue with Cefazolin for 14 days as repeat respiratory culture showed MSSA. She has picc line in place . Review of R111 Nursing Evaluation Summary, dated 2/27/25, reflected, Skin assessment completed and open areas to coccyx and right gluteal fold noted as well as DTI[deep tissue injury] to right heel, no other skin issues noted. Review of R111 Wound Notes, dated 2/27/25 through -----, reflected the following: 2/27/25-Coccyx-3.69 x 1.48 cm 3/4/25--Coccyx unstageable PU-3.6 x 3.7 unable to determine depth related to slough. -Right ischium stage 2 pressure-0.6 x 0.5 x 0.1 cm -Right heel deep tissue injury-1.4 x 1 x 0 cm 3/18/25-Coccyx unstageable PU-9.7 x 7.2 x unable to determine related to slough/dark non- granulation. Note, Caregiver staff to provide frequent turning and repositioning to offload wounds. -Right heel deep tissue injury-1.1 x 1.2 x 0cm 3/25/25-Coccyx unstageable PU-11.9 x 8.9 x unable to determine depth related to slough, deterioration. -Right heel-1.1 x 1 x 0 Continue review of wound note, dated 3/25/25, reflected, Ordered 2 V xray of sacral wound d/t continued acute deterioration AEB[as evidenced by] increase in size, significant odor, and delayed healing. Ordered metrogel applied to wound followed by dakins gauze. Later during documentation reviewed xray results showing suspicion for osteomyelitis. Discussed results with physician and authorized transfer to [NAME] ER for advanced imagining, culturing, abx [antibiotic]selection, and debridement of wound. DON notified. Called facility and notified nursing of findings and requested pt be sent to [NAME] ER along with xray results . Review of R111 Provider Progress Note, dated 4/7/25, reflected, Chief Complaint / Nature of Presenting Problem: Re admission, osteomyelitis History Of Present Illness:[AGE] year old seen today for re admission she was in the hospital secondary to osteomyelitis. There is no discharge summary at this time. Reviewed progress notes in [named EMR] and she was admitted to the hospital with concern for worsening decubitus ulcer, she had CT scan that showed coccygeal soft tissue ulceration . worrisome for osteomyelitis. She was placed on IV antibiotics and ID was consulted. Review of R111 Hospital Infectious Disease Consult, dated 4/2/25, revealed diagnosis that included osteomyelitis of scrum and coccyx, stage 4 pressure ulcer and sepsis. Review of R111 Treatment Administration Record, dated 3/1/25 through 3/25/25, reflected R111 had 4 missed wound treatments, as evidenced by no documentation as completed, for worsening coccyx pressure wound. Review of R111 facility, Documentation Survey Report v2(Task Report), dated 3/1/25 through 3/25/25, reflected R111 had task, Assist/Remind to Turn and Reposition per Care Plan and PRN. The Report reflected R111 had 23 eight-hour shifts that R111 was not turned and repositioned, as evidenced by no documentation as completed. Resident #105(R105) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R105 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included cerebral vascular accident with current comatose state, acute respiratory failure with anoxic brain damage with tracheostomy, Pulmonary embolism, diabetes mellitus, hypertension, and one stage 2 pressure ulcers present on admission and one unstageable pressure ulcer not present on admission. The MDS reflected R105 was dependent on staff for all care. Continued review of the MDS, dated [DATE], reflected R105 had one new unstageable pressure wound not present on admission (12/24/24). During a telephone interview on 4/9/25 at 9:32 a.m., R105 family I reported R105 admitted to facility 10/30/24 with an open area on coccyx area and on left side. R105 family I reported R105 coccyx area was almost healed, and staff stopped repositioning R105 and wound gradually worsened and R105 developed new skin breakdown on right side at the facility. R105 family I reported R105 was readmitted several times to the hospital for repeat wound infections, last time on 3/26/25 and stated, tired of it, she had been through enough. R105 family reported spoke with management several times with concerns that R105 was not being turned and repositioned every two hours and they hung a turning log on wall over R105 bed that staff were instructed to document every time R105 was turned. R105 family member reported log was incomplete and still in R105 room. During an observation and record review on 3/9/25 at 9:40 a.m., R105 name was posted outside room door and turning log document was hanging on the wall above the head of the bed. The log reflected, Resident needs to be turned q2[every two] hours and PRN [as needed]. Continued review of the log reflected first entry 3/13/25 at 6:40 p.m. with L circled that indicated turn direction with a total of six entries including last, dated 3/16/25, for four days. (If R105 was turned every two hours, should be 12 entries each day on log for a total of 156 entries between 3/13/25 and 3/26/25). Review of R105 Electronic Medical Record (EMR), dated 10/30/24 through 3/26/25, reflected R105 admitted to facility 10/30/24 and transferred to hospital 12/10/24 and return 12/24/24. Continued review of the EMR reflected R105 was transferred to the hospital on 1/28/25 and returned to facility 2/21/25. Continued review of the EMR reflected R105 readmitted back to the hospital on 3/26/25 and had not returned to the facility. Review of R105 Provider Progress Note, dated 10/31/24, reflected, History Of Present Illness: [AGE] year old seen today for new admission. She is currently resting in bed and her husband is at bedside. She had PEA [pulseless electrical activity] arrest and CT [computed tomography scan] chest which showed PE [pulmonary embolism] with moderate clot burden and multifocal consolidation and groundglass disease. She was seen by IR [interventional radiology] and had thrombectomy. CT showed cerebral ischemia. Per notes brainstem reflexes intact but not definite sign of higher function. She was seen by neurology. She was treated for UTI [urinary tract infection]. Urine culture showed e faecium and respiratory cultures showed pseudomonas. She does have trach in place and peg tube. Her husband tells me before she was hospitalized with her blood clots she was pretty healthy. Review of R105 Pertinent Charting-Skin Progress Note, dated 10/31/24 at 8:31 a.m., reflected, Event Date: 10/30/24 Location of skin area being documented: coccyx and left rear thigh Description: pressure ulcers .Physician notification: Resident admitted to facility with wounds, Provider aware. Review of R105 Social Services Progress Note, dated 11/4/24, reflected, IDT [interdisciplinary team] met with res and husband for initial CC [care conference] .Expressed concerns about preventing pressure wounds. Nursing explained res is on a schedule for repositioning . Review of R105 Provider Wound Notes, dated 11/5/24 through 12/3/24, reflected the following: 11/5/24-Coccyx stage 3 pressure-5.5 x 3.9. 0.2 cm -Left rear thigh stage 2 pressure with no measurements noted. Wound Additional Orders-Caregiver staff to provide frequent turning and repositioning to offload wounds. 11/12/24-Coccyx stage 3 pressure-1.4 x 1.7 x 0.2 cm -Left rear thigh stage 2 pressure-RESOLVED. 11/26/24-Coccyx stage 3 pressure-0.6 x 0.4 x 0 cm 12/3/24-Coccyx stage 3 pressure-1.11 x 0.94 cm Review of Provider Note, dated 12/10/24, reflected, This is an acute new problem Condition is guarded 47yo[year old] female with respiratory failure, anoxic brain damage, HTN[hypertension] who has a BP[blood pressure] of 87/53 with a HR[heart rate] of 118 and now desaturating down to 88% on 2L[liters]. She is grey appearing, tachypneic. Orders : Transfer to Emergency Department . Review of R105 Hospital Discharge documentation, dated 12/24/24, reflected R105 had discharge diagnosis that included, severe sepsis, pyelonephritis, pneunomonitis, and decubitus ulcers. Review of R105 Provider Progress Note, dated 12/30/24, reflected, patient with new pressure ulcers on R[right] & L[left] buttocks. L buttocks [NAME] areas of blistering, no drainage, R buttocks is an area of redness, no open wound .Physical Exam - Notes : SKIN stage 1 pressure ulcer R buttocks, stage 2 pressure ulcer L buttocks .Pressure ulcer of left buttock, stage 1 This is an acute new problem Condition is stable cover with xeroform, change daily wound care consultL89312 - Pressure ulcer of right buttock, stage 2 (Primary) This is an acute new problem Condition is stable cover with xeroform, change daily wound care consult . Review of R105 Wound Notes, dated 12/24/24 through 1/28/25, reflected the following: 12/24/24-Coccyx stage 3 pressure-6.57 x 7.92 cm(no mention of other wounds) 12/30/24-Coccyx stage 3 pressure-9.07 x 5.58 cm (worsened) 12/31/24-Coccyx stage 3 pressure-7.9 x 8 x 0.2 cm -Right gluteus blister-4 x 5.9 x 0.1 cm, non-viable dark epithelial (New Facility acquired) 1/7/25-Coccyx stage 3 pressure-9.1 x 5.7 x 0.3 cm(Worsened) -Right gluteus blister -4.8 x 3.6 x 0.2 cm (Facility acquired) 1/14/25-Coccyx stage 3 pressure-8.6 x 4.5 x 0.3 cm -Right gluteus blister-3.2 x 1.8 x 0.2 cm (Facility acquired) 1/21/25-Coccyx stage 3 pressure-7.9 x 4.6 cm, overall wound condition deterioration. -Right gluteus blister-2.7 x 1.2 cm (Facility acquired) 1/28/25-Coccyx stage 3 pressure-7.4 x 4.1 cm -Right gluteus blister-3.1 x 1.8 cm (Facility acquired) Review of R105 provider note, dated 1/28/25, reflected, .Called husband to request consent for conservative sharps debridement of wounds. Husband requested pt be sent to [named] ER [emergency room ] for further evaluation of wounds and debridement in hospital as he is currently unwilling to allow debridement within facility. Facility leadership and nurse notified and pt[patient] transferred to [named] ER . Review of R105 Hospital Discharge Summary, dated 2/20/25, reflected, Patient is a [AGE] year-old female who presented to [named hospital] with worsening sacral ulcer .admitted to medicine for sacral ulceration, abdominal abscess .SURGERY Consulted, S/p Bedside Debridement Sacral ulceration 1/30/2025-RECOMMEND Continue DAILY wound care at Discharge. RECOMMEND Continue frequent repositioning. RECOMMEND CLOSE Follow up SURGERY/Wound Clinic at discharge if Able . Review of R105 Nurse Progress Note, dated 2/23/25, reflected, Resident returned from Hospital with left upper arm midline /IV ATB therapy(meropenem) for bacterial infection to be continued until 2/28/25. Review of R105 History and Physical, dated 3/1/25, reflected, She is being seen for readmission to facility after hospitalization at [named]. She presented to the ED with worsening sacral ulcer and fever .Surgery was performed on bedside debridement of the sacral ulcer on 1/30/25. She will need ongoing daily wound care and follow up with the [named] wound clinic .Abscess of abdominal cavity . Review of R105 Wound Notes, dated 3/4/25 through---, reflected the following: 3/4/25-Sacrum pressure-7.1 x 6.4 x unable to determine true depth. -Right gluteus blister-2 x 1 x unable to determine true depth. (Facility acquired) 3/11/25-Sacrum pressure-6.7 x 3.8 x unable to determine true depth, Tissue type slough -Right gluteus blister-3 x 1.7, Tissue type slough/crusting (Facility acquired) 3/18/25-Sacrum pressure-7.7 x 3.8 x unable to determine true depth, Tissue type: slough. -Right gluteus unstageable pressure-2.8 x 1.2 x unable to determine true depth, slough. (Worsening and Facility acquired) 3/25/25-Sacram pressure-6.4 x 5.8 x unable to determine true depth, slough -Right gluteus unstageable pressure-0.6 x 0.5, unable to determine true depth, slough. (Worsening and Facility acquired) Review of R105 Skin Care Plan, dated 10/30/24, reflected, Resident has impaired skin integrity as evidenced by: Unstageable pressure wound to sacrum, Unstageable pressure injury to rear right thigh related to immobility, anoxic brain damage, respiratory failure, tube feed status .Revision on: 03/20/2025. Continued review reflected interventions that included, Administer treatment(s) per orders .Assist resident with turning and repositioning as needed . Review of R105 Nurse Progress Note, dated 3/26/25, reflected, Res[resident] was having appt with wound clinic. Doctor sent her to [named] ER d/t[related to] worse than anticipated infection to the wounds . Review of R105 Treatment Administration Record, dated 12/1/24 through 3/26/25, reflected R105 had 21 missed wound treatments, as evidenced by no documentation as completed, for coccyx wound and facility acquired right gluteus pressure wound. Continued review of the TAR reflected documentation indicating to see Progress Notes with no evidence of Progress Notes completed on correlating dates. Review of R105 facility, Documentation Survey Report v2(Task Report), dated 1/1/25 through 3/26/25, reflected R105 had task, Assist/Remind to Turn and Reposition per Care Plan and PRN. The Report reflected R105 had 37 eight-hour shifts that was not turned and repositioned, as evidenced by no documentation as completed. During an interview on 4/10/25 at 2:15 p.m., Unit Manager (UM) G reported wounds were assessed every seven days wound team that included wound nurse and wound provider. UM G reported would expect floor nurses to follow Physician treatment orders and document on Treatment Administration Record (TAR) as completed. UM G reported would expect Certified Nurse Aids (CNA) staff to turn and reposition residents every two hours if indicated on the Care Plans and document in the Task documentation (CNA Point of Care Electronic Medical Record). UM G reported the TAR and the Task documentation should not have wholes (no documentation as completed). UM G reported would follow up. Requested UM G for evidence that R106 facility acquired pressure wound was unavoidable. During a telephone interview on 4/10/25 at 4:20 p.m., Wound Nurse (WN) J reported R105 had small coccyx wound on admission that worsened and was later documented as Sacrum wound. WN G reported R105 developed facility acquired pressure ulcer to right gluteus that started blister and was later reclassified to unstageable because of slough in base of wound. WN G reported R105 Coccyx wound was documented as stage 3 pressure wound on admission related to hospital documentation with prior history and verified was small on admission with 0.2 cm depth. During a second interview on 4/10/25 at 4:40 p.m., UM J reported it was discovered recently Wound Nurse (WN) G was not documenting wound treatments as completed on TAR on Tuesdays. UM J verified R105, R106 and R111 had holes on TAR and reported some were documented in progress notes as treatments in place and not on TAR and was unsure why and verified should be documented on TAR as completed with no holes, which reflect missed treatments. UM G reported facility has had issue with staffing for past few months and recent improvements in past two weeks. UM G reported had worked the floor several times in past 2 months to fill in for call-ins with long shifts. UM G reported had also worked as CNA staff to make sure facility has at least three CNA staff in facility. During a second telephone interview on 4/10/25 at 4:58 p.m., WN G reported R105 was unable to locate evidence R105, R106 or R111 worsening pressure ulcers and facility acquired pressure ulcers were unavoidable and reported appropriate interventions were on the Care Plans and staff were expected to follow Care Plans and physician orders. WN G verified R105, R106 and R111 were all at high risk for skin breakdown. WN G reported last week had noticed that wound rounds were not documented as completed on TAR and verified if nurses complete treatment orders should document on TAR as completed. WN G reported facility had staffing issues past couple months with recent improvements. WN G reported facility had several residents that required every two hour turn and repositioning assistance with times with only three CNA staff in entire facility and reported was not possible turn residents every 2 hours.

This citation pertains to intake MI00151358, MI00150638 and MI00151852. Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL's), including bathing/showering for four dependent resident (R103, R104, R106, and R110) reviewed of ADL care, resulting in increased worsening of pressure wounds and likelihood of feelings of worthlessness, disrespect and the potential for infection. Findings include: Review of three complaints received by the State Agency alleged the facility failed to assist and/or provide residents with ADL care including showering, oral care and grooming. Resident #106(R106) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R106 was a [AGE] year-old male admitted to the facility on [DATE], with re-admission 3/13/25 related to wound infection with other diagnoses that included traumatic brain dysfunction, cerebral vascular accident, acute respiratory failure with anoxic brain damage with tracheostomy, contracture of left knee and right knee. The MDS reflected R106 was dependent on staff for all care. Continued review reflected R106 had been discharged to hospital 4/1/25. Review of R106 Documentation Survey Report(Task Report), dated 2/1/25 through 3/31/25, reflected R106 had five missed showers, as evidenced by no documentation as completed. Continued review reflected 51 shifts with no oral care provided as evidenced by no documentation or documentation that oral care was not provided. Continued review reflected R106 had task, Assist/Remind to Turn and Reposition per Care Plan and PRN[as needed]. The Report reflected R106 had 42 eight-hour shifts that R106 was not turned and repositioned, as evidenced by no documentation as completed. Resident #103(R103) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R103 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included cerebral vascular infarction, vascular dementia, mild neurocognitive disorder, and depression. The MDS reflected R103 required partial to moderate assist with showering and dressing. Continued review of R103 MDS reflected resident had dentures and had been discharge from facility 3/24/25. Review of R103 Documentation Survey Report (Task Report), dated 3/17/25 through 3/24/25, reflected R103 had one missed showers, as evidenced by no documentation as completed, with no shower for five days and was present at facility for a total of seven days. Continued review reflected five shifts with no oral care provided as evidenced by no documentation or documentation that oral care was not provided. Review of R103 Care Plan, dated 3/17/25, reflected no mention of R103's dentures including ADL assist for oral care. Resident #104 (R104) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included cerebral vascular infarction with partial paralysis. The MDS reflected R104 required partial to moderate assist with showering and had been discharged from the facility 3/27/25. Review of R104 Documentation Survey Report(Task Report), dated 2/24/25 through 3/27/25, reflected R104 had five missed showers, as evidenced by no documentation as completed. Resident #110 (R110) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R110 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included traumatic spinal cord injury with partial paralysis, anxiety and depression. The MDS reflected R110 was dependent on staff for care including with showering. During an interview on 4/8/25 at 4:19 p.m., R110 was laying in bed and appeared calm and pleasant and able to answer questions without difficulty. R110 reported had missed several showers in past three months and believed it was related to not enough staff to meet residents needs. R110 reported on several evening shifts over past three months there was only three to four Certified Nurse Aid in the entire facility that included ventilator unit. R110 reported had completed several facility grievances related to staffing concerns and missed showers and reported past two weeks have seen slight improvement. Review of R110 Documentation Survey Report(Task Report), dated 1/1/25 through 3/31/25, reflected R110 had nine missed showers, as evidenced by no documentation as completed, including time frame of 20 days without showering or bathing care. Review of facility Grievance Forms, dated 1/1/25 through current, reflected several reported concerns with missed showers, staffing and linen changes. During a telephone interview on 4/9/25 at 8:26 a.m., Ombudsman L reported had received several complaints from residents and families related staffing concerns because care needs were not being met. During an interview on 4/9/25 at 11:15 a.m., Registered Nurse Manager (RN) L reported had taken over staff scheduling in past two weeks after prior facility scheduler left. RN L reported staffing had been difficult for past two months with prior scheduler issues, frequent call in's, terminations, and open shifts. RN L reported managers had been picking up shifts to meet minimum staffing requirements. During a telephone interview on 4/9/25 at 12:26 p.m., Certified Nurse Aid (CNA) D reported staffing had been an issue at facility for past two to three months with recent improvements over past two weeks since new scheduler. CNA D reported several complaints form residents about missed showers. CNA D reported often worked day shift and reported often arrived to shift with at least three residents who required full bed changes related to being saturated in urine at least five days per week for last month. CNA D reported often only three CNA staff scheduled on night shift and did not feel resident needs were being met related to not enough staff and reported had reported to management and completed concern form with no changes until last two weeks. During a telephone interview on 4/9/25 at 4:05 p.m., Confidential Staff (CS) M reported facility has had staffing issue for past three months. CS M reported resident basic needs were not being met including incontinence care, turn/reposition, showers, oral care and range of motion. CS M reported over past three months second and third shift had been the worse with only enough time to complete incontinence care and repositioning for dependant residents two times per shift and should be every two hour with minimal assist from nurse staff. CS M reported restorative staff pulled to floor for resident care five of five days per week for past couple months. During an interview on 4/10/25 at 2:15 p.m, Unit Manager G reported would expect CNA staff follow Kardex including every two hour incontinence care, repositioning and showers as scheduled and document in Tasks and verified should not be holes on Tasks with no documentation. During an interview on 4/10/25 at 5:50 p.m., Unit Manager G reported there was 32 of 69 residents in facility that required two person assist with care.

This citation pertains to intakes: MI00151418, MI00151694, MI00151358, MI00150699, MI00150638, MI00151442, and MI00151852. Based on observation, interview and record review, the facility failed to ensure sufficient levels of nursing staff to meet resident needs and supervision for seven residents (Resident R102, R103, R104, R105, R106, R110 and R111) and per resident council with the potential for unmet care needs and facility residents to not attain or maintain the highest practicable physical, mental, and psychosocial well-being. Finding include: During an interview on 4/8/25 at 10:55 a.m., Admission Staff N reported facility census was 69 and Director of Nursing B and Nursing Home Administrator A were not currently in the facility. Review of seven complaints received by the State Agency alleged the facility failed to maintain sufficient staff levels to meet resident needs including prevent worsening of pressure ulcers and prevent avoidable fall with injury. Review of the Centers for Medicare and Medicaid Services PBJ Staffing Report for first quarter reflected the facility triggered for excessively low weekend staffing. Resident #102(R102) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R102 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included left hip fracture post fall at home, current post care for left hip surgical revision post fall with fracture and infection requiring intravenous antibiotics via central line catheter, peripheral vascular disease, hypertension (high blood pressure), diabetes mellitus, and anemia. The MDS reflected R102 had a BIM (assessment tool) score of 12 which indicated his ability to make daily decisions was moderately impaired, and he required substantial to maximum assist with transfers. Review of the complaint received by the State Agency alleged the facility failed to prevent an avoidable fall for R102, who was known high risk for fall, that resulted in rib fractures on 12/14/24. During an interview on 4/9/25 at 10:29 a.m., RN C reported had just arrived for day shift on 12/14/24 around 6:00 a.m. when R102 fell out of bed and was unable to recall if R102 floor mat was in place or where bed was position at time of the fall. RN C reported the positioning wedges were NOT in place and should have been. RN C reported R102 did not complain of pain initially and Hoyer was used to place R102 back in bed and then complained of left hip pain. RN C reported notified required staff and family and reported R102 wife remained at the bedside through day and night related to R102 confusion and concerns for safety. RN C reported was not able to provide R102 one on one care as needed related to increased confusion. RN C reported spend additional time with family and R102 for safety concerns and still have other residents needs that needed to be met on highly skilled ventilator unit. Review of R102 Hospital CT(computed to-mography) of the chest/abdomen/pelvic, dated 12/15/24, reflected, .FINDINGS .Nondisplaced fracture of the right third anterior rib, and possibly fourth rib especially identified . Resident #105(R105) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R105 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included cerebral vascular accident with current comatose state, acute respiratory failure with anoxic brain damage with tracheostomy, Pulmonary embolism, diabetes mellitus, hypertension, and one stage 2 pressure ulcers present on admission and one unstageable pressure ulcer not present on admission. The MDS reflected R105 was dependent on staff for all care. Continued review of the MDS, dated [DATE], reflected R105 had one new unstageable pressure wound not present on admission (12/24/24). During a telephone interview on 4/9/25 at 9:32 a.m., R105 family I reported R105 admitted to facility 10/30/24 with an open area on coccyx area and on left side. R105 family I reported R105 coccyx area was almost healed, and staff stopped repositioning R105 and wound gradually worsened and R105 developed new skin breakdown on right side at the facility. R105 family I reported R105 was readmitted several times to the hospital for repeat wound infections, last time on 3/26/25 and stated, tired of it, she had been through enough. R105 family reported spoke with management several times with concerns that R105 was not being turned and repositioned every two hours and they hung a turning log on wall over R105 bed that staff were instructed to document every time R105 was turned. R105 family member reported log was incomplete and still in R105 room. Review of R105 Treatment Administration Record, dated 12/1/24 through 3/26/25, reflected R105 had 21 missed wound treatments, as evidenced by no documentation as completed, for coccyx wound and facility acquired right gluteus pressure wound. Continued review of the TAR reflected documentation indicating to see Progress Notes with no evidence of Progress Notes completed on correlating dates. Review of R105 facility, Documentation Survey Report v2(Task Report), dated 1/1/25 through 3/26/25, reflected R105 had task, Assist/Remind to Turn and Reposition per Care Plan and PRN. The Report reflected R105 had 37 eight-hour shifts that was not turned and repositioned, as evidenced by no documentation as completed. Resident #106(R106) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R106 was a [AGE] year-old male admitted to the facility on [DATE], with re-admission 3/13/25 related to wound infection with other diagnoses that included traumatic brain dysfunction, cerebral vascular accident, acute respiratory failure with anoxic brain damage with tracheostomy, contracture of left knee and right knee. The MDS reflected R106 was dependent on staff for all care. Continued review reflected R106 had been discharged to hospital 4/1/25. Review of R106 Electronic Medical Record, dated 10/1/24 through 4/1/25, reflected R106 had three facility acquired pressure wounds that worsened including stage 4 pressure ulcer(full thickness tissue loss with exposed bone and/or tendon). Review of R106 Documentation Survey Report(Task Report), dated 2/1/25 through 3/31/25, reflected R106 had five missed showers, evidenced by no documentation as completed. Continued review reflected 51 shifts with no oral care provided as evidenced by no documentation or documentation that oral care was not provided. Continued review reflected R106 had task, Assist/Remind to Turn and Reposition per Care Plan and PRN. The Report reflected R106 had 42 eight-hour shifts that R106 was not turned and repositioned, as evidenced by no documentation as completed. Resident #111(R111) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R111 was a [AGE] year-old female admitted to the facility on [DATE], with re-admission 4/5/25 related to wound infection with other diagnoses that included non-traumatic brain dysfunction, heart failure, and seizure disorder. The MDS reflected R111 was dependent on staff for all care. Continued review of the MDS reflected R111 had one unstageable pressure wound related to slough in wound bed and one unstageable pressure wound related to suspected deep tissue injury both on admission. Review of R111 EMR, dated 2/26/25 through 4/10/25, reflected R111 was admitted with unstageable pressure ulcer that worsened to stage 4 pressure wound that required hospitalization and surgical intervention for osteomyelitis. Review of R111 Hospital Infectious Disease Consult, dated 4/2/25, revealed diagnosis that included osteomyelitis of scrum and coccyx, stage 4 pressure ulcer and sepsis. Review of R111 Treatment Administration Record, dated 3/1/25 through 3/25/25, reflected R111 had 4 missed wound treatments, as evidenced by no documentation as completed, for worsening coccyx pressure wound. Review of R111 facility, Documentation Survey Report v2(Task Report), dated 3/1/25 through 3/25/25, reflected R111 had task, Assist/Remind to Turn and Reposition per Care Plan and PRN. The Report reflected R111 had 23 eight-hour shifts that R111 was not turned and repositioned, as evidenced by no documentation as completed. Resident #103(R103) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R103 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included cerebral vascular infarction, vascular dementia, mild neurocognitive disorder, and depression. The MDS reflected R103 required partial to moderate assist with showering and dressing. Continued review of R103 MDS reflected resident had dentures and had been discharge from facility 3/24/25. Review of R103 Documentation Survey Report(Task Report), dated 3/17/25 through 3/24/25, reflected R103 had one missed showers, as evidenced by no documentation as completed, with no shower for five days and was present at facility for a total of seven days. Continued review reflected five shifts with no oral care provided as evidenced by no documentation or documentation that oral care was not provided. Review of R103 Care Plan, dated 3/17/25, reflected no mention of R103's dentures including ADL assist for oral care. Resident #104(R104) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included cerebral vascular infarction with partial paralysis. The MDS reflected R104 required partial to moderate assist with showering and had been discharged from the facility 3/27/25. Review of R104 Documentation Survey Report (Task Report), dated 2/24/25 through 3/27/25, reflected R104 had five missed showers, as evidenced by no documentation as completed. Resident #110(R110) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R110 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included traumatic spinal cord injury with partial paralysis, anxiety and depression. The MDS reflected R110 was dependent on staff for care including with showering. During an interview on 4/8/25 at 4:19 p.m., R110 was laying in bed and appeared calm and pleasant and able to answer questions without difficulty. R110 reported had missed several showers in past three months and believed it was related to not enough staff to meet residents needs. R110 reported on several evening shifts over past three months there was only three to four Certified Nurse Aid in the entire facility that included ventilator unit. R110 reported had completed several facility grievances related to staffing concerns and missed showers and reported past two weeks have seen slight improvement. Review of R110 Documentation Survey Report(Task Report), dated 1/1/25 through 3/31/25, reflected R110 had nine missed showers, as evidenced by no documentation as completed, including time frame of 20 days without showering or bathing care. Review of facility Grievance Forms and Resident Council, dated 1/1/25 through 4/8/25, reflected several reported concerns with missed showers and staffing concerns. Review of the facility staffing working schedules for past three months reflected several with three to four CNA staff on second and third shift. According to facility assessment the average facility census was 64 with ventilator unit. The facility assessment reflected 41% of residents were dependant on staff for care. During a telephone interview on 4/9/25 at 8:26 a.m., Ombudsman L reported had received several complaints from residents and families related to staffing concerns because care needs were not being met. During an interview on 4/9/25 at 11:15 a.m., Registered Nurse Manager (RN) L reported had taken over staff scheduling in past two weeks after prior facility scheduler left. RN L reported staffing had been difficult for past two months with prior scheduler issues, frequent call in's, terminations, and open shifts. RN L reported managers had been picking up shifts to meet minimum staffing requirements. During a telephone interview on 4/9/25 at 12:26 p.m., Certified Nurse Aid (CNA) D reported staffing had been an issue at facility for past two to three months with recent improvements over past two weeks since new scheduler. CNA D reported several complaints form residents about missed showers. CNA D reported often worked day shift and reported often arrived to shift with at least three residents who required full bed changes related to being saturated in urine at least five days per week for last month. CNA D reported often only three CNA staff scheduled on night shift and did not feel resident needs were being met related to not enough staff and reported had reported to management and completed concern form with no changes until last two weeks. During a telephone interview on 4/9/25 at 4:05 p.m., Confidential Staff (CS) M reported facility has had staffing issue for past three months. CS M reported resident basic needs were not being met including incontinence care, turn/reposition, showers, oral care and range of motion. CS M reported over past three months second and third shift had been the worse with only enough time to complete incontinence care and repositioning for dependant residents two times per shift and should be every two hour with minimal assist from nurse staff. CS M reported restorative staff pulled to floor for resident care five of five days per week for past couple months. During an interview on 4/10/25 at 2:15 p.m, Unit Manager G reported would expect CNA staff follow Kardex including every two hour incontinence care, repositioning and showers as scheduled and document in Tasks and verified should not be holes on Tasks with no documentation. During an interview on 4/10/25 at 5:50 p.m., Unit Manager G reported there was 32 of 69 residents in facility that required two person assist with care.

This citation refers to intake MI00151694 and MI00150699. Based on interview and record review, the facility failed to provide adequate supervision for resident with known high risk for falls and implement care planned interventions to prevent fall injuries for 1 residents (R102) out of 3 residents reviewed for falls, resulting in R102 fall with injury requiring emergency room treatment and hospital admission. Findings included: Resident #102(R102) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R102 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included left hip fracture post fall at home, current post care for left hip surgical revision post fall with fracture and infection requiring intravenous antibiotics via central line catheter, peripheral vascular disease, hypertension (high blood pressure), diabetes mellitus, and anemia. The MDS reflected R102 had a BIM (assessment tool) score of 12 which indicated his ability to make daily decisions was moderately impaired, and he required substantial to maximum assist with transfers. Review of the complaint received by the State Agency alleged the facility failed to prevent an avoidable fall for R102, who was known high risk for fall, that resulted in rib fractures on 12/14/24. Review of R102 Progress Notes dated 12/11/24, reflected, .Fall precautions per facility policy. Condition is guarded .History of Present Illness .Patient was admitted to the facility today and is awaiting full H&P[history and physical] and review by the primary team. The nurse consulted (name of) Health to assess the patient, to review discharge medications and orders and to ensure safe transition of care. Review of available paperwork and consultation with patient/nurse was completed to identify and manage high risk conditions and medications while awaiting evaluation by primary team. Per discharge docs: discharge dx L [diagnosis left] hip fracture. Patient is an [AGE] year-old male who presents as a level 3 trauma after a unwitnessed fall. Patient had just got out of [named] when he fell . During his last hospital admission he was found to have bacteremia and he was started on IV [intravenous] ampicillin. He was discharged was given oral antibiotics and then presented to our emergency department. Patient was found to have postoperative changes the left total hip arthroplasty with commuted displaced periprosthetic fracture of the proximal femur with suspicion for infected periprosthetic joint in the left hip, he was also found to have L5[lumbar5] vertebral body stature loss and on initial evaluation was retaining urine. Orthopedics was consulted for the left hip periprosthetic fracture. They repaired the fracture and replaced with a new periprosthetic. Infectious disease was consulted due to bacteremia on last hospital visit and concern for infected periprosthetic they recommended IV ampicillin and was found to actually have positive cultures from the OR that were positive for MRSA [Methicillin-resistant Staphylococcus aureus]. He was then placed on daptomycin IV while in the hospital. Infectious disease recommends oral antibiotic . Neurosurgery was consulted for L 5 vertebral body stature loss/fracture they recommended LSO when out of bed and activity. If able to tolerate PT/OT [physical therapy/occupational therapy] with brace will follow-up outpatient with neurosurgery. Urology was consulted due to concern for possible bladder outlet obstruction. They recommended maintaining Foley for 5 to 7 days after ambulatory and continuing Flomax. and to follow-up outpatient. Patient was taken to the operating room for irrigation and excisional debridement of left anterior hip wound with revision of left hip hemiarthroplasty prosthesis to a new prosthesis and ORIF [open reduction and internal fixation] of left periprosthetic proximal femur fracture. Patient required preoperative blood transfusions due to low hemoglobin. Patient tolerated the procedure well and was tolerating diet, was urinating and adequately with Foley, and worked with physical therapy. Physical therapy recommended PA CR [medical professionals] . Review of R102 Progress Note, dated 12/14/24 at 7:31 a.m., reflected, Date of Service: 12/14/2024 6:08 AM CT Details: Nurse Name: [named Registered Nurse (RN) C] Patient Name: [named R102] Primary Chief Complaint: Fall With Injury History Present Illness: patient has a recent left hip surgery. He had unwitnessed fall. Currently complains of left hip pain and his leg is externally rotated. On prophylactic heparin .Diagnosis, Assessment/Plan: M25552 - Pain in left hip (Primary) rule out fracture Condition is stable Orders: obtain x-ray left hip Assess pain per protocol Fall precautions per facility protocol Monitor with neurochecks per facility protocol Notify a clinician of any change in condition Disposition: Stay at Facility . Signed Date: 12/14/2024 6:15 AM Review of R102 Nurse Progress Note, dated 12/14/25 at 7:38 a.m., reflected, Found on the floor sitting, surgical incision bleeding but incision intact, left leg shorter then right and slightly inward, Dr on call [named provider] notified and stat x-ray 4 views ordered, ordered via [named mobile Xray company] Review of R102 Physician Communication Progress note, dated 12/14/24 11:07 a.m., reflected RN C reported R102 had pulled out PICC line in place for antibiotics for osteomyelitis (infection of the bone). Review of R102 Nurse Progress Note, dated 12/14/24 at 3:35 p.m., reflected, CNA [certified nurse aid] reported that res[resident] is sitting on the floor. He was having his both legs underneath him, arms next to him facing door. Per CNA night CNA was telling her how he was restless and not slept last night, he was sitting on the edge of the bed and she placed him to lay in bed shortly before 6am. Res stated he was trying to get to his phone (he doesn't have one). No increased pain to left hip, neuro's WNL [within normal limits]. While laying in bed left leg was looking shorter and slightly inward, not able to move to the side, incision to surgical side intact but bleeding observed to abd pads in place. Stat x-ray 2 views ordered, labs from yesterday evaluated by on call and no n.o[new orders] at this time, our provider to eval on Monday. Later res pull his PICC line and order received to reinsert it to cont IV ABX [antibiotics]. On call, DON [director of nursing] and family notified. New intervention with perimeter mattrasse in place Review of R102 Progress Note, dated 12/15/24 at 2:01 a.m., reflected, Primary Chief Complaint: Radiology review: abnormal results and/or requiring provider assessment . Summary: Nurse reports pt fell yesterday at 0600 c/o pain xray completed, she is reporting results. Xray revealed-intact left hip arthroplasty with ORIF transfixing proximal femur new since 12/3/2024, w/ periprosthetic fracture at base of greater trochanter with modest displacement new since 12/3/24. Please correlate clinically, and f/u is recommended. Nurse states she gave acetaminophen 650mg about 30 minutes ago. Will review imaging further, in the mean time nurse to give acetaminophen and apply ice to the affected area, can call radiology for clarification, pcp f/u on Monday if decide to keep in place Orders : Give an additional acetaminophen 325mg po once now Can apply ice pack to the affected area x15minutes prn as tolerated Contact radiology in the morning for clarification of results Monitor and call for change in condition Add to PCP list for review of imaging on Monday Disposition : Stay at Facility .Signed Date: 12/15/2024 7:23 AM. Addendum Details: *of note regarding initial consult- other than increased restlessness pt was reportedly otherwise stable per nurse assessment. After further review of results recommend transfer to hospital to assess stability of recent left hip arthroplasty. Audio call at 0818, spoke w/ [named nurse], states she is day nurse for pt, gave order regarding ED transfer, she verbalized understanding Orders: Transfer to ED for further evaluation and treatment .Addendum Created Date:2024-12-15 08:32:50 Review of R102 Nurse Progress Notes, dated 12/15/24 at 3:40 a.m., reflected, notified on call [named provider] at 3:06am of x-ray results. Placed information in physician communication book for follow-up. Review of R102 Interdisciplinary Team (IDT)-Interdisciplinary Progress Note, dated 12/17/24, reflected, Late Entry: Note Text: IDT reviewed. Resident admitted to our facility after a fx[fracture] of the hip x2[two times]. His second fx requiring surgical intervention was while hospitalized . Prior to the fall, we initiated wedges and updated the CP in an attempt to prevent a fall. We had also posted signage in the room encouraging the resident to utilize his call light with the permission of his wife. He was on frequent turning per facility protocol. We reached out to our admissions team who obtained an XR[Xray] report from 12/15. This report impression showed no signs of a fracture. The CNA caring for this resident received education on the importance of following the care plan in place. We will continue to educate all staff and residents. Review of R102 Care Plan, dated 12/12/24, reflected R102 was at risk for fall/injury and had interventions that included, low bed .Mat to floor next to bed .Non-skid footwear to reduce the risk of slipping as the resident allows. Date Initiated: 12/13/2024 .Ensure placement of wedges (2) at the R shoulder and R knee when resting in bed. Date Initiated: 12/13/2024 .Non-skid footwear to reduce the risk of slipping as the resident allows. Date Initiated: 12/13/2024 . Review of R102 Fall Incident Report, dated 12/14/24 at 6:25 a.m., reflected R102 had an unwitnessed fall and was found on floor next to bed confused with injury to top of scalp. The report reflected notes that included, wedges ordered to be in place to right site of hip and shoulder were sitting on the night stand of res discovered sitting on the floor. The Report reflected no mention of care planned fall prevention intervention in place at the time of the fall including level of bed, footwear, or floor mat. During an interview on 4/9/25 at 10:29 a.m., RN C reported had just arrived for day shift on 12/14/24 around 6:00 a.m. when R102 fell out of bed and was unable to recall if R102 floor mat was in place or where bed was position at time of the fall. RN C reported the positioning wedges were NOT in place and should have been. RN C reported R102 did not complain of pain initially and Hoyer was used to place R102 back in bed and then complained of left hip pain. RN C reported notified required staff and family and reported R102 wife remained at the bedside through day and night related to R102 confusion and concerns for safety. RN C reported was not able to provide R102 one on one care as needed related to increased confusion. RN C reported spend additional time with family and R102 for safety concerns and still have other residents needs that needed to be met on highly skilled ventilator unit. During a telephone interview on 4/10/25 at 12:26 p.m., Certified Nurse Aid (CNA) D reported worked 12/14/24 day shift when R102 had fall out of bed. CNA D reported was rounding at start of shift and saw R102 on the floor next to bed and called, code purple. CNA D reported R102 laying directly on the floor with no mat in place with pool of blood on floor located by R102 left hip. CNA D reported R102 was very confused and stated was attempting to reach phone because he was in the barn, but did not have a phone. CNA D reported bed was at knee level but not at lowest position and positioning wedges were sitting in chair, not in use at time of fall. CNA D reported was upset because wedges should have been in place in bed to help prevent R102 fall out of bed per the Kardex and were not. CNA C wanted to send R102 to the hospital, but provider ordered Xray. During an interview on 4/9/25 at 3:00 p.m., Assistant Director of Nursing (ADON) E reported would expect staff to follow Care Plans and Kardex including interventions to prevent falls. During an interview on 4/10/25 at 12:18 p.m., Nurse Manager Infection Control (NM) F reported would expect staff to follow Care Plans and have interventions in place including prior to R102 that had high risk for falls. NM F verified R102 Xray completed on 12/14/24 changes since 12/3/24. During an interview on 4/10/25 at 3:06 p.m. R102 family H reported R102 originally fell at home and fractured left hip that required surgical repair 11/17/24, then had an unwitnessed fall with re-fracture of left hip at another facility on 12/3/24 that required surgical repair on 12/6/24. R102 family H reported discussed at length with facility R102 concern about safety and high risk for falls on admission and care meetings prior to R102 fall with rib fractures on 12/14/24 and hospital admission on 12/15/24. R102 family H reported R102 was determined to have new rib fractures and pelvic fractures after additional radiology studies completed at the hospital and additional surgery related to left hip hematoma. R102 family H reported R102 was currently on hospice services and reported was upset and stated, this should not have happened. R102 family H reported after facility notified her that R102 had fallen on 12/14/24 went to facility and remained at bedside because was told staff could not be with R102 all the time and was worried about his safety because of increased confusion and repeat attempts to get up. Review of R102 Hospital CT(computed to-mography) of the chest/abdomen/pelvic, dated 12/15/24, reflected, .FINDINGS .Nondisplaced fracture of the right third anterior rib, and possibly fourth rib especially identified . Review of R102 prior Hospital Records, dated 12/4/24 through 12/11/24, revealed no mention of rib fractures including CT of chest/abdomen/pelvis performed.

This citation pertains to intake number MI00149947. Based on observation, interview, and record review the facility failed to provide for one out of three residents (Resident #7) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds. Findings Included: Per Resident #7's (R7) electronic medical record (EMR) R7 was admitted to the facility on [DATE]. Diagnoses included right and left knee contractures. In an observation, and attempt to interview, on 2/27/2025 at 9:46 AM, R7 was observed in bed. R7 was observed to have contractures to both arms, both hands and fingers, neck, and was not able to communicate. R7's feet/heels were observed to be lying on the mattress with nothing in between R7's feet/heels and the mattress in order to offload the pressure from the mattress. Offloading boots (boots with air in them that prevents heels from touching the bed mattress and relieves pressure of the heels) were noted to be on the floor in front of R7's closet. An approximately 5 x 5 centimeter (cm) circle dark area was observed on the side of R7's left outer foot. During an observation on 2/27/2025 at 10:25 AM, it was observed that R7 had a pressure ulcer located on the left trochanter (left hip bone), and a coccyx pressure ulcer was also observed. The offloading boots were not on R7's feet. On 2/27/2025 at 10:45 AM, Certified Nurse Aid (CNA) C stated that she did not know the schedule for R7's offloading boots, and stated that she could see the boots were on the floor, but did not put them on or off of R7 because she assumed the restorative aids did that. CNA C did not put the boots on R7 prior to leaving R7's room. Record review of R7's care plans revealed R7 was to, To have padded boots (offloading boots) on feet at all times., dated 2/17/2025. In an interview on 2/27/2025 at 10:52 AM, Certified Occupational Therapy Assistant (COTA) D stated that the CNAs were responsible for making sure R7's offloading boots were on him at all times. In an interview on 2/27/2025 at 12:58 PM, Licensed Practical Nurse (LPN) E stated that if R7's offloading boots were documented on his care plan to be on him at all times then, Yes the boots should be on him at all times, and said the CNAs were responsible in ensuring they were on him. In an observation on 2/27/2025 at 1:00 PM, R7 was observed without the offloading boots on, a pillow was between both legs, both of R7's feet, heels, and sides of his feet were observed resting on the mattress. During the 1:00 PM observation CNA F stated she knew R7 had the boots, but said sometimes R7 would wear them and other times he would not. CNA F she did not really know. Record review of a Wound Evaluation dated 2/17/2025 revealed R7 had a picture taken of a darkened area on the outer side of his left foot. The picture revealed a dark circle which was documented to be 3.23 cm x 3.07 cm x 1.46 cm (area, length, width) in measurement. The dark circle was documented to be a hematoma (blood collected under the skin from broken blood vessels due to trauma or injury). Per the Resident Assessment Instrument 3.0 (RAI) manual dated October 2023, version 1.18.11 page M-27, a Deep Tissue Injury (DTI) is identified by a Purple or maroon area of discolored intact skin due to damage of underlying soft tissue . The manual further revealed, Deep tissue injuries may sometimes indicate severe damage. Identification and management of deep tissue injury (DTI) is imperative. The observation of the picture of the side of R7's left foot revealed a DTI and not a hematoma, as there was no documentation of trauma or injury to R7's left foot. Record review of a wound assessment dated [DATE], revealed R7 had a wound to the left trochanter (hip). The wound measured at 27 x 5.7 x 6.1 x <0.1 cm (area, length, width, depth), meaning the wound was an open wound with depth. However, the wound was documented to be a blister. Upon observation of the picture the wound bed was not visible due to eschar (a type of dead tissue that forms a dry, black, or brown covering over wounds) and therefore was unstagable (the wound bed cannot be observed due to being obscured by the dead tissue). Upon reference to the RAI manual on page M-8 the manual revealed, Pressure ulcers that have eschar .tissue present such that the anatomical tissue cannot be visualized or palpated in the wound bed, should be classified as unstagable . Record review of R7's progress notes dated 2/16/2025 revealed, .Left hip appears to beworsening (sic), wound is deeper with increased drainage and borders less taut. Cleansed and dressing changed . Therefore, the wound was not a blister. Review of a Wound Evaluation dated 10/29/2024, revealed R7 had a stage 4 pressure ulcer to his coccyx (butt bone) that was measured to be 0.48 x 1.07 x 0.65 x 0.1 cm. The evaluation revealed the wound was facility acquired (it happened at the facility). Review of another Wound Evaluation dated 2/25/2025, revealed R7's coccyx pressure ulcer measured 11.32 x 4.48 x 3.73 x 0.4 cm, and the bed of the wound was covered with slough (dead tissue that is typically white, yellowish, debris, and remnants of tissue) making the wound bed not visible rendering the wound unstagable. The evaluation revealed the wound was documented to be a stage 4. Per the RAI manual, Pressure ulcers that have slough (yellow, tan, gray, green or brown) .tissue present such that the anatomical tissue cannot be visualized or palpated in the wound bed, should be classified as unstagable . Review of an active care plan dated 8/1/2024 and revised on 2/20/2025 revealed, Resident (R7) is at risk for impaired skin integrity related to Cerebral Hemorrhage, Respiratory Failure, and Contractures. Stage 4 pressure wound to coccyx, Blister to rear left trochanter, hematoma to left lateral foot The care plan had an intervention for R7 to have, .Padded boots on feet at all times, dated 2/17/2025. There were not further updated interventions to the care plan. In an interview on 2/27/2025 at 1:36 PM, Registered Nurse (RN) G. who was the wound nurse, stated R7's left lateral (side) foot was a hematoma which was a blister, discolored tissue. RN G stated she thought maybe it was a DTI. RN G said R7 was to have the boots on his feet at all times, and said the boots were an intervention on R7's care plan. RN G said all staff CNAs and Nursing were supposed to be sure the boots were on R7 at all times, and assure his feet were elevated off the mattress. RN G stated that R7's left trochanter wound should have been documented as an unstagable pressure ulcer and not a blister. RN G further stated that there were no added interventions to R7's care plan for pressure ulcers other than the boots, upon the development of the pressure ulcers. RN G stated that in her opinion she did not know that she would have added any other interventions to R7's care plans, nor could she think of any interventions that should have been added for pressure ulcer preventions and/or treatment. RN G said as far as R7's coccyx pressure ulcer, he must have been left on his back to long. RN G said no root cause analysis, Interdisciplinary Team, care conferences were conducted regarding R7's pressure ulcers in order to determine the cause of R7's skin breakdown. In an interview on 2/27/2025 at 2:15 PM, Director of Nursing (DON) B stated R7 did not tolerate being up in any chair, and stated R7's Kardex (CNA document for providing care) did reveal for the CNAs to have R7's boots on him at all times.

This citation pertains to intake number MI00149947 Based on observation, interview, and record review the facility failed to ensure for one out of seven residents (Resident #7) a comprehensive care plan, including revisions, were in place for prevention and promotion of pressure ulcer healing. Findings Included: Per Resident #7's (R7) electronic medical record (EMR) R7 was admitted to the facility on [DATE]. Diagnoses included right and left knee contractures. In an observation, and attempt to interview, on 2/27/2025 at 9:46 AM, R7 was observed in bed. R7 was observed to have contractures to both arms, both hands and fingers, neck, and was not able to communicate. R7's feet/heels were observed to be lying on the mattress with nothing in between R7's feet/heels and the mattress in order to offload the pressure from the mattress. Offloading boots (boots with air in them that prevents heels from touching the bed mattress and relieves pressure of the heels) were noted to be on the floor in front of R7's closet. An approximately 5 x 5 centimeter (cm) circle dark area was observed on the side of R7's left outer foot. During an observation on 2/27/2025 at 10:25 AM, it was observed that R7 had a pressure ulcer located on the left trochanter (left hip bone), and a coccyx pressure ulcer was also observed. The offloading boots were not on R7's feet. On 2/27/2025 at 10:45 AM, Certified Nurse Aid (CNA) C stated that she did not know the schedule for R7's offloading boots, a stated that she could see the boots where on the floor, but did not put them on or off of R7 because she assumed the restorative aids did that. CNA C did not put the boots on R7 prior to leaving R7's room. Record review of R7's care plans revealed R7 was to, To have padded boots (offloading boots) on feet at all times., dated 2/17/2025. In an interview on 2/27/2025 at 10:52 AM, Certified Occupational Therapy Assistant (COTA) D stated that the CNAs were responsible for making sure R7's offloading boots were on him at all times. In an interview on 2/27/2025 at 12:58 PM, Licensed Practical Nurse (LPN) E stated that if R7's offloading boots were documented on his care plan to be on him at all times then, Yes the boots should be on him at all times, and said the CNAs were responsible in ensuring they were on him. In an observation on 2/27/2025 at 1:00 PM, R7 was observed without the offloading boots on, a pillow was between both legs, but both of R7's feet, heels, and sides of his feet were observed resting on the mattress. During the 1:00 PM observation CNA F stated she knew R7 had the boots, but said sometimes R7 would wear them and other times he would not. CNA F she did not really know. Record review of a Wound Evaluation dated 2/17/2025 revealed R7 had a picture taken of a darkened area on the outer side of his left foot. The picture revealed a dark circle which was documented to be 3.23 cm x 3.07 cm x 1.46 cm (area, length, width) in measurement. The dark circle was documented to be a hematoma (blood collected under the skin from broken blood vessels due to trauma or injury). Per the Resident Assessment Instrument 3.0 (RAI) manual dated October 2023, version 1.18.11 page M-27, a Deep Tissue Injury (DTI) is identified by a Purple or maroon area of discolored intact skin due to damage of underlying soft tissue . The manual further revealed, Deep tissue injuries may sometimes indicate severe damage. Identification and management of deep tissue injury (DTI) is imperative. The observation of the picture of the side of R7's left foot revealed a DTI and not a hematoma, as there was no documentation of trauma or injury to R7's left foot. Record review of a wound assessment dated [DATE], revealed R7 had a wound to the left trochanter (hip). The wound measured at 27 x 5.7 x 6.1 x <0.1 cm (area, length, width, depth), meaning the wound was an open wound with depth. However, the wound was documented to be a blister. Upon observation of the picture the wound bed was not visible due to eschar (a type of dead tissue that forms a dry, black, or brown covering over wounds) and therefore was unstagable (the wound bed cannot be observed due to being obscured by the dead tissue). Upon reference to the RAI manual on page M-8 the manual revealed, Pressure ulcers that have eschar .tissue present such that the anatomical tissue cannot be visualized or palpated in the wound bed, should be classified as unstagable . Record review of R7's progress notes dated 2/16/2025 revealed, .Left hip appears to beworsening (sic), wound is deeper with increased drainage and borders less taut. Cleansed and dressing changed . Therefore, the wound was not a blister. Review of a Wound Evaluation dated 10/29/2024, revealed R7 had a stage 4 pressure ulcer to his coccyx (butt bone) that was measured to be 0.48 x 1.07 x 0.65 x 0.1 cm. The evaluation revealed the wound was facility acquired (it happened at the facility). Review of another Wound Evaluation dated 2/25/2025, revealed R7's coccyx pressure ulcer measured 11.32 x 4.48 x 3.73 x 0.4 cm, and the bed of the wound was covered with slough (dead tissue that is typically white, yellowish, debris, and remnants of tissue) making the wound bed not visible rendering the wound unstagable. The evaluation revealed the wound was documented to be a stage 4. Per the RAI manual, Pressure ulcers that have slough (yellow, tan, gray, green or brown) .tissue present such that the anatomical tissue cannot be visualized or palpated in the wound bed, should be classified as unstagable . Review of an active care plan dated 8/1/2024 and revised on 2/20/2025 revealed, Resident (R7) is at risk for impaired skin integrity related to Cerebral Hemorrhage, Respiratory Failure, and Contractures. Stage 4 pressure wound to coccyx, Blister to rear left trochanter, hematoma to left lateral foot The care plan had an intervention for R7 to have, .Padded boots on feet at all times, dated 2/17/2025. There were not further updated interventions to the care plan. In an interview on 2/27/2025 at 1:36 PM, Registered Nurse (RN) G. who was the wound nurse, stated R7's left lateral (side) foot was a hematoma which was a blister, discolored tissue. RN G stated she thought maybe it was a DTI. RN G said R7 was to have the boots on his feet at all times, and said the boots were an intervention on R7's care plan. RN G said all staff CNAs and Nursing were supposed to be sure the boots were on R7 at all times, and assure his feet were elevated off the mattress. RN G stated that R7's left trochanter wound should have been documented as an unstagable pressure ulcer and not a blister. RN G further stated that there were no added interventions to R7's care plan for pressure ulcers other than the boots, upon the development of the pressure ulcers. RN G stated that in her opinion she did not know that she would have added any other interventions to R7's care plans, nor could she think of any interventions that should have been added for pressure ulcer preventions and/or treatment. RN G said as far as R7's coccyx pressure ulcer, he must have been left on his back to long. RN G said no root cause analysis, Interdisciplinary Team, care conferences were conducted regarding R7's pressure ulcers in order to determine the cause of R7's skin breakdown. In an interview on 2/27/2025 at 2:15 PM, Director of Nursing (DON) B stated R7 did not tolerate being up in any chair, and stated R7's Kardex (CNA document for providing care) did reveal for the CNAs to have R7's boots on him at all times.

This citation pertains to intake M100134214 Based on interview and record review, the facility failed to provide timely cardiopulmonary resuscitation (CPR) and according to standards of practice for one (Resident # 6) of one reviewed for emergency resuscitation, resulting in Immediate Jeopardy when R6 was found unresponsive without pulse or respiration with a full 5-minute delay prior to the initiation of CPR including one full minute listening for breath and heart sounds. This deficient practice resulted in death for R6 with the likelihood that the 54 facility residents who are a full code to not receive timely CPR. Findings include: Resident #6 (R6) was readmitted to facility [DATE] with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease, acute ischemic heart disease, sleep apnea, and nicotine dependence. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] reflected a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 9 (moderate cognitive impairment). Section G of MDS revealed that R6 required one-person limited assist with bed mobility, transfers, and toilet use, and was independent with meals after set-up. Review of a second MDS dated [DATE] reflected that R6 deceased while at the facility. Review of R6's medical record completed with the following findings noted: Advance Directives/Medical Treatment Decisions form scanned into R6's medical record reflected I do not choose to formulate or issue any Advance Directives at this time. I want efforts made to prolong my life and want life-sustaining treatment to be provided signed and dated by R6 and a facility representative on [DATE]. Order dated [DATE] at 9:42 PM stated, Full Resuscitate. Care Plan Focus with an [DATE] date of initiation and a [DATE] date of revision stated, Resident has an Advanced Directive. Resident is a full code. Nurses' Notes dated [DATE] at 7:07 PM and completed by Registered Nurse (RN) C stated, .About 1730 (5:30 PM) I found resident was found unresponsive. I tried to wake him to no avail. 1731 (5:31 PM) I immediately went to nurse (RN D's name) and told him (R6's name) was unresponsive and I saw (Physician I's name) and asked (RN D's name) to get him while I went back to the (R6's name). I grabbed a stethoscope to listen for breathing and heart sounds. 1733 (5:33 PM) I am back at the bedside of (R6's name) and he remains unresponsive as I listen for a full minute for breath and/or heart sounds. 1734 (5:34 PM) Overhead I hear the code called by (Social Worker F's name). 1735 (5:35 PM) (Physician I's name) arrives and begins compressions and the respiratory therapist brings a bag mask and begins bagging. (Physician I's name, RN G's name, RN H's name, and I) rotate compressions. A nurse grabs the AED (Automated External Defibrillator) and backboard and the AED is placed on (R6's name) as compressions and breaths continue. 1740 (5:40 PM) EMS (Emergency Medical Service) arrives and takes over. They place a mechanical compression device on the resident and continue breaths. The team continued to work on him for 5 rounds before calling time of death at 1748 (5:48 PM). Physician from (local hospital's name) pronounced (R6's name) death as respiratory failure . Nurses' Notes dated [DATE] at 7:26 PM and completed by RN C stated, .Around 1600 (4:00 PM) I check the resident to take his VS (Vital Signs) as the tech came to me a few minutes before alerting me his BP (Blood Pressure) and SPO2 (Oxygen saturation--a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) was low. I went to take a manual BP, but was unable to get a read. I retook the BP with the machine and got ,d+[DATE] and SpO2 was 97% (percent) on 5L (liters). He was fatigued, but responsive .I was worried about his BP and was planning to call the doctor for the next steps. I thought he may need IV (intravenous) fluids as he was not eating or drinking much. Physician Progress Note with a [DATE] 4:56 AM created date and a [DATE] 4:56 AM effective date stated, .Patient seen for acute cardiopulmonary arrest .Called to room urgently as patient had a cardiopulmonary arrest and had a code performed .Is still a full code and became unarousable and pulseless .Code performed for 45 minutes, EMS arrived and participated with them. Patent had chest compressions and bagging, had acute automatic defibrillator placed and was not in a shockable rhythm. Code continued once EMS arrived. Patient ultimately expired . Medical Certificate of Death provided by R6's Family Member J and signed by Physician I on [DATE] indicated, Cause of Death as Coronary artery disease. Certificate of Death provided by R6's Family Member J and signed by Physician I on [DATE] and signed by Registrar with a Date Filed of [DATE] indicated, Cause of Death as Acute Respiratory Failure Due to Covid 19 Due to End stage chronic obstructive pulmonary disease. In an interview on [DATE] at 2:32 PM, Social Worker (SW) F stated that RN D came into the Nursing Home Administrators (NHA) office at approximately 5:00 PM on [DATE], informed both Physician I and herself that R6 was not breathing, and confirmed calling the Code Blue (used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention) overhead to R6's room. Per SW F, Physician I exited the NHA office to go to R6's room and that, from what she could recall, RN D called 911. In an interview on [DATE] at 2:49 PM, RN G confirmed participation in R6's code as stated that a Code Blue was called to R6's room number in the afternoon of [DATE]. RN G stated that he was on the vent unit when the code was called, went to R6's room on the opposite end of the building, and stated that RN C was present in R6's room and was doing something with the Vital Sign cart. RN G confirmed that RN H, Physician I, and a Respiratory Therapist entered R6's room and participated in the code, as well. In an interview on [DATE] at 3:10 PM, RN H stated that the facility offered CPR classes and that she had renewed her CPR certification in a class offered within the facility in October of 2022. RN H stated that the steps in CPR included assessing a resident for responsiveness, checking the carotid pulse for one minute, verifying code status, calling a code if warranted, and initiating CPR. During the same interview, RN H sated that when the code was called overhead on [DATE], she ran from the north to south end of the building to R6's room. RN H stated that upon arriving to the room, she went to get the AED (Automated External Defibrillator) as instructed, returned to R6's room, entered room and provided AED to RN G and as a shock was not advised, rotated into chest compressions with RN G, RN C, and Physician I. In a telephone interview on [DATE] at 3:36 PM, RN C confirmed familiarity with R6 stating that she was his assigned nurse from 6:00 AM to 6:30 PM on [DATE]. RN C stated that she was approached by RN D on [DATE] at approximately 5:00 PM with concerns that R6 did not look right. RN C stated that she proceeded to enter R6's room and upon assessment, noted him to be unresponsive, was unable to palpate a pulse, and that his body was ice cold. RN C stated that she exited R6's room, informed RN D that R6 was unresponsive, went back to room to check pulse and breathing and to try to get him to respond but that she did not hear breath or heart sounds with the stethoscope and that a short time later, Physician I entered room, stated that R6 was a full code, verified absence of heart and lung sounds, and started chest compressions. RN C stated that at no time did she check R6's code status, initiate a code or request that another staff member announce a code, or make any effort to initiate CPR as recalled that R6 was recently diagnosed with cancer, was considering Hospice, and thought that he was a DNR (Do-Not-Resuscitate). In an interview on [DATE] at 7:38 AM, Director of Nursing (DON) B stated that she was not involved in R6's code but confirmed that she was CPR certified. Per DON B, the steps involved in CPR included determining unresponsiveness by completing a sternal rub (application of a stimulus with the knuckles of closed fist to the center chest of a patient who is not alert) and checking for a pulse. DON B stated that she would check a carotid pulse for thirty seconds to one minute and if questioning would get out a stethoscope and check an apical pulse. DON B stated that if an individual was determined to be unresponsive, would check code status, call for assist to call code and initiate CPR. DON B stated that if no one was around to assist and wasn't sure of code status, would initiate CPR until the code status could be verified and if an individual was confirmed to be a DNR, would then stop CPR. In an interview on [DATE] at 8:02 AM, RN D confirmed familiarity with R6, stated that he worked the 6:00 AM to 6:00 PM shift on [DATE], and that he was assigned to the other medication cart on the unit on that date. RN D stated that although he was not assigned to R6 on [DATE], that he just happened to walk down toward R6's room, noted R6's door to be open a little and stated, he looked pale and just didn't look right from the doorway. RN D stated that he informed R6's assigned nurse, RN C, and that she entered R6's room, at that time, and reapproached him fairly quickly, probably within 1 to 1.5 minutes, to notify him that R6 was unresponsive. RN D stated that everything from that date was kind of a blur but recalled running down to the NHA office and alerting both Physician I and SW F that R6 was unresponsive. Per RN D, SW F stated that R6 was a full code and that she announced the code overhead while he ran back to R6's room to notify RN C and then proceed to call 911. RN D denied checking R6's code status prior to alerting Physician I and SW F that R6 was unresponsive. During the same interview, RN D stated that the facility offered CPR certification and that he had completed his prior recertification at a class held within the facility. RN D stated that when a resident was noted to be unresponsive, he would complete a sternal rub and check breathing and pulse by physically looking at the chest for respirations and checking a radial or carotid pulse for fifteen to thirty seconds. RN D stated that he would then exit room, yell, and look for assist, check code status, call code immediately if no one was present to assist, and then would delegate individuals to call 911 and obtain a crash cart while CPR was initiated. In a telephone interview on [DATE] at 10:04 AM, Physician I stated that R6 had severe COPD (Chronic Obstructive Pulmonary Disease), CAD (coronary artery disease), and significant depression over many years with suicidal ideation and close Psychiatric follow-up. Per Physician I, R6's biggest physical decline started with abdominal pain which resulted in a work-up and eventual diagnosis of pancreatic cancer and that around the time he was diagnosed with cancer, R6 developed Covid. Physician I stated that, from what he could remember, R6 was fairly asymptomatic from the Covid as his oxygen levels remained stable and he was still getting up. Physician I stated that he did not believe that he was personally notified of R6's oxygen level of 87% in the AM of [DATE] and upon review of the call logs from his on-call service, confirmed that he did not see any calls from that date/time. Physician I further confirmed that he did not receive a specific call from staff regarding R6 throughout the day on [DATE] and that if he would have been notified of concerns with progressive hypoxia, he would have reviewed the chart to assure that the appropriate orders were in place. During the same interview, Physician I confirmed that RN D entered the NHA office on [DATE], notified him that R6 was unresponsive, and seemed confused about R6's code status. Physician I stated that he proceeded to R6's room, made sure no one was confused as to R6's Full Code status and confirmed that CPR needed to be carried out although Hospice had been contemplated by R6. Physician I sated that he was pretty sure that he was the one that initiated chest compressions and that as the rest of the team arrived, they joined in. According to the American Heart Association, If a victim is unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the healthcare provider should check for a pulse for no more than 10 s (seconds) and, if no definite pulse is felt, should assume the victim is in cardiac arrest .Protracted delays in CPR can occur when checking for a pulse at the outset of resuscitation efforts as well as between successive cycles of CPR. Healthcare providers often take too long to check for a pulse and have difficulty determining if a pulse is present or absent. There is no evidence, however, that checking for breathing, coughing, or movement is superior to a pulse check for detection of circulation. Thus, healthcare providers are directed to quickly check for a pulse and to promptly start compressions when a pulse is not definitively palpated. (https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support#:~:text=2.-,If%20a%20victim%20is%20unconscious%2Funresponsive%2C%20with%20absent%20or%20abnormal,victim%20is%20in%20cardiac%20arrest.) According to the Mayo Clinic, .Trained and ready to go. If you're well-trained and confident in your ability, check to see if there is a pulse and breathing. If there is no pulse or breathing within 10 seconds, begin chest compressions. Start CPR with 30 chest compressions before giving two rescue breaths . (https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600) Review of the facility policy titled Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS) with a [DATE] reviewed/revised date stated, Policy: The purpose of this policy is to provide guidelines for the initiation of Cardiopulmonary Resuscitation(CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest .Procedures for administering CPR shall incorporate the steps covered in the American Heart Association, BLS training material .Policy Explanation and Compliance Guidelines: If a resident experiences a cardiac arrest or respiratory arrest .facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advance directives and any related physician order, such as code status . On [DATE] at 11:23 AM, NHA A and DON B were notified of the Immediate Jeopardy that was identified on [DATE] and began on [DATE], due to the facility's failure to provide timely cardiopulmonary resuscitation (CPR) and according to standards of practice. Immediate Jeopardy was removed on [DATE] when the facility had the following in place: On [DATE], the Administrator educated the Director of Nursing on checking of code status, the timeline and steps for assessing pulse and respirations when a resident is found unresponsive (assessing for pulse and respirations to be completed immediately for 10 seconds), and initiating CPR. On [DATE], the Director of Nursing and/or designee began immediate education of facility staff on checking of code status, the timeline and steps for assessing pulse and respirations when a resident is found unresponsive (assessing for pulse and respirations to be completed immediately for 10 seconds), and initiating CPR. -The facility has 37 Licensed Nurses and Respiratory Therapists. -As of [DATE] at 1:00pm, the facility has educated 12 of the 37 Licensed Nurses and Respiratory Therapists. -Any staff not educated will not be permitted to work a shift until education has been completed. The facility Medical Director was notified on [DATE]. The Director of Nursing and/or designee completed a chart audit on every resident and compared the advanced directives to the physician order for accuracy on [DATE]. The QAPI committee has reviewed the Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) and the Notification of Changes policy and has deemed them appropriate on [DATE]. The facility had an Adhoc QAPI meeting including the Medical Director on [DATE] and deemed this abatement plan appropriate. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

This citation pertains to intake M100134214 Based on interview and record review, the facility failed to routinely assess and monitor a resident with COVID-19 for one (Resident # 6) of 3 residents reviewed for quality of care, resulting in failure to identify a change in resident condition resulting in ongoing deterioration to death. Findings include: Resident #6 (R6) was readmitted to facility [DATE] with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease, acute ischemic heart disease, sleep apnea, and nicotine dependence. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] reflected a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 9 (moderate cognitive impairment). Section G of MDS revealed that R6 required one-person limited assist with bed mobility, transfers, and toilet use, and was independent with meals after set-up. Review of a second MDS dated [DATE] reflected that R6 deceased while at the facility. Review of R6's medical record completed with the following findings noted: Physician Progress Note dated [DATE] at 11:23 AM stated, .acute COVID 19 positive .patient has some decreased breath sounds, otherwise appears relatively asymptomatic, denies chest pain or shortness of breath . Nurses' Notes dated [DATE] at 2:16 PM stated, .Resident noted to be complaining of shortness of breath today. Rapid test for COVID completed and came back positive. Provider is aware. Review of all Progress Notes revealed no additional Physician Notes or Nurses' Notes from [DATE] through [DATE]. Orders-Administration Note dated [DATE] at 3:56 PM and 3:57 PM stated, .Resident is resting comfortably and does not want to take meds (medications). Nurses' Notes dated [DATE] at 7:07 PM and completed by Registered Nurse (RN) C stated, .About 1730 (5:30 PM) I found resident was found unresponsive. I tried to wake him to no avail. 1731 (5:31 PM) I immediately went to nurse (RN D's name) and told him (R6's name) was unresponsive and I saw (Physician I's name) and asked (RN D's name) to get him while I went back to the (R6's name). I grabbed a stethoscope to listen for breathing and heart sounds. 1733 (5:33 PM) I am back at the bedside of (R6's name) and he remains unresponsive as I listen for a full minute for breath and/or heart sounds. 1734 (5:34 PM) Overhead I hear the code called by (Social Worker F's name). 1735 (5:35 PM) (Physician I's name) arrives and begins compressions and the respiratory therapist brings a bag mask and begins bagging. (Physician I's name, RN G's name, RN H's name, and I) rotate compressions. A nurse grabs the AED (Automated External Defibrillator) and backboard and the AED is placed on (R6's name) as compressions and breaths continue. 1740 (5:40 PM) EMS (Emergency Medical Service) arrives and takes over. They place a mechanical compression device on the resident and continue breaths. The team continued to work on him for 5 rounds before calling time of death at 1748 (5:48 PM). Physician from (local hospital's name) pronounced (R6's name) death as respiratory failure . Nurses' Notes dated [DATE] at 7:26 PM and completed by RN C stated, .Around 1600 (4:00 PM) I check the resident to take his VS (Vital Signs) as the tech came to me a few minutes before alerting me his BP (Blood Pressure) and SPO2 (Oxygen saturation--a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) was low. I went to take a manual BP, but was unable to get a read. I retook the BP with the machine and got ,d+[DATE] and SpO2 was 97% (percent) on 5L (liters). He was fatigued, but responsive .I was worried about his BP and was planning to call the doctor for the next steps. I thought he may need IV (intravenous) fluids as he was not eating or drinking much. Physician Progress Note with a [DATE] 4:56 AM created date and a [DATE] 4:56 AM effective date stated, .Patient seen for acute cardiopulmonary arrest .Called to room urgently as patient had a cardiopulmonary arrest and had a code performed .Is still a full code and became unarousable and pulseless .Code performed for 45 minutes, EMS arrived and participated with them. Patent had chest compressions and bagging, had acute automatic defibrillator placed and was not in a shockable rhythm. Code continued once EMS arrived. Patient ultimately expired . COVID Skilled Note dated [DATE] at 6:15 PM with a [DATE] 3:00 AM lock date indicated [DATE] 10:21 PM Vital Signs as follows: Temperature (Temp): 98.9 degrees Fahrenheit, Blood Pressure (BP): ,d+[DATE], Pulse: 59 beats per minute, Respirations (Resp): 16 breaths per minute, O2 sats (oxygen saturation): 92.0% (percent) with oxygen via Nasal Cannula. Note also indicated that R6 had a positive Covid test, was in Covid isolation, and had loss of appetite with assessment including no additional details regarding R6's cardiac and respiratory status. COVID Skilled Note dated [DATE] at 2:15 AM with [DATE] 3:00 AM lock date reflected the same Vital Signs obtained [DATE] at 10:21 PM with Temperature: 98.9 degrees Fahrenheit, Blood Pressure: ,d+[DATE], Pulse: 59 beats per minute, Respirations: 16 breaths per minute, O2 sats: 92% with oxygen via Nasal Cannula. Note also indicated that R6 had a positive Covid test, was in Covid isolation, and had loss of appetite with assessment including no additional details regarding R6's cardiac and respiratory status. Order dated [DATE] at 2:13 PM with [DATE] 10:00 PM start date stated, Vital Signs including oxygen saturation each shift. Review of Medication Administration Record dated [DATE] through [DATE] reflected order, Vital Signs including oxygen saturation each shift with entries as follows: [DATE] Night BP: ,d+[DATE], Temp: 97.6, Pulse 71, Resp: 18, O2 sats: 93% [DATE] Day BP: ,d+[DATE], Temp: 97.6, Pulse 71, Resp: 18, O2 sats: 86% [DATE] Evening BP: ,d+[DATE], Temp: 98.2, Pulse: 63, Resp: 16, O2 sats: 90% [DATE] Night BP: ,d+[DATE], Temp: 98.1, Pulse: 77, Resp: 20, O2 sats: 98% [DATE] Day BP: ,d+[DATE], Temp 97.2, Pulse: 86, Resp: 20, O2 sats: 91% [DATE] Evening BP: ,d+[DATE], Temp: 97.2, Pulse 86, Resp: 20, O2 sats 94% [DATE] Night BP: ,d+[DATE], Temp: 97.2, Pulse 86, Resp: 20, O2 sats 94% [DATE] Day BP: ,d+[DATE], Temp: 97.2, Pulse 86, Resp: 20, O2 sats 94% [DATE] Evening BP: ,d+[DATE], Temp: 97.2, Pulse 86, Resp: 20, O2 sats 94% [DATE] Night BP: ,d+[DATE], Temp: 98.9, Pulse: 59, Resp: 16, O2 sats: 92% [DATE] Day BP: ,d+[DATE], Temp: 98.9, Pulse: 59, Resp: 16, O2 sats: 87% Review of all Vital Signs documented within the March MAR, Vital Sign tab within PCC (Point Click Care), and the [DATE] and [DATE] COVID Skilled Notes reflected the same Blood Pressure, Temperature, Pulse, and Respiratory Rate on [DATE] night and [DATE] day shifts; the same Blood Pressure, Temperature, Pulse, and Respiratory Rate across the [DATE] day, [DATE] evening, [DATE] night, [DATE] day, and [DATE] evening shifts; and the same Blood Pressure, Temperature, Pulse, and Respiratory Rate on [DATE] night and [DATE] day shifts. In a telephone interview on [DATE] at 12:14 PM, Certified Nurse Aide (CNA) E stated familiarity with R6 and confirmed that she was R6's assigned CNA on [DATE] from 6:00 AM to 6:00 PM. Per CNA E, R6 was independent with transfers, toilet use, and wheelchair mobility prior to his Covid diagnosis but quickly became weaker, required more assist, started sleeping more, and did not get out of bed. CNA E stated that at the beginning of her 6:00 AM to 6:00 PM shift on [DATE], R6 was alert and talkative but by the middle of the shift, R6 was no longer responding to her. CNA E stated that in the morning of [DATE], she obtained R6's vital signs, did not recall that any of the vital signs were out of his normal and that it was her routine to enter the vital signs into the computer but that if she did not, she would have just given them to the nurse to enter. CNA E stated that she also emptied R6's catheter and set up his breakfast tray and recalled that he ate his ice cream but thought that he may have refused the remainder of the meal. CNA E stated that with 10:00 AM rounds on [DATE] R6 was sleeping, she awakened him to check his brief but that he was still half asleep, grunted but did not arouse any further. Per CNA E, R6 was still sleeping with 2:00 PM rounds, moaned when she tried to awaken him, was no longer responding verbally, hands were cold and that she could not obtain his oxygen level, blood pressure, or pulse with the vital sign machine. CNA E stated that she watched R6's breathing and although could not recall what his respirations were, stated that his respirations were really quick. CNA E stated that she exited the room and alerted RN C of R6's decreased level of responsiveness and inability to obtain vital signs and that RN C acknowledged her stating that she would have to check his vital signs manually. CNA E stated that as she was concerned about R6, she tried to awaken him again around 3:00 PM without success and again alerted RN C. CNA E stated that she was unsure if RN C checked on R6 as she proceeded to continue with rounds on remainder of assigned residents and that she did not see R6 again until she completed postmortem care. In a telephone interview on [DATE] at 3:36 PM, RN C confirmed familiarity with R6 stating that she was his assigned nurse from 6:00 AM to 6:30 PM on both [DATE] and [DATE] and denied receiving any information in report on either date that would have indicated a change in status for R6. RN C stated that on [DATE], R6 did ok throughout the shift and that, from what she could recall, his vital signs had been stable. On [DATE], RN C stated that R6 was more tired than usual and seemed lethargic at start of shift but that when she entered his room at approximately 8:00 AM, he had eaten some ice cream for breakfast and that she reviewed his vital signs and didn't see anything out of the ordinary. When questioned as to why the blood pressure, temperature, pulse, and respirations documented on the MAR for [DATE] day shift reflected the exact values as the shift prior ([DATE] night shift), RN C stated that happened when the use last charted option was selected when documenting vital signs on the MAR but that she had charted the vitals that CNA E had obtained and entered into the chart earlier that morning. When informed that review of R6's medical record contained no documented vital signs from the morning of [DATE], RN C clarified that sometimes the CNA's obtained the vital signs and provided them to the nurse so that the nurse could enter them but could not recall that if on that day the CNA entered the vitals or if she entered them herself after the CNA provided them to her. When questioned about the [DATE] day shift MAR reflecting an O2 sat level of 87%, RN C stated that R6 had been on oxygen but that she could not recall the number of liters and stated that she did not have to adjust the number of liters as recalled that his level was fine on whatever number he was already on. RN C stated that she entered R6's room next between 12:00 PM and 1:00 PM at which time he was noted to be sluggish, slower to verbally respond, and moving slower but that he still took the medication cup from her and took his medication independently. RN C stated that she completed a brief assessment on R6 during that time which included an assessment of his level of consciousness and listened to heart and lung sounds but that information was not documented as everything checked out ok at that time. RN C stated that as R6's vital signs had been fine earlier in the shift (which reflected the documented vital signs from [DATE] at 10:21 PM), she did not consider obtaining follow up vital signs at that time even though R6 was noted to be sluggish and slower to verbally and physically respond then he had been at start of the [DATE] 6:00 AM shift. RN C stated that she next observed R6 at approximately 4:00 PM as he had scheduled medications due at that time. Per RN C, R6 was observed from the doorway of his room and as he was resting comfortably she did not enter his room to check on him further or attempt to administer his scheduled 4:00 PM medications. RN C denied having any verbal interaction with R6 at that time. RN C stated that she checked on R6 again at approximately 5:00 PM as was approached by RN D with concerns that R6 did not look right. RN C stated that R6 was unresponsive at that time, no pulse was palpated, and that his body was ice cold. RN C stated that she exited R6's room, informed RN D that R6 was unresponsive, went back to room to check pulse and breathing and try to get him to respond but that she did not hear breath or heart sounds with the stethoscope and that a short time later, Physician I entered room, confirmed R6 was a full code, and started chest compressions. RN C stated that at no time during the [DATE] 6:00 AM to 6:00 PM shift did CNA E notify her that she was unable to awaken R6 or obtain vital signs. Per RN C, both R6's 6:00 AM and 2:00 PM vital signs were fine, to her knowledge, as CNA E never approached her with any concerns. Furthermore, RN C stated that she could not recall trying to obtain a BP, prior to the 5:00 PM check, and that she used the electronic machine at that time denying that she had tried obtaining a manual BP prior. RN C denied physician notification of changes in vital signs including oxygen saturation levels as stated that, to her knowledge, R6's vital signs were stable throughout the shift until approximately 5:00 PM when he was unresponsive. Furthermore, RN C denied that she had notified physician of the lethargy that she had noted at start of shift or R6's poor oral intake as stated that she thought he was a DNR (Do-Not-Resuscitate) as he had recently been diagnosed with cancer and was considering Hospice. In an interview on [DATE] at 7:38 AM, Director of Nursing (DON) B stated that when a resident was diagnosed with Covid, an order would be written for completion of vital signs and stated that vital signs should be completed every shift (three times daily) and that a nursing assessment should be completed within a Covid Skilled Note once daily. Per DON B, although a Covid assessment was completed and documented once daily, the expectation would be for an assessment to be completed and documented within a nurse progress note when a change in resident condition was depicted and for physician notification at that time. Regarding the documentation of identical vital signs from shift to shift, DON B stated that this had not been identified with R6 and would need time to review the chart further. Upon review of R6's vital signs documented within the [DATE] MAR and the vital signs documented within the Vital Sign task, DON B confirmed that the blood pressure, pulse, temperature, and respirations documented for the day shift of [DATE] were the same vital signs documented for the night shift on [DATE]. DON B further stated that she believed R6's vital signs were obtained the morning of [DATE] but must not have been documented and stated that she would dig to see if she could find them somewhere. DON B provided no additional assessment or vital sign documentation for R6 prior to survey exit. In an interview on [DATE] at 8:02 AM, RN D confirmed familiarity with R6, stated that he worked the 6:00 AM to 6:00 PM shift on [DATE], and that he was assigned to the other medication cart on the unit on that date. RN D stated that although he was not assigned to R6 on [DATE], that he just happened to walk down toward R6's room, noted R6's door to be open a little and stated, he looked pale and just didn't look right from the doorway. RN D stated that he informed R6's assigned nurse, RN C, and that she entered R6's room, at that time, and reapproached him fairly quickly, probably within 1 to 1.5 minutes, to notify him that R6 was unresponsive. In a telephone interview on [DATE] at 10:04 AM, Physician I stated that R6 had severe COPD (Chronic Obstructive Pulmonary Disease), CAD (coronary artery disease), and significant depression over many years with suicidal ideation and close Psychiatric follow-up. Per Physician I, R6's biggest physical decline started with abdominal pain which resulted in a work-up and eventual diagnosis of pancreatic cancer and that around the time he was diagnosed with cancer, R6 developed Covid. Physician I stated that, from what he could remember, R6 was fairly asymptomatic from the Covid as his oxygen levels remained stable and he was still getting up. Physician I stated that he did not believe that he was personally notified of R6's oxygen level of 87% in the AM of [DATE] and upon review of the call logs from his on-call service, confirmed that he did not see any calls from that date/time. Physician I further confirmed that he did not receive a specific call from staff regarding R6 throughout the day on [DATE] and that if he would have been notified of concerns with progressive hypoxia, he would have reviewed the chart to assure that the appropriate orders were in place. Physician I stated that if there was no indication in R6's medical record that he was contacted, then he probably wasn't and stated that he did not recall providing an order to increase R6's oxygen level to 5 liters. Review of the facility policy titled Notification of Changes with a [DATE] reviewed/revised date stated, Policy .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification .For changes of condition the facility may use: SBAR (Situation, Background, Assessment, and Recommendation) process for assessment, documentation and report to the practitioner 2. Care Paths for the INTERACT (Interventions to Reduce Acute Care Transfers) program 3. Sepsis protocols .Circumstances requiring notification include .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status .3. Circumstances that require a need to alter treatment. This may include: a. New treatment b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition .

This Citation Pertains to Intake Numbers: MI 814, MI 858, MI 385, and MI 975. Based on observation, interview, and record review, the facility failed to institute and operationalize policies and procedures to ensure an environment free of abuse including verbal abuse and mental abuse for two residents (Resident #704 and Resident #705) of seven residents reviewed for abuse and dignity, resulting in lack of administrative oversight to monitor and identify increased risk of abuse by staff, prevent abuse, and Resident #704 experiencing verbal abuse and Resident #705 being subjected to verbal and mental abuse, including intimidation, fear of retaliation, emotional distress, and verbalization of embarrassment, shame, emotional distress, and fear. Findings include: Resident #705: Review of intake documentation, dated received 4/6/22, revealed a Facility Reported Incident (FRI). The intake was pertaining to an allegation of verbal abuse by facility staff member, Certified Nursing Assistant (CNA) A towards Resident #705 in which the CNA yelled at the Resident. The intake documentation indicated a FRI had previously been submitted to the submitted to the State Agency on 3/8/22 related to the allegation. Record review revealed Resident #705 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and was totally dependent upon staff for the completion of all Activities of Daily Living (ADLs). The MDS further revealed the Resident displayed no behaviors and/or potential indicators of [CONDITION(S)] including hallucinations/delusions. On 7/20/22 at 1:10 PM, an observation and interview occurred with Resident #705 in their room. The Resident positioned on their back in bed. A tube feeding pump was present in the room. The Resident was observed to have a [CONDITION(S)], [CONDITION(S)], suprapubic catheter, and wound dressings in place on both of their lower extremities. When asked about care in the facility, Resident #705 revealed they are dependent upon staff for all their needs. Resident #705 was then queried if facility staff treat them with dignity and respect and revealed they had issues with a CNA and a nurse. Resident #705 stated (CNA A) came in here (resident room) one night and was cussing and screaming at me. Resident #705 revealed CNA A no longer provided care to them following the incident but still worked at the facility. Resident #705 stated, They (facility) still put (CNA A) on my hall (assigned work area) so my roommate and I have to depend on someone else to come and take care of us. With further inquiry regarding what had transpired, Resident #705 reiterated CNA A came into their room, shut the door, and started yelling and cussing at them. Resident #705 verbalized they were scared CNA A was going to physically harm them. With further inquiry, Resident #705 indicated they were happy CNA A was no longer coming into their room but did not feel that it was right for them (gestured toward roommate) to not receive timely care because they had to wait for a staff member from a different hall to come when CNA A was working. When asked if their assigned nurse assists them, Resident #705 revealed not all nurses provide ADL care. The Resident elaborated some nurses will come in and try to do it on their own which was also concerning to them. Resident #705 revealed they were concerned about safety due to lack of adequate staffing and stated, Third shift is horrible. Resident #705 was then queried regarding the nurse they previously mentioned having an issue with and stated, I don't feel safe when (Nurse E) is here either. Resident #705 was asked why they did not feel safe when Nurse E was working and replied, They switched me and (Resident #707's) tube feed rate and I got too much (tube feeding). Resident #705 revealed they experienced GI distress after the rate error and identified the error themselves when they asked to see the rate on the pump. Resident #705 indicated they had other concerns but appeared hesitant and did not provide additional information. Review of facility provided investigation documentation included the following: - Incident and Accident Report: Date of Incident: 3/30/22 . Condition prior to incident: Alert . Location: Resident Room . Unobserved . Staff-to-resident: Abuse/Neglect . Brief Description: Allegation of Abuse . Action Taken . State Notified . Suspension Pending Investigation (CNA A) . - Resident #705 Statement: Date and time of incident: 3/5/22 . Date and place of interview: 3/9/22, Resident Room, 1430 (2:30 PM) . Statement . Resident was telling aid about CNA from the night before not turning and not emptying bags. Resident asked to speak with (CNA A). (CNA A) stormed into room and closed door. (CNA A) asked why resident was talking 'shit' to co-workers and not directly to them. Resident stated that they wanted to talk to them about why they didn't turn or empty bags the night before. (CNA A) stated that (Resident #705) was lucky that they got turned 'once' because they were to busy helping the nurse that night. (CNA A) started yelling about switching showers because these 'Mother [OBSCENITY] s' won't take showers unless I am here to give it to them. I don't know what the '[OBSCENITY] ' they are going to do when I am not their tech this summer. Resident asked to be repositioned and CNA did and emptied bag then asked, 'Did I redeem myself'? Original statement read to resident. Resident agreed that it was accurate. The only thing (Resident #705) had to add was that (CNA A) told (CNA B) and (Registered Nurse [RN] G) that next morning. Reviewed the timeline with (Resident #705) . said the incident occurred Saturday and (CNA A) told the staff Sunday morning . Spoke w/Resident again regarding incident. Resident stated that (CNA A) came in room, got in their face, and said 'you mother [OBSCENITY] why are you talking about me' . stated they swore about other staff and residents . stated that it was verbal abuse . - RN G Statement: Date and place of interview: 4/4/22 via phone . I know about the verbal altercation between (Resident #705) and (CNA A) . All the info I heard was through hearsay of other people . (Resident #705) didn't tell me anything about it directly . (Statement not signed by RN G) - Staff H Statement: Date and place of interview: 4/4/22 . (CNA A) told me about the interaction between them and (Resident #705) after it happened/before it was investigated. (CNA A) told me that (Resident #705) called them a[OBSCENITY]y CNA. I don't recall exactly what (CNA A) told me they said to (Resident #705) but I know it was not reportable. (CNA A) did not say they screamed, yelled, or swore at (Resident #705). (CNA A) and I spoke after the investigation and (CNA A) remained with their original statement of not having screamed, yelled, or swore at (Resident #705). - CNA B Statement: Date and time of incident: 3/6/22 6 AM . Date and place of interview: 3/30/22 . When I got here (CNA A) said, 'Girl come here, I have to tell you about your boy. (CNA A) pulled me into dining room . told me they yelled at (Resident #705), that they 'cussed them out' and that (RN C) could hear it down at their med cart. I didn't know where the med cart was at the time. The next day (CNA A) was sending me messages denting that they had done anything to abuse (Resident #705) . (Signed by CNA B) . Below CNA B's signature, writing was present in different handwriting which detailed, When I went into (Resident #705's) room, they started to tell me about the incident . said (CNA A) came in cussing and yelling at them. I told (Resident #705) that I was aware that (CNA A) told me. (Resident #705) asked if (CNA A) was out there bragging about it. I told them I don't know if it was bragging but they did tell me about it. (Resident #705) did not give specifics on what (CNA A) said or where they were standing. (Resident #705) told me they had a green (complaint) form written up about (CNA A). (Resident # 705) also said they didn't believe (CNA A) was still there with how they spoke to them. - CNA A Statement: Date and time of interview: 3/30/22 at 12:10 PM . The next morning, I have report (not sure who to) and then left. I don't really talk to the day shift unless it is to give report. I don't recall exacts for the incident, my previous statement had all the details. It was fresh in my brain at the time. I have not talked to (CNA B) about this. I think they might have been working that next morning. I have not worked with (Resident #705) since the original investigation. (Resident #705) has asked staff to come have me come care for them . has told aides that I am a good CNA and would like for me to come in even if I had a witness with me. - Typed word document, signed by the facility Administrator but not the staff member, dated 4/5/22 at 7:43 PM indicating Licensed Practical Nurse (LPN) I did not recall any verbal alterations between a staff member and Resident. - Typed word document, signed by the facility Administrator but not the staff member, dated 4/5/22 at 7:24 PM indicating CNA D's statement was reviewed with them and they had no further things to add. - Typed word document, signed by the facility Administrator but not the staff member, dated 4/5/22 at 7:36 PM indicating RN C's statement was reviewed with them and they had no further things to add. - Typed word document, signed by the facility Administrator but not the staff member, dated 4/5/22 at 7:56 PM indicating CNA J had not heard anything about a verbal incident between (CNA A) and (Resident #705). - 10 Resident Interview Questionnaires, without room number, with the following Yes/No questions: Do you feel safe in the facility? and Do you have any outstanding concerns with staff members? Review of the Resident names listed revealed only nine of the ten Residents questioned resided in the same unit and/or general area of the facility as Resident #705 and would therefore not have the same staff assignments. - Mental Health Provider Note, dated 3/15/22: Complaint: hx (history)/sx (signs) of anxiety, depression, [CONDITION(S)]; r/o (rule out) delusional disorder . [AGE] year-old seen regarding sx in chief complaint . seen at facility SW (Social Worker) request; pt (patient) has been delusional, making false allegations. (Resident #705) alert . made paranoid statements about 'some of the staff' and reports 'can yell if I need to at them' . Encourage positive communication with staff regarding needs or or problems . Recommend staff redirect as needed . Therapeutic Interventions Attempted: +Exploration of coping patterns . Assessment & Plan: Generalized Anxiety Disorder . Major depressive disorder . Primary [CONDITION(S)] . Delusional disorders (rule-out) Plan: Monitor . symptoms of [CONDITION(S)] with feedback to prescriber . The note indicated the provider was evaluating Resident #705 based upon the SW request related to facility identification of the Resident being delusional and making false allegations. The note did not identify if the provider assessed the validity of the allegations, nor did it provide context related to the paranoid statements about staff. - Mental Health Provider Note, dated 3/29/22: Complaint: Increase in anxiety, paranoid thoughts, follow up evaluations per psychologist and social worker request . [AGE] year old male . recently seen . for anxiety, depression, and delusions . seen today . regarding mood instability . noted with a constricted affect as well as some suspicious thinking . tells me generally doing okay . denies sadness, anxiety . reports that sleep has been somewhat poor . reports that some things have happened here at the facility that does not want to discuss . tells me that now having witnesses come in the room . report that is feeling suspicious at times . The note did not identify the nature of the paranoid thoughts. - Mental Health Provider Note, dated 4/8/22: Complaint: hx (history)/sx (signs) of anxiety, depression, [CONDITION(S)]; delusional disorder . [AGE] year-old seen regarding sx in chief complaint . seen at facility SW request, as (Resident #705) has again made allegations against a staff member . (Resident #705) was laconic, irritable and reports being 'mistreated' by 'rude remarks' when reportedly made demands to the staff member. When asked what they said, (Resident #705) did acknowledge '(staff) looked busy' . report of what said . became more severe in the 2nd recitation . - Facility Investigation Summary . Conclusion: The facility could not substantiate the allegation of abuse. Through interview and resident record review, the resident and staff member had a disagreement with one about as previously reported . and closed by the state agency . Note: Provided investigation documentation did not include staffing schedule/assignments for date of the allegation, documentation of actions and/or education provided to staff, and/or any information pertaining to the original allegation/interviews. Upon request, the Administrator provided investigation documentation associated the allegation of abuse. The original facility investigation revealed the incident was reported to the State Agency on 3/8/22. The following documentation was noted in the investigation documentation provided: - CNA A Statement: We (Resident #705 and I) had a disagreement on Saturday b/c (because) (Resident #705) called me a[OBSCENITY]y CNA and needed to redeem myself. On Saturday, (Resident #705) asked (CNA D) why (we) switched assignments and told (CNA D) it is b/c I felt guilty from the night before. The prior night I helped (Licensed Practical Nurse [LPN] AR) turn/reposition people as they were doing wound care. I turned (Resident #705) twice and completely forgot to empty their bags. I went in and talked to (Resident #705). (The Resident) was mad they had (CNA D) and not me. I was sorry and forgot about their (catheter and [CONDITION(S)] drainage) bags because I was busy. (Resident #705) told me I am normally very punctual. I explained I was helping other as well. This was after they got their vodka. We talked it out and (Resident #705) apologized. (CNA D) was not in the room. I was not screaming but my voice was stern. I did not cuss at them. Note: Statement signed by Administrator on 3/8/22 and CNA A on 3/17/22. - CNA D Statement: Didn't witness any residents or staff members yelling or swearing at each other . Note: Signed by Interviewer (unable to read signature) on 3/9/22 and not signed by CNA D. - RN AS Typed Statement, dated 3/8/22: I wasn't in (Resident #705's) room ever. I know (CNA A) was upset because (Resident #705) accused them of being a[OBSCENITY]y CNA and they went in and talked to (the Resident). I could hear the CNA talking to the Resident but could not hear what was being said . The only time I walked down that hall was to go outside to smoke or get my food. (Note: Signed by Director of Nursing [DON] but not RN AS). - Resident #705 Statement: Date of Incident: 32/5/22 . Date and Place of Interview: 3/9/22, Resident room . Resident was telling aid about CNA from the night before not turning and not emptying bags . (CNA A) stormed into room and closed door. (CNA A) asked why resident was talking 'shit' to coworker and not directly to them. Resident stated they wanted to talk to them about why they didn't turn or empty bags the night before. (CNA A) stated that (Resident #705) was lucky they got turned once because they were too busy helping the nurse that night. (CNA A) started yelling about switching showers because these 'mother f-ers' won't take showers unless I am here to give it to them. I don't know what the '[OBSCENITY] ' they are going to do when I am not their tech . Resident asked to be repositioned and (CNA A) did and emptied bad then asked, 'Did I redeem myself. Note: Not signed and not noted as reviewed with Resident. - Documentation indicating CNA A was suspended on 3/8/22 Pending Investigation and returned to work 3/11/22. - Record of In-Service for CNA A dated 3/11/22 detailing, Staff provided education on appropriate language in resident care areas. Staff also educated on conflict resolution and to come to management instead of doing it themselves . via phone. The investigation documentation provided did not include staffing schedule/assignments for date of the allegation and/or an interview/statement from LPN AR. On 7/21/22 at 9:15 AM, another interview was completed with Resident #705 in their room. The Resident was observed in bed, positioned on their back. A small dry erase board was noted on the wall in the Resident's room with 0740 written on it. When asked about the dry erase board, Resident #705 revealed it is the time they were last repositioned. Resident #705 stated, I started having them write it down. The Resident revealed the staff had not been turning them every two hours and they developed pressure wounds in the facility. The Resident revealed they wanted to ensure they are turned every two hours as they are unable to turn and reposition themselves due to being paralyzed. Resident #705 stated, I have no feeling from the chest down. When asked, Resident #705 revealed they were able to lift their arm slightly but did not have any fine motor control. Resident #705 was queried regarding what had occurred with CNA A and reiterated CNA A came into their room, shut the door, and was cussing and screaming at them. When asked how they felt about the incident, Resident #705 stated, I was upset. When asked if they felt safe when the incident happened, Resident #705 replied, No. Resident #705 explained they were stuck in this bed and had no way to defend themselves if someone tried to hurt them. With further discussion, Resident #705 disclosed they were scared at the time of the incident and became really upset after the facility investigation was completed because they felt the other night shift staff working had all lied to protect CNA A. Resident #705's Medication Error Reports were requested from the facility for the past year and reviewed. Review revealed documentation of two errors, one staff self-reported error related to incorrect timing of a respiratory medication on 4/22/22 and one error on 6/29/22 of omission of 8:00 PM medications identified on 7/5/22 through a chart audit. Note: The process for reporting medication errors is through nurse self-reporting, documentation, and/or chart audits. An interview was completed with CNA B on 7/21/22 at 11:13 AM. When queried regarding the incident involving Resident #705 and CNA A, CNA B stated, When I got here in the morning, (CNA A) called me into the little lounge with the pop machines and said 'I gotta tell you about your boy' and how they went off on them. When asked if CNA A told them what they said specifically, CNA B revealed CNA A told them they cussed and yelled at Resident #705. With further inquiry, including CNA A's tone and demeaner when they called them into the lounge, CNA B revealed their impression was that CNA A was both mad and bragging at the same time. CNA B was asked if they provided care to Resident #705 after CNA A spoke to them and indicated they did. CNA B stated, (Resident #705) tried to tell me (what happened) when I went in (to their room) and I told them I had already heard about it. CNA B was then asked if what CNA A told them was reportable as abuse and indicated it was. When queried if they reported the occurrence, CNA B stated, I heard that it was already taken care of, so I didn't go to (the Administrator) or anything. When asked for clarification, CNA B revealed they thought the incident had been reported. When asked who told them it had been reported, CNA B revealed they could not recall and then stated, Maybe it was (CNA A) who said (the Administrator) had to be called. CNA B revealed they became aware later that the incident had not been reported. On 7/25/22 at 10:35 AM, Resident #705 was sitting in the hallway of the facility in their wheelchair. The Resident stopped this surveyor and indicated they would like to discuss an incident which had occurred. On 7/25/22 at 11:17 AM, an interview was completed with Resident #705. The Resident revealed they decided they wanted to discuss an incident which had occurred with RN E but were worried about retaliation from the facility and staff. When asked what they meant and what they were concerned about, Resident #705 stated they are, not crazy and have no where else to go. Resident #705 stated, I don't know what would happen if they kicked me out. Resident #705 was asked what happened and stated RN E was buying alcohol for them for a while. The Resident revealed they have an order to receive alcohol at the facility at night and stated, (RN E) was getting it cheaper, that's what (RN E) told me. When asked how they normally obtain alcohol, Resident #705 disclosed Activities staff purchase it and give it to the nurses to administer. Resident #705 continued, There was a night (RN E) was supposed to be here from 6:00 PM to midnight. Resident #705 stated, (RN E) was doing my final med pass which was bringing me my Vodka so I could go to sleep at approximately 12:30 AM. When asked the date of the incident, Resident #705 revealed they were unsure of the date. The Resident stated, (RN E) brought a little over half a fifth (of Vodka) into my room and sat at the edge of me bed talking with me and giving me my Vodka. Resident #705 revealed the Vodka bottle size was a fifth and the door to their room was closed when asked. Resident #705 was then asked how much Vodka they receive at night and stated, I was supposed to get 60 milliliters (mL) but (RN E) gave me a lot more than that. When asked, Resident #705 revealed nursing staff administer the Vodka through his PEG tube (gastrostomy). Resident #705 stated, (RN E) was taking a med cup and doing shots with me. We finished off the bottle. Resident #705 then stated, I don't remember how we got to the conversation of (RN E's) breasts. Resident #705 was asked to clarify and revealed RN E told them they had breast implants. Resident #705 stated, (RN E) left the room and came back with a pic of when they first got their implants and showed me those. When asked about the picture, Resident #705 revealed the picture was on a piece of white paper like it had been printed or copied. Resident #705 revealed they were quite drunk at the time and stated, (RN E) ended up taking their top off. Bra and everything. Resident #705 revealed they told RN E it had been three years since they had seen a woman's breasts and indicated they were remorseful about saying that after what happened. When asked what happened, Resident #705 stated they were embarrassed and ashamed to talk about it. Resident #705 became visibly emotional and stated, The door was shut, the curtain was closed. (RN E's) bra was off and everything. (RN E) got overtop of me, showing me their breasts. Resident #705 revealed RN E told them they had saline implants but wished they would have gotten silicone. Resident #705 expressed concern that no one would believe what they were saying and label them as crazy and as trying to cause trouble because that is what some of them (facility staff) do. Resident #705 then stated, On the inside of their left breast, towards the top, there were lines like it was sagging there. Almost like a shriveled-up prune when (RN E) bent over. The Resident articulated they would have no way of knowing that prior to the incident. Resident #705 continued, (RN E) was putting them (breasts) in my face and in my mouth. (RN E) was bending over me. Resident #705 revealed RN E went into the bathroom after that occurred and stated, (RN E) took a video of themself masturbating in the bathroom and put my hand down there so I could feel (them) . Resident #705 was visibly distraught when talking about the incident. Resident #705 then stated, (RN E) came in the next day and was telling me that the shots (alcohol) hit them on the way home, and they put a dent in their new car. Resident #705 specified, (RN E) told everyone else here that they hit a deer. Resident #705 continued, It wasn't long after that that (RN E) started wanting a witness in the room with them and acting really weird. Resident #705 indicated they just wanted to forget the whole thing. Resident #705 revealed they feel horrible and that they had too much to drink (alcohol). When asked if they recalled who else was working when the incident occurred, Resident #705 was unable to recall. With further inquiry, Resident #705 stated, It's embarrassing as hell. It's embarrassing to think I would let that happen. Everyone is going to know about it, and it disgusts me. Resident #705 indicated they did not think it was right that any of it happened and were concerned they would be kicked out of the facility. When asked if they felt safe in the facility now, Resident #705 revealed they were concerned and scared of what RN E might do now especially after they told the truth. Resident #705 revealed RN E does things to upset them now. When asked, Resident #705 stated, (RN E) turns on the light because they know I want it off. Resident #705 revealed they were referring to the light in the hallway at night. The Resident disclosed other staff will turn the light directly outside of their room off and RN E will turn it back on. The Resident revealed they felt RN E was doing it purposefully to intimidate them. Resident #705 then stated, It made me feel like employees here can do anything they want and can abuse anyone they want, and nothing will happen to them. Resident #705 continued, Like with (CNA A), they (facility staff) made me feel like I was lying. I thought (CNA A) was going to hit me and there is nothing I can do about it. I am a quadriplegic; I can't even block them. When asked if they felt safe in the facility now, Resident #705 revealed they were concerned and scared of what RN E might do especially after they told the truth. Resident #705 revealed RN E does things to upset them now. Resident #705 was asked what upsets them and stated, (RN E) turns on the light because they know I want it off. When asked, Resident #705 revealed they were referring to the hallway light at night. The Resident disclosed other staff will turn the light directly outside of their room off and RN E will turn it back on. The Resident revealed they felt RN E was doing it purposefully to intimidate them. Resident #705 then stated, It made me feel like employees here can do anything they want and can abuse anyone they want, and nothing will happen to them. Resident #705 continued, Like with (CNA A), they (facility staff) made me feel like I was lying. I thought (CNA A) was going to hit me and there is nothing I can do about it. I am a quadriplegic; I can't even block them. At 12:18 PM on 7/25/22, the Administrator was notified of Resident #705's allegations of abuse. When queried regarding Resident #705, the Administrator stated, (Resident #705) attempts to manipulate staff and pit them against each other. When asked why/how they made that determination about Resident #705, the Administrator indicated the Resident talks to staff about other staff and wants people fired when they do not provide care the way the Resident thinks is correct and timely. The Administrator was queried why they called the Resident manipulative but did not provide specific examples and/or clarifying explanation. The Administrator stated, (Resident #705's) stories become very grandiose. When asked to clarify, the Administrator indicated the Resident's renditions of what had occurred became worse each time they were asked about an incident. On 7/26/22 at 5:25 AM, an interview was completed with Certified Nursing Assistant (CNA) A. When queried regarding Resident #705, CNA A revealed two investigations have happened at the facility. When asked what occurred, CNA A stated, (Resident #705) likes to be turned ever two hours and I was like 20 minutes or so late and they were upset about it. CNA A continued, I told (Resident #705) there are 12 to 15 of you and one of me and indicated the situation was smoothed over. CNA A revealed the next night another CNA had Resident #705 and the Resident said something to that CNA about being upset about me not turning them every two hours and that (Resident #705) called me a[OBSCENITY]y ass CNA. CNA A stated, So I went into talk to (Resident #705). When asked if they were upset or mad when they went into Resident #705's room, CNA A replied, I was upset that (Resident #705) called me a[OBSCENITY]y ass CNA. CNA A stated Resident #705 apologized to them for saying that. CNA A was asked if Resident #705's room door was open or closed and replied, closed. When queried if they yelled at Resident #705, CNA A stated, I had a tone, but I wouldn't say I yelled. When asked if they used profanity when speaking to the Resident, CNA A indicated they did not recall using profanity directed at the Resident. When queried regarding Resident #705 when they went in their room to confront them with the door shut, CNA A stated, (Resident #705) was upset. CNA A then stated, From what I heard from other techs (CNAs), (Resident #705) was upset for about a week. When queried why they went into Resident #705's room when they were upset, CNA A indicated they wanted to confront the Resident and ask them why they said that. When asked if they spoke to anyone else about what occurred, CNA A replied, I just talked to them about what (Resident #705) said. CNA A was then asked if they told CNA B about it and replied, I just said that (Resident #705) and I got into it. CNA A was asked when they spoke to CNA B and revealed it was right around when it occurred. CNA A was asked why they had denied talking to CNA B in the statements they provided to the facility and indicated it was a misunderstanding. No further explanation was provided. A review of the medication cart controlled substance documentation book on 7/27/22 at 9:00 AM revealed no log/form for Resident #705's alcohol. An interview was completed with RN AO on 9:13 AM on 7/27/22. RN AO was asked where Resident #705's alcohol is maintained and replied, In the med room. When asked if there is a form or method to monitor the amount of alcohol Resident #705 has, RN AO replied, No narc (narcotic sheet). Observation of the medication room and alcohol occurred at the time with RN AO. Three fifths of [NAME] vodka were sitting on the counter in a dark colored plastic shopping bag. One fifth was open and two were unopened. There were three receipts noted in the bag. The receipts were dated 6/23/22 at 1:12 PM and two receipts dated 7/7/22 at 3:12 PM. When asked if the facility maintains the receipts for Resident #705's alcohol, RN AO revealed they were not aware of the receipts being kept or any system being in place to monitor the amount of alcohol brought into the facility. An interview was completed with the Administrator on 7/27/22 at 9:20 AM. The Administrator was queried regardin[TRUNCATED]

This Citation Pertains to Intake Numbers MI 847 and MI 499. Based on observation, interview and record review, the facility failed to operationalize policies and procedures to prevent the development of pressure ulcers (wounds caused by pressure), ensure comprehensive pressure ulcer care, assessment, documentation, and management per professional standards of practice for three residents (Resident #705, Resident #713 and Resident #714) of five residents reviewed resulting in lack of implementation of interventions and sufficient staff to prevent pressure ulcer development, lack of infection control principles during wound care, development and worsening of multiple facility-acquired pressure ulcers including unstageable (full thickness tissue loss with unknown depth) pressure ulcers, hospitalization due to infection, and the likelihood for further pressure ulcer development, infection, and decline in overall health status. Findings include: Resident #705: On 7/20/22 at 1:10 PM, Resident #705 was observed in their room. The Resident was in bed, positioned on their back and uncovered. Resident #705 was observed to have a [CONDITION(S)], [CONDITION(S)] bag, and suprapubic catheter. The musculature in the Resident's legs were visibly atrophied and wound dressing were noted on both lower extremities. Resident #705 had Prafo (boot with firm plastic form, aluminum supports and [NAME] liner to prevent/treat contractures and minimize pressure on the heel) boots in place on boot of their feet and a foam spacer was in-between their legs, right above the knees. The spacer was held in place with straps that went around the outside of both the legs. The Resident's mattress did not fit the bed frame and a large gap was present between the end of the mattress and the footboard of the bed. An alternating air mattress was in place. The mattress controller was set at auto firm and a flashing warning light was present indicating, low pressure. When queried, Resident #705 revealed their mattress had not been working. When asked if facility staff were aware, Resident #705 replied they were. When queried regarding the wound dressing on their knees, Resident #705 stated, It's pressure sores from rubbing. With further inquiry, Resident #705 revealed they have severe muscle spasms, and their legs and knees would rub together which caused the pressure ulcer. The Resident stated they have no feelings in their legs and did not realize. Resident #705 was asked if the wounds developed at the facility and revealed they had some when they first were admitted , some healed and developed other pressure ulcers at the facility. Resident #705 stated, I don't get repositioned regularly and indicated the facility is short staffed. On 7/20/22 at 4:00 PM, a second observation of Resident #705 occurred in their room. The Resident was in bed, positioned on their back with the Prafo boots and foam spacer in place between their legs. The alternating air mattress remained set at auto firm with the low pressure warning light on. Review of the facility provided CMS 802 Resident Matrix Form revealed Resident #705 had an unstageable, facility-acquired pressure ulcer. Record review revealed Resident #705 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and totally dependent upon staff for the completion of all Activities of Daily Living (ADLs). The MDS detailed Resident #705 had an unhealed pressure ulcer but did not specific the stage and/or number. Review of Resident #705's prior MDS assessments revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] - 11/19/19, Admission MDS Assessment detailed Resident #705 was admitted to the facility with three Stage four (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcers - 11/19/20, Annual MDS Assessment detailed Resident #705 had three Stage four pressure ulcers. - 11/20/21, Annual MDS Assessment detailed Resident #705 had four stage two (partial thickness tissue loss) pressure ulcers, three stage three (full thickness tissue loss) pressure ulcers, and four unstageable pressure ulcers. - 12/21/21, Discharge (return anticipated) MDS Assessment revealed Resident #705 had one stage four pressure ulcer. - 2/14/22, Admission MDS Assessment revealed Resident #705 had two stage three pressure ulcers, one stage four pressure ulcer, and one unstageable pressure ulcer. All MDS assessments indicated the Resident did not have a wound infection. Review of progress note documentation in Resident #705's Electronic Medical Record (EMR) revealed the Resident had developed multiple pressure ulcers while at the facility: - 8/21/21: physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient normally has legs wrapped to help reduce friction. Patient currently has wounds to left great toe, top of left foot, left shin, right knee, multiple spots, and left heel. Staff unwrapped legs today to do wound care measurements . Patient does have redness to right foot across the full top where also has necrotic areas. This might have been secondary to tight binding . Note: The MDS assessment dated [DATE] indicated Resident #705 had one stage four pressure ulcer. - 8/25/21: physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Progressive Care Progress Note . Assessment of wounds . Patient is a quadriplegic . laying in bed . multiple wounds to bilateral lower extremities secondary to pressure and rubbing . (1) right foot area that 100% eschar (dead tissue) with large area of [CONDITION(S)] (redness) around it wrapping around both sides of the foot . (2) right shin approximately 80% eschar and 20% slough . (3) right knee that is 100% eschar . (4) left medial knee is 100% eschar . (5) left lateral knee that 100% . (6) left heel which is approximately 20% slough, and 80% granulation tissue . (7) left top foot which is approximately 50 % eschar 50% slough . wound care is orders in place . rebind legs . Assessment and Plan: Right foot ulceration with surrounding [CONDITION(S)]: Monitor wound closely as [CONDITION(S)] appears slightly larger than previously. Spoke with staff about not wrapping patient's leg so tight as infection and lack of blood flow can both cause patient to lose their foot . Seven wounds were identified in the note. - 8/31/21: SOC-Skin . Resident has multiple new wounds. (1) Right top of foot 13 (length- centimeters [cm]) X 5.5 (cm- width) X UTD (depth-Unable to Determine-Unstageable) . (2) Right shin 1.0 X 1.0 X UTD .(3) Right knee 3.0 X 2.5 X UTD . (4) Left medial knee 3.2 X 2.5 X UTD . (5) Left lateral knee 1.5 X 1.5 X UTD . (6) Left shin 2.5 X 1.0 X UTD . (7) Left hallux 3.0 X 2.5 X UTD . (8) Left heel 6.0 X 3.5 X UTD . (9) Left lateral ankle 2.5 X 1.5 X UTD . (10) Left top foot 3.5 X 3.0 X UTD . Ten wounds were identified in the note. - 10/21/21: physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Chief Complaint: Staff are asking me to look at the left knee wound, states that it is malodorous and necrotic . Patient has multiple wounds. The left knee has positive drainage bleeding. The bone is showing. There is a small area that is possibly necrotic tissue. He recently saw the wound clinic and is scheduled to go back there on November 4, 2021. The right foot bone is also visible . Multiple pressure wounds. Some bandage was able to visualize on the left knee wound. This is an extensive wound with the bone muscle and tendons showing. There is a small area of tissue that is possibly necrotic. It is slight gray in color. Patient is to follow up with wound doctor . 1. Left knee wound, stage 4 . 2. Right foot wound . stage 4 . 3. Right knee wound . stage 2 to 3 . 4. Left foot wound . stage 2 . - 10/24/21: Nurses' Notes . while cleansing scrotal wound there was noted to be a split opening and bone is seen. there are no s/sx (signs/symptoms) infection noted and will continue with tx (treatment) as written - 10/30/21: Orders - Administration Note . Cleanse scrotal wound with NS (Normal Saline). Pat dry. apply collagen (wound treatment) to wound bed and cover with bordered foam every night shift for wound care. wound is 8.0 ([sic] SB of 1.0) x 3.0 x 0.7 (cm) with bone exposure, granulation tissue noted. small ss (serosanguinous) drainage, no s/sx infection noted - 11/3/21: Nurses' Notes . Left kneecap lost stability and its loose d/t (due to) wounds to the inside knee and ligaments instability. NP (Nurse Practitioner) notified . - 12/14/21: physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Chief Complaint: Swelling and redness under left knee . area is a stage 4 wound which is very extensive . Review of clinical census documentation for Resident #705 revealed the Resident was transferred to the hospital Emergency Department (ED) on 12/20/21 for less than 24 hours and transferred again on 12/21/21. - 12/21/21 at 10:37 AM: Transfer Form . Most Recent Blood Pressure: 94/56 (decreased). Date: 12/21/21 at 7:07 AM . Pulse: 103 (elevated) . Temperature: 99.3 F (Fahrenheit- elevated) . Pain: BLE (Bilateral Lower Extremity) wounds, gluteal fold wounds . - 12/21/21: SOC- Skin . (1) Right top of foot 11.0 X 6.0 X UTD, (2) Right ankle 4.5 X 2.5 X 0.2, (3) Right knee 7.0 X 7.0 X 0.2, (4) Right medial knee 5.2 X 3.5 X UTD, (5) Right malleolus 2.5 X 1.3 X UTD, (6) Right plantar 3.5 X 2.5 X 0.3, (7) Left medial knee 13.0 X 10.0 X UTD, (8) Left lateral knee 2.2 X 3.0X UTD, (9) Left shin 6.5 X 2.2 X 0.3, (10) Left malleolus 2.6 X 2.1 X 0.2, (11) Left top foot 6.5 X 2.2 X 0.3, (12) Left heel 2.3 X 1.3 X 0.2, (13) Left heel superior 1.5 X 0.6 X 0.2, (14) Left calf 4.7 X 2.3 X UTD, (15) Left gluteal and (16) scrotum wounds not measured . Followed by wound clinic . Resident is being transferred to the hospital for [CONDITION(S)] and low Hgb (hemoglobin- red blood cells) . Sixteen Wounds identified in the note. - 12/21/21: physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Follow-up on ER visit, [CONDITION(S)], and possible fractures . Patient sent to ER last night for critical (low) Hgb (hemoglobin) had a transfusion as well as x-rays that showed 3 fractures in the left leg. X-ray states 'there is intra-articular impaction fracture of the tibial plateau and probable minimal fracture of the fibular head . underlying nondisplaced fracture cannot be excluded. Lateral dislocation of the patella and medial displacement of the distal femur all is suspected. Extensive overlying soft tissue [CONDITION(S)] and joint effusion' . patient has chronic wound with exposed bone and probable infection, does not get out of bed other than showers . findings are likely pathological and related to possible [CONDITION(S)] . Patient agreed to go back to the hospital and was sent out via ambulance . - 2/9/22 at 3:37 AM: Nursing Evaluation Summary . Resident re-admit from hospital via stretcher . BLE (Bilat Lower Extremity) wounds covered with kerlix and resident 'prefers they be done during the day'. Bilateral Ischium each has small open area noted to be open with hypergranulated (excess granulation tissue which fills the wound bed and creates a raised mass) tissue. No drainage noted . - 2/9/22: physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . - 2/15/22: SOC-Skin . (1) Right dorsum foot 17.0 X 11.0 X 0.0 (closed), (2) Right ankle 2.0 X 1.5 X 0.0 (closed), (3) Right medial calf 9.0 X 2.5 X 0.0 (closed), (4) Right knee 1.0 X 1.0 X 0.0 (closed), (5) Right lateral foot 9.0 X 2.5 x 0.0 (closed), (6) Left medial knee 8.5 X 5.5 X UTD, (7) Left lateral knee 1.5 X 1.5 X 0.0 (closed), (8) Left shin 7.5 X 3.5 X 0.0 (closed), (9) Left medial malleolus 3.5 X 2.0 X 0.0 (closed), (10) Left lateral malleolus 0.5 X 1.5 X 0.0 (closed), (11) Left lateral calf 1.0 X 0.5 X 0.0 (closed), (12) Left Dorsum foot 2.0 X 1.0 X 0.0 (closed), (13) Right Ischial tuberosity 0.5 X 0.5 X 0.1, (14) Left Ischial tuberosity 1.0 X 1.0 X 0.1 . Resident readmitted from the hospital 2/8/22. The wounds with 0.0 depth are epithelialized and closed. Will continue on SOC skin . Fourteen wounds identified including 11 closed/healed wounds, one unstageable wound, and two small pressure ulcers. - 3/3/22: physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . multiple wounds in various stages on BLEs, redness and [CONDITION(S)] noted below the wound on the left knee . -4/1/22: Nurses' Notes . Right shin 1.5 X 0.1 cm 50% slough. Right lat (lateral) foot 9.5 X 2.5cm 40% slough. Right calf sup 5.0 X 0.6 cm 100% scab. Right calf post 1.2 X 0.3cm 100% scab. Right bottom of foot 3.0 X 0.5 (cm) 40% slough. Left top of shin 2.0 X 1.5cm 100% scab. Left top of foot 0.5 X 0.5cm 100% scab. Left heel 8.0 X 3.5 30% slough. Left knee 6.0 X 5.0 cm Bone, granulation and slough - 4/12/22: SOC-Skin . Right shin 1.5 X 0.1 cm 50% slough (yellow colored devitalized tissue resulting from dead cells, protein, and fiber), Right lat (lateral) foot 9.5 X 2.5 cm 40% slough, Right calf . 5.0 X 0.6 cm 100% scab . Right calf post 1.2 X 0.3 cm 100% scab . Right bottom of foot 3.0 X 0.5 40% slough, Left top of shin 2.0 X 1.5 cm 100% scab, Left top of foot 0.5 X 0.5 cm 100% scab, Left heel 8.0 X 3.5 30% slough, Left knee 6.0 X 5.0 cm. Bone, granulation and slough . - 4/12/22: Infectious Disease Consult Note . 4/11/22 . Requested to see patient for positive urine culture . (readmitted ) on December 21st with left knee [CONDITION(S)]. Had MRI confirming [CONDITION(S)] (infection in bone) . - 4/19/22: SOC-Skin . Resident's wounds have been clarified to the following: Left front of knee: 3.5x 4cm unable to measure depth . Stage 4 pressure injury. Left Lateral Knee: 0.8 x0.5 x less than 0.1cm. This wound visualized as a stage 2 . Left Shin: 7 x2.4 x0.1 cm. Unstageable pressure injury . Left Calf: 3 x 1.2 cm Unstageable pressure injury . Left Heel: 3.5 x 2.5 cm. Deep Tissue Injury (DTI- Unstageable pressure ulcer) Visualized as a dark purple intact blister. Right Bottom of Foot: 6.5 x 2 x 0.1 cm. Unstageable pressure injury . moderate to heavy amount of serous drainage noted. Right Lateral Foot: 6.5 x3.5 cm. Depth unable to be measured (Unstageable) . Right Dorsum of Foot: 0.9 x0.5 cm. Visualized as a stage 2. Appears to have previously been a part of right lateral foot wound, as there is blanchable scar tissue connecting these wounds. Right Calf: 2 x0.8 cm. Unstageable pressure injury . All wound measurements clarified due to history of multiple wounds to bilateral lower extremities that have been in varying stages of healing with some wounds splitting into two wounds .has noted wounds to Left foot and left lower extremity dating back to April 2021. He has wounds to right foot dating back to August of 2021 . Potential referrals: Resident is awaiting potential above the knee amputation . due to chronic [CONDITION(S)] of right knee. Surgery is pending MRI . - 5/3/22: SOC- Wound . Wound 1 . Wound Type: Pressure . Unstageable . Right Medial Calf . Follow up . Wound 2 . Wound Type: Pressure . Unstageable . Left Shin . Follow up . Wound 3 . Wound Type: Pressure . Unstageable . Lateral Right Foot . Follow up . Wound 4 . Wound Type: Pressure . Unstageable . Left Medial Calf . Follow up . Wound 5 . Wound Type: Pressure . Unstageable . Right Dorsum Foot . Follow up . Wound 6 . Wound Type: Pressure . Stage 4 . Left Front of Left Knee #1 . Follow up . Wound 7 . Wound Type: Pressure . Stage 2 . Left Front of Left Knee #2 . Follow up . Wound 8 . Wound Type: Pressure . DTI . Left Heel . Follow up . Wound 9 . Wound Type: Pressure . Unstageable . Right Plantar Foot . Follow up . - 7/18/22: Wound Evaluation . Pressure - Stage 2 . Location not set. New- Minutes old . In-House Acquired . Dimensions . Length: 3 cm . Width: 0.8 cm . New . Right buttock wound reopened . - 7/18/22: Wound Evaluation . Pressure - Unstageable . Right Calf (Rear) . 3 Months Old . Acquired: Not Set . Dimensions . Length: 8 cm . Width: 2.8 cm . Deepest Point: 0.6 cm . Exudate . Light . Serosanguineous . - 7/18/22: Wound Evaluation . Pressure - Stage 4 . Left Knee . 3 Months Old . Acquired: Not Set . Dimensions . Length: 3 cm . Width: 3 cm . Exudate . Light . Serosanguineous . - 7/19/22: SOC- Wound . Wound 1 . Wound Type: Pressure . Unstageable . Right Medial Calf . Follow up . Wound 2 . Wound Type: Pressure . Stage 4 . Front of Left Knee . Wound 3 . Wound Type: Pressure . Stage 2 . Right Buttock . Initial SOC (new pressure ulcer) . Care plan updated . Yes . Nutrition/Hydration intake adequate for wound healing . Yes . Date Provider Notified: 7/18/22 . Review and comparison of Resident #705's first documented wound measurements following their readmission from the hospital in February 2022 revealed the Resident was discharged from the facility to the hospital on 12/21/21 with 16 wounds including six unstageable pressure ulcers. The Resident was readmitted on [DATE] and wound measurements were completed on 2/15/22. The measurements revealed the Resident had one unstageable pressure ulcer on their left lateral knee, which the Resident developed at the facility and was transferred to the hospital with, two small pressure injuries, and 11 healed pressure ulcers when readmitted to the facility. Note: The documentation did not correlate with the pressure ulcer information submitted on Resident #705's MDS Assessments which indicated the Resident was discharged to the hospital on 12/21/21 with one stage four pressure ulcer and returned on 2/14/22 with two stage three pressure ulcers, one stage four pressure ulcer, and one unstageable pressure ulcer. An observation of Resident #705 occurred on 7/21/22 at 9:15 AM. The Resident was in their room, positioned on their back in bed. The alternating air mattress remained set at auto firm with low pressure warning indicator light on. The gab between the end of the mattress and the foot board was unchanged from observations on 7/20/22. A small dry erase board was noted on the wall in the Resident's room with 0740 written on it. When asked about the dry erase board, Resident #705 revealed it is the time they were last repositioned. Resident #705 stated, I started having them write it down. The Resident revealed the staff had not been turning them every two hours and they developed pressure wounds in the facility. The Resident revealed they are unable to turn and reposition themselves and did not want to develop more pressure ulcers. When asked, Resident #705 revealed the board was helpful, but they were still not consistently turned/repositioned every two hours. Resident #705 conveyed they had a pressure ulcer on their buttocks again. On 7/21/22 at 9:30 AM, Certified Nursing Assistant (CNA) B entered Resident #705's room. An interview was completed at this time. When queried regarding the low pressure warning light on the Resident's alternating air mattress controller, CNA B revealed they were Not sure what the light meant. When asked about the gap between the footboard and the mattress, CNA B revealed it had been like that. CNA B was asked When asked who monitors the air mattresses and the bed frames and mattress to ensure proper function and fit/size and replied, Nurses. An interview was conducted with Registered Nurse (RN) AC on 7/21/22 at 9:49 AM. RN AC was queried regarding nursing staff role and responsibilities related to monitoring and assessment of resident beds and mattresses to ensure appropriateness and function. RN AC replied, We look at them and indicated any concerns identified by nursing staff are reported. When asked if monitoring of alternating air mattress functionality and settings is completed in the EMR, RN AC replied, No. When queried regarding Resident #705's mattress, RN AC disclosed the air mattress had not been working and would not switch to alternating from auto firm. RN AC continued, I reported it a couple weeks ago. RN AC was asked the date they reported the mattress was not working, RN AC and revealed it was right after they returned from vacation. RN AC was then asked when they returned from vacation RN AC reviewed their calendar and revealed it was around June 17th on a weekend but was unable to provide a specific date. When queried regarding the facility procedure to report concerns regarding equipment and alternating air mattress malfunctions, RN AC indicated Resident #705 had a rented air mattress and revealed they attempted to contact the external vendor. RN AC stated, The (vendor phone reporting) system was down so I left a note for (the Assistant Director of Nursing [ADON]). RN AC was then asked about Resident #705's mattress being approximately eight inches shorter than the bed frame and stated, Maybe because the legs are up (lower part of the bed elevated). An observation of Resident #705's bed was completed with RN AC at this time. Resident #705 was not in their room and the bed was flat. RN AC confirmed the gap between the end of the alternating air mattress and the footboard of the bed was approximately eight inches. When queried regarding the reason for the gap, RN AC replied, I don't know. I never noticed. RN AC was queried if the mattress not fitting the bed frame appropriately may impact pressure zones and functionality of the mattress and revealed they were unsure. When queried if Resident #705's alternating air mattress was assisting to prevent pressure ulcer development and worsening when it was set to auto firm and unable to be changed to alternating, RN AC replied, No. On 7/21/22 at 10:20 AM, an interview was completed with the Assistant Director of Nursing (ADON). When queried regarding Resident #705's alternating air mattress being set at auto firm, staff reports of the mattress not being able to switch to alternating, and the low pressure alarm. The ADON indicated they were unaware the mattress was not working. When queried regarding the mattress being approximately eight inches shorter than the bed frame and how/if that may impact the pressure areas on the mattress, the ADON indicated they were unsure. The ADON revealed Resident #705's mattress and bed frame were rented from an external vendor. Review of Resident #705's current and resolved care plans revealed an active care plan entitled, The resident is at risk for skin breakdown to pressure areas and/or boney prominences r/t (related to) [CONDITION(S)], muscle weakness, muscle spasm, generalized anxiety, major depression, chronic pain, immobility. The resident has actual pressure related impairment to the following areas: Right medial calf, Front left knee, Front right knee. Hx (History): L (Left) Medial Malleolus, L Front Knee, R (Right) Ischial Tuberosity, L Ischial Tuberosity, L Lateral Calf. Resident is particular about wound care and at times resident chooses to not allow nurses to complete the measurements and treatments . (Initiated: 2/8/22; Revised: 7/12/22). Care plan interventions included: - Administer medications as ordered . (Initiated: 2/8/22) - Administer treatments as ordered . (Initiated: 2/8/22) - Encourage resident to utilize heel protecting boots while in bed and up in chair (Initiated: 2/8/22) - Evaluate/record/monitor wound healing. Measure length, width, and depth were possible. Evaluate and document status of wound perimeter, wound bed and healing progress. Report improvements and decline to the MD (Initiated: 2/8/22) - Float heels while Resident is in bed (Initiated: 2/8/22) - Resident's wound surgeon recommends limited time up in chair. Resident often choose to not follow recommendation. Encourage to lay down. Resident rarely chooses to get out of bed at this time. - The resident requires a low air loss mattress (Initiated: 2/8/22) - Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - Encourage resident to utilize leg spacing cushions and/or rolled up linen with leg wraps to protect resident from muscle spasms (Initiated: 2/8/22) - Turn and reposition resident as allows/requests (Initiated: 2/8/22) Review of Resident #705's Health Care Provider orders in the EMR revealed the Resident did not have an active order for an alternating air mattress. A discontinued order for a Low air loss bed (Ordered 11/20/20) was discontinued on 12/21/21 due to the Resident being hospitalized . The Resident also did not have an active order for turning/repositioning and/or Prafo boots. An interview was completed with the facility Administrator on 7/25/22 at 9:20 AM. When queried regarding Resident #705's alternating air mattress, the Administrator replied, It (Resident #705's bed) was brought to my attention of Friday. When asked if they were aware the length of time the mattress had not been functioning and nursing staff verbalization of notification to the ADON, the Administrator did not provide further information. On 7/25/22 at 10:35 AM, Resident #705 was observed sitting in their wheelchair in the hall of the facility with their Prafo boots in place. The wound dressing on the Resident's left knee was visibly saturated with bright, red colored drainage. On 7/25/22 at 11:17 AM, Resident #705 was observed sitting in their wheelchair in the enclosed outside common area of the facility. Resident #705 was wearing the Prafo boots they were when in bed. The wound dressings on Resident #705's left knee was visibly saturated with a significant amount of bright red colored drainage. The dressing on the right lower shin was also saturated with visible drainage on the external aspect of the dressing. An interview was completed at this time. When asked, Resident #705 revealed they needed the dressings changed. When queried how often the Prafo boots are removed by staff, Resident #705 replied, When they (staff) change the dressings or doing Range of Motion (ROM). Resident #705 was queried regarding the frequency they receive ROM and replied, (CNA B) is the only Restorative staff and they get pulled to the floor all the time so maybe a day a week. On 7/25/22 at 4:00 PM, Resident #705 was observed in their room. The Resident was in bed, positioned on their back. An interview was completed with CNA T on 7/25/22 at 7:30 PM. When queried regarding Resident #705, CNA T revealed Resident #705 wants to be turned every two hours and it can be difficult to get to them when most of the residents in the hall are completely dependent upon staff. When asked, CNA T confirmed that Resident #705 is supposed to be turned every two hours and identified the Resident has valid concerns because they do not get turned every two hours due to staffing. CNA T revealed the facility is short staffed and does not incorporate resident acuity in staffing which results in delayed care. When asked, CNA T specified the majority of the residents on the vent/vent central unit require two-assist but there will only be one CNA scheduled and no one available to assist so they are forced to provide care on their own. CNA T detailed they are unable to complete incontinence care and reposition all the residents on the unit in a two-hour time frame. CNA T stated the residents are the ones who suffer. On 7/26/22 at 4:30 AM, an observation of Resident #705 occurred in their room. The Resident was positioned on their back in bed. The mattress remained shorter than the bed frame. On 7/26/22 at 5:25 AM, an interview was completed with Certified Nursing Assistant (CNA) A. When queried regarding Resident #705, CNA A indicated the Resident is very particular about their care and being turned every two hours. CNA A revealed it is almost impossible to turn residents every two hours due to staffing and the acuity of residents on the unit. CNA A verbalized they typically work on the Vent and Vent Central units of the facility and most of the residents who reside on that unit require two-person assistance. When asked how many residents on the Vent units only require one assist, CNA A revealed there were seven residents. CNA A then stated, Short (staffed) pretty much every week. CNA A revealed there have been multiple night shifts where there is only one CNA working on the Vent/Vent Central units. When asked if there was adequate staff to turn and reposition dependent residents every two hours, CNA A decisively replied, No. Resident #705 was observed in their room at 7:10 AM on 7/26/22. The Resident was in bed, positioned on their back. The mattress and bed frame remained unchanged. An interview was completed with the facility Administrator on 7/26/22 at 8:05 AM. When queried regarding Resident #705's mattress not functioning and bed frame. The Administrator stated, (Vendor) has on their records that they picked up that bed frame on 2/8/22 and they switched out the mattress on 2/14/22. When asked how that was possible, when they had stated the bed frame and mattress were from the vendor, the Administrator replied, We haven't been getting billed for it. Clearly it was still here. When queried about the mattress malfunctioning, the Administrator stated, We switched that out Friday. When asked why the mattress was not addressed prior to identification by the State Surveyor, the Administrator was unable to provide an explanation. When queried regarding documentation of monitoring and evaluation of resident care equipment in the facility, the Administrator replied, Not for those. When asked to explain, the Administrator revealed the facility did not maintain documentation evaluation and/or functioning of beds and mattresses obtained from vendors. When queried regarding Resident #705 developing a pressure ulcer on their buttocks during the timeframe when the alternating air mattress was not functioning, the Administrator did not provide an explanation. On 7/27/22 at 4:35 AM, an interview was completed with RN AM. When queried regarding Resident #705's wounds, RN AM revealed the Resident had facility-acquired pressure ulcers. RN AM was asked about interventions to prevent pressure ulcer development and/or worsening and indicated the facility utilizes alternating air mattresses. When queried regarding Resident #705's air mattress not functioning, RN AM did not provide an explanation. RN AM was queried regarding the frequency in which residents with or at risk for pressure ulcers are turned/repositioned and replied, Supposed to be every two hours but we haven't had the staff for that. RN AM revealed the staffing was a significant concern which was affecting resident care and outcomes including pressure ulcers. RN AM then stated, Things have gotten worse with (the current Director of Nursing [DON]). When asked what they meant, RN AM revealed the previous DON would make sure there was staff to work, and the managers would cover if needed by the current DON does not do that. When asked, RN AM replied [TRUNCATED]

This Citation Pertains to Intake MI 583. Based on observation, interview and record review, the facility failed to ensure adequate staffing and implement and operationalize policies and procedures to prevent falls for two residents (Resident #708 and Resident #711) of three residents reviewed, resulting in lack of implementation of planned, meaningful, and reasonable interventions to prevent falls, a non-verbal, ventilator dependent resident falling from their bed to the floor during care with resulting facial/head injury, ongoing lack of application of interventions, and the likelihood for additional falls and psychosocial distress utilizing the reasonable person concept. Findings include: Resident #711: On 7/20/22 at 3:42 PM, an observation of Resident #711 occurred in their room. The Resident was in bed and did not respond, verbally or non- verbally, when spoke to. Resident #711 was noted to be both tall and of healthy weight. The Resident had a [CONDITION(S)] (surgically created opening in the front of the neck into the trachea to ensure an open passageway for respirations) and a ventilator (machine which replaces or assists natural breathing) was in use for respiratory support. An alternating air mattress was present on the bed and the Resident was receiving tube feeding (nutritional administered via surgically placed tube). An interview was completed with Licensed Practical Nurse (LPN) AV on 7/20/22 at 3:49 PM. When queried regarding Resident #711, LPN AV revealed the Resident was ventilator dependent and non-verbal. Record review revealed Resident #711 was admitted to the facility on [DATE] with diagnoses which included heart failure, respiratory failure with [CONDITION(S)] and ventilator dependence (unable to breath without use of mechanical ventilator), and gastrostomy (a surgically created opening through the abdominal into the stomach for the introduction of food). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was nonverbal, in a vegetative state, and required two-person, total assistance to complete Activities of Daily Living (ADLs) including bed mobility and transferring. Review of the facility provided CMS- 802 Resident Matrix form revealed Resident #711 had a fall with injury. Review of progress note documentation in Resident #711's Electronic Medical Record (EMR) revealed the following: - 5/23/22 at 11:32 AM: Dietary Progress Notes . Admission Nutrition Assessment . Hospital weight: 194.0 (pounds) . - 5/26/22 at 11:12 PM: Pertinent Charting-Falls . Date of Fall: 05/26/2022 . Situation Details: observed rolling out of bed while up on left side and falling to floor. Assessment: small skin tear to right side of scalp with [NAME] noted injury-[NAME] and small skin tear to right side of scalp. Mitigating Factors: staff member had resident on left side and let them go to get more gloves . Interventions: 2-person assist with bed mobility and while changing brief on resident . - 5/27/22 at 7:12 AM: Pertinent Charting- Falls . Right side of head continues with redness . - 5/27/22 at 11:16 AM: SOC- Falls . Resident was being changed by aide in bed. Aide had soiled gloves and turned to grab clean gloves, which were located behind them. Resident had been resting on left side and began to roll forward off of the bed. Aide attempted to stabilize resident on the bed, but was unable to and resident rolled off of the bed and onto the floor . Reddened areas to resident's face with a small skin tear noted . Factors involved (acute condition/environment, etc.): Resident on an air mattress, which may have contributed to resident rolling out of bed easier . Resident changed to a 2 person assist with bed mobility. - 5/29/22 at 3:00 PM: Pertinent Charting- Falls . scab to right scalp . Review of Resident #711's Nursing Admission Evaluation dated 5/17/22 revealed Resident #711 was determined to be a High Risk for falls. The assessment further detailed, Section II. Activities of Daily Living . Level of assistance needed to move in bed . Dependent . Review of Resident #711's care plan revealed a care plan entitled, The resident is at risk for falls related to: Respiratory failure . (Initiated and Revised: 5/18/22). The care plan included the interventions: - Anticipate and meet the resident's needs based on nursing assessments (Initiated: 5/18/22) - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Initiated: 5/18/22) - Bed in low position when not providing care (Initiated: 5/18/22) Following Resident #711's fall, the care plan was edited to include the following interventions: - Bed Mobility: (dependent) with assist of (2) staff members for turns (Initiated and Revised: 5/26/22) - Bed wheels locked at all times, unless transporting or moving (Initiated: 6/7/22) - Determine causative factors of fall and resolve or minimize (Initiated: 5/26/22) - Review information on past falls and attempt to determine cause of falls. Record possible root causes. Remove any potential causes if possible. Educate resident/family/caregivers as to causes (Initiated: 6/7/22) Review of the care plan history revealed a bed mobility intervention was not in place nor implemented until 5/26/22. Another care plan titled, The resident needs activities of daily living assistance related to: Respiratory failure . (Initiated and Revised: 5/18/22) was noted in Resident #711's Electronic Medical Record (EMR). The care plan included the interventions: - Bedfast: The resident is bedfast all or most of the time (Initiated: 5/18/22; Revised: 5/23/22) - Toilet Use: The resident is not toileted (Initiated: 5/18/22) - Transfer: The resident requires Mechanical Lift (Hoyer) with 2 or more staff assist for transfers . (Initiated: 5/18/22; Revised: 5/23/22) The intervention, Bed Mobility: (dependent) with assist of (2) staff members for turns (Initiated and Revised: 5/26/22) was added to the care plan following the Resident's fall in the facility. Review of Resident #711's Nursing Admission Evaluation dated 5/17/22 revealed Resident #711 was determined to be a High Risk for falls. The assessment further detailed, Section II. Activities of Daily Living . Level of assistance needed to move in bed . Dependent . Review of facility provided documentation related to Resident #711's fall included the following: - Incident and Accident Report: Date: 5/26/22 . 2215 (10:15 PM) . Memory Impaired . Physically Impaired . Decision Making Impaired . Condition prior to incident: Unresponsive . Witness: (Nursing Assistant AW) . Fall . Description: While being changed, the resident was on left side and continues over rolling out of bed and landing face down . Injury type . skin tear . hematoma/bruise . Level of assistance resident requires: 2 . - Fall RCA Investigation Tool . 6. What level of assistance was resident receiving at time of fall? X 1 assist . No intervention in place for mobility . Conclusion: Resident changed to 2-person assist with bed mobility and cares. Resident dependent with care and became unstable on bed when aide had resident on their side and turned to grab a new pair of gloves . The RCA Tool included a hand drawn picture displaying the fall. The picture showed the Resident face down on the left side of the bed, in-between the ventilator and the bed. The CNA was on the right side of the bed (towards the room door). - Nursing Assistant AW handwritten statement, dated 5/26/22 at 10:35 PM: I was providing care to (Resident #711)- brief change. I had rolled (the Resident) onto their left side and left go of them for a moment to grab new gloves from behind me. Resident started to roll forward off the bed. I attempted to get a hold of them and pull them back onto the bed, but they had already gone to far and fell on to the floor. I immediately opened door and called to nearest nurse for assistance. Note: Provided documentation did not detail the height of the bed at the time of the fall. Review of Resident #711's Documentation Survey Report for July 2022 revealed the task ADL- Bed Mobility revealed facility staff continued to use one staff member for bed mobility. Documentation from 7/1/22 to 7/20/22 for each shift (days, afternoons, and nights) detailed the following: - Day shift: There was no documentation of task completion five times. Task completed with one staff assist occurred 10 times and two staff assist occurred five times. - Afternoon shift: There was no documentation of task completion three times. Task completed with one staff assist occurred nine times and two staff assist occurred seven times. - Night shift: There was no documentation of task completion 10 times. Task completed with one staff assist occurred nine times and two staff assist occurred three times. An interview was conducted with Nursing Assistant AW on 7/25/22 at 3:35 PM. When queried regarding Resident #711's fall, Nursing Assistant AW revealed Resident #711's fall occurred during their second week at the facility and their first week (working) on their own. When asked what happened, Nursing Assistant AW revealed they were changing the Resident's brief by themselves. Nursing Assistant AW stated, (Resident #711) rolled out of bed and landed on their face with their head turned. Nursing Assistant AW stated, This incident was more about their mattress. When asked what they meant, The edge of their mattress was slopping down. I found out they had the wrong mattress. Nursing Assistant AW revealed the mattress was changed after the Resident fell . When asked if the Resident's [CONDITION(S)] and/or vent became disconnected when they fell , Nursing Assistant AW replied, I'm not sure. When queried the height of the bed at the time of the fall, Nursing Assistant AW replied, Waist high (approximately three feet). When asked if Resident #711 was supposed to have one or two people for ADL care and bed mobility, Nursing Assistant AW stated, Was a one (person assist) at that time but nurse changed to two after that. When queried how they knew the Resident only needed one person assistance, Nursing Assistant AW stated, The staff I was shadowing (during orientation) all did it with one assist. With further inquiry regarding their orientation, Nursing Assistant AW revealed (CNA A) orientated them and had changed Resident #711's brief by themselves. Nursing Assistant AW then stated, We are so short staffed that most of the time have to do with one (staff). When queried regarding the Resident's response when they fell , Nursing Assistant AW indicated Resident #711 is non-verbal and did not respond. When queried regarding the Resident's injuries, Nursing Assistant AW indicated the nurse assessed the Resident after they feel but stated, They hit their head and was bleeding. On 7/26/22 at 5:25 AM, an interview was completed with Certified Nursing Assistant (CNA) A. When queried, CNA A indicated they typically worked in the vent side of the facility. When queried if they trained Nursing Assistant AW, CNA A revealed they did. When queried regarding the number of staff needed to turn and reposition residents receiving mechanical ventilation, CNA A revealed they prefer to have two staff but there are a few residents who only require one assist. CNA A was asked who the residents only requiring one assist were and stated three resident names. (Resident #711) was not included. When asked why those residents only required one assist whereas all others required two, CNA A replied, They can help roll. CNA A was asked if there was enough staff in the facility to roll the roll residents with two assist and replied, No and I can't do (turn and reposition) these people (residents) every two hours by myself. When asked if other staff assisted to provide ADL care including incontinence care and turning, CNA A replied, If they have time but did not elaborate regarding the frequency in which assistance is provided when asked. An interview was conducted with the facility Administrator on 7/26/22 at 9:50 AM. When queried regarding Resident #711's fall and the facility procedure for assessment and determination of level assistance required for transfers and mobility, the Administrator revealed nursing staff make the determination upon admission in the nursing assessment. When asked if residents are evaluated by therapy services for mobility and transfer needs upon admission, the Administrator revealed therapy does not evaluate unless the resident is going to be seen. The Administrator was asked if Resident #711 was evaluated and indicated they would need to review the medical record. When queried regarding Resident safety during repositioning including emotional well-being when they are completely dependent upon another person for movement, turning, and repositioning and there is only one person in their room with their bed elevated, the Administrator reiterated that nursing staff evaluate and determine assistance required for care. On 7/26/22 at 4:35 AM, an interview was completed with Registered Nurse (RN) F. When queried if they were working when Resident #711 fell out of bed, RN F revealed they were working the night a resident fell out of bed right on their face. RN F stated the Resident fell right on the IV pole and you could see the IV pole in their face. With further inquiry, RN F revealed they were speaking about a different Resident and not Resident #711. When asked about Resident #711's fall on 5/26/22, RN F revealed they were not working on the night the resident fell but did work the following night. RN F was asked if it was safe to roll and reposition Resident #711 with only one staff member at any time during their admission, RN F replied, Not safe to turn with one person. When asked if there was a concern related to Resident #711's mattress, RN F was unable to recall. When asked if there was adequate staffing for two staff to provide ADL car e On 7/27/22 at 9:30 AM, the Administrator revealed Resident #711 did not have a PT (Physical Therapy) evaluation. An interview was completed with Licensed Practical Nurse (LPN) AR on 8/2/22 at 9:00 AM. When asked if they were working on 5/26/22 when Resident #711 fell , LPN AR indicated they did not think so. LPN AR was queried regarding turning and repositioning residents who are ventilated and stated, Should not turn with one person (staff) but they do. LPN AR revealed there is not always enough staff in the facility on night shift to have two people to turn residents. An interview was completed with RN E on 8/2/22 at 12:30 PM. When asked, RN E indicated they recalled Resident #711's fall on 5/26/22. When queried what had occurred, RN E specified they were not in the room at time of the fall but that the Resident rolled out of bed during care. When asked, RN E revealed the staff member was changing the Resident's brief alone when the fall happened. RN E was asked if it is typical for one staff member to change a Resident's brief when the Resident is ventilated, non-responsive, and completely dependent. RN E did directly respond but stated, There was no intervention for Resident #711's bed mobility. When queried if they considered it safe to roll and reposition a 190-pound resident who is also completely dependent with a [CONDITION(S)] and on a ventilator with only one staff member, RN E replied, That is why I added the intervention for two (staff assist). When asked about Resident #711's injuries, RN E revealed the Resident landed face down and had a big goose egg and quite a bit of blood from the injury on their head. When asked if their ventilator and/or [CONDITION(S)] were affected, RN E was unable to recall. RN E was also unable to recall if Resident #711's head hit anything other than the floor and what specifically caused the injury with bleeding. When asked why the Resident was not transferred for further assessment due to their inability to respond, RN E indicated the Health Care Provider was notified. No further explanation was provided. When asked if there was a concern related to Resident #711's mattress, RN E was not able to recall. An interview was completed with Therapy Director AX on 8/2/22 at 11:13 AM. When queried regarding Therapy evaluation of residents for turning and repositioning, Director AX stated, It should be standard practice. We would assess for bed mobility and transfer. When queried regarding Resident #711 not being evaluated by Therapy staff for bed mobility needs/assistance level, Director AX was unable to provide an explanation and stated, That falls to nursing. An interview was completed with the facility Administrator on 8/3/22 at 1:05 PM. When queried regarding Resident #711's fall in the facility and why the Resident did not have a care plan in place for two-person assistance prior to the fall when their MDS and nursing admission assessment documentation indicated they were completely dependent and required two-person assistance for bed mobility, the Administrator was unable to provide an explanation. Resident #708: A review of Resident #708's medical record revealed an admission into the facility on [DATE] with re-admission on 4/8/21 with diagnoses that included acute respiratory failure with [CONDITION(S)], [CONDITION(S)], diabetes, stroke, [CONDITION(S)], urinary tract infection, pain in right hand, heart failure, [CONDITION(S)], muscle weakness, [CONDITION(S)] and anxiety disorder. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14/15 that indicated intact cognition. Further review of the MDS revealed the Resident had functional limitation in range of motion with impairment on one side of the upper extremity and on one side of the lower extremity and needed extensive assistance with two persons physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. A review of Resident #708's fall incidents and Fall RCA Investigation Tool revealed the following: -Dated 1/14/22, time of incident 5:00 PM, brief description: Resident was transferring to bedside commode and got weak and sat on the floor. CNA (Certified Nursing Assistant) was assisting resident to t/f (transfer) with gait belt. Initial root cause of the fall? Resident has left side weakness/paralysis, does not do well with taking to many steps with t/f. Resident is supposed to be 2 PA (physical assist) with gait belt and hemiwalker-stand pivot. Conclusion: Resident got weak during t/f Commode should be as close to bed as possible. CNA was t/f with 1PA when resident is 2PA. -Dated 4/21/22, time of incident 8:45 PM, Brief Description: Resident lowered to the floor by CNA post shower, after legs became weak. CNA attempted 1 person transfer without gait belt. Initial root cause of the fall? Only one CNA and no gait belt was used. Conclusion: Resident was transferred by 1 CNA. Kardex states that resident required 2 person assist with transfers. No injuries noted. A review of Resident #708's Care Plan revealed the following: -Focus: The resident is a t risk for falls related to: Left side weakness, with a goal The resident will be free of falls through the review date. -Focus: The resident needs activities of daily living assistance related to: obesity, resistive to care at times, CHF (congested heart failure), schizo ([CONDITION(S)]), [CONDITION(S)], dementia, left sided weakness, with interventions of Transfers: Resident is 2 person assist, stand pivot with hemi-walker and gait belt, date initiated 4/8/21 and revision on 9/9/21. On 7/20/22 at 1:12 PM, an observation was made of Resident #708 lying in bed, dressed. The Resident answered questions and conversed in conversation appropriately. The Resident had indicated that she was unable to use her right arm and hand after having a stroke. The Resident was asked about adequate staffing and the Resident reported the facility does not have enough staff and talked of long wait times for call lights to be answered. The Resident reported staff need two people to get me out of bed and stated, sometimes I just stay in bed. The Resident continued and stated, They need two people to transfer me, they are supposed to have two. When asked if she had any falls, the Resident reported she had a fall when only one person transferred her after her shower trying to get back into bed. When asked if she was injured, the Resident indicated she was not injured. On 7/28/22 at 12:20 PM, an observation was made of Resident #708 lying in bed. The Resident was pleasant and conversed in conversation. When asked if the Resident had any other staffing concerns, the Resident reported not enough staffing and stated, No one wants to work, they don't have enough. The Resident indicated that staff was too busy and sometimes has to wait over half an hour before someone comes to answer the light. The Resident stated, I had a fall, only one CNA was helping, I am supposed to have two staff. When asked if they had used a gait belt, the Resident stated, No, I am supposed to have that on also. The Resident voiced there was not enough help, they need two people to transfer me. The Resident reported sitting on the bedpan for two hours on Saturday with the call light on. On 8/1/22 at 10:52 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #708's incident and accident report for 1/14/22 and 4/21/22. The Resident's transfer status of two-person physical assistance and use of gait belt with transfers was reviewed with the DON. The DON indicated that the Resident was to have two persons assist with transfers and that the gait belt was to be used. When asked to talk with CNA H, the DON indicated that the CNA was not available for interview and reported she was off of work. A review of facility policy titled, Use of Assistive Devices, reviewed/revised 1/1/2022, revealed, Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Policy Explanation and Compliance Guidelines: 1. Assistive devices are tools, products, types of equipment, or technology that help individuals perform tasks and activities. They may help the individual move around, see, communicate, eat, or get dressed. Assistive devices include: . e. Mobility aids . 2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care . Review of facility policy/procedure entitled, Falls - Clinical Protocol (Revised: 1/1/22) revealed, 1. As part of an initial and ongoing resident assessment, the staff will help identify individuals . Admission Evaluation Data Form, which includes the falls risk evaluation . 2. Based on the assessment an initial plan of care will be developed and implemented to address identified risk. This will be revised as necessary. 3. The Minimum Data Set (MDS) and subsequent CAAs will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls. 4. Goals of the plan of care . may include, but not limited to reduction of falls, minimize injury from falls, and/or prevent falls while maintaining and/or improving resident abilities and quality of life. 5. Interventions should be developed and implemented per the assessed needs .

This citation pertains to intake MI 604. Based on interview and record review the facility failed to ensure that one of one resident (#10) assessed for diabetes was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: According to an article published in the Annals of Long-Term Care, 10/2019, titled Creating [MEDICATION(S)] Standing Order to Treat Severe [CONDITION(S)] in Long-Term Care: Glucose is the primary fuel source for the body and is critical for normal brain function. [CONDITION(S)] [a dangerous condition that manifests as an .altered mental status, [CONDITION(S)], coma, and, if left untreated, brain damage and death] is generally defined as a blood glucose level below 70 mg/dL [milligrams per deciliter] .The signs and symptoms of [CONDITION(S)] first present in patients when their blood glucose levels reach 60 mg/dL and increase in severity as their levels fall to 50 mg/dL, with the most dangerous effects occurring at blood glucose levels below 40 mg/dL .[MEDICATION(S)] injections are recognized as a rescue agent for patients with severe [CONDITION(S)]. According to Fundamentals of Nursing, Concepts, and Practice by Mosby. Potter, Perry, A.G., 8th edition, The professional standard of quality for documentation of the residents' health care in a medical record is the information must be true and complete. A review of the facility policy titled [CONDITION(S)] Management, dated 1/1/21, reflected: under Policy: It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic episode. Under Compliance Guidelines: .3. Residents that have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. A bedside blood glucose test should be administered for any resident reporting or experiencing symptoms of [CONDITION(S)] such as: a. Shakiness, b. Nervousness or anxiousness, c. Sweating, chills or clammy skin, d. Fast heartbeat, e. Irritability, f. Confusion, g. Dizziness or lightheadedness, h. hunger, i. Nausea, j. Pallor, k.Feeling sleepy, l. Weakness or having no energy, m. Blurred or impaired vision, n. Tingling or numbness in the lips, tongue or cheeks, o. Headaches, p. Coordination problems, q. Seizures. 5. If the blood glucose reading is 70 mg/dL or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders with follow up of blood glucoses as indicated, and notify the practitioner of the results as ordered .8. The blood sugar(s) and treatment will be documented as per facility protocol (e.g., resident chart, MAR [medication administration record], eMAR [computerized MAR], etc.). The policy failed to mention unable to arouse or unresponsive as a symptom of [CONDITION(S)], nor is there a [CONDITION(S)] protocol per Nursing Home Administrator A. According to the pharmaceutical insert for [MEDICATION(S)], Directions for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . For adults .1 mg by subcutaneous [under the skin] intramuscular [into the muscle] into the upper arm, thigh or buttock, or intravenous injection .5. An unconscious patient will usually awaken within 15 minutes following the [MEDICATION(S)] injection. If the response is delayed, there is no contraindication to the administration of an additional dose of [MEDICATION(S)]; however, in view of the deleterious effects of cerebral [CONDITION(S)] emergency aid should be sought so that intravenous glucose can be given .6. After the patient responds, supplemental carbohydrate should be given to restore liver glycogen and to prevent secondary [CONDITION(S)]. Arouse the patient as quickly as possible because prolonged [CONDITION(S)] may result in damage to the central nervous system. According to the facility's admission record, Nursing Admission Evaluation dated 1/12/21 and the plan of care, Resident #10 (R10) was admitted to the facility on [DATE] for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On admission R10 had moderate cognitive impairment with a BIMS (Brief Inventory of Mental Status screen) of 11/15, refused to answer questions about his health and often looked away; required supervision for meals; required two persons for bed mobility, transfers, hygiene and toileting; had difficulty eating solid food; showed signs of moderate depression; did not ambulate and had areas of skin impairment on his coccyx and softening of his heels. A review of the electronic medical record dated 1/15/21 at 7:00 am, reflected a physician's order for [MEDICATION(S)] one application PRN [as needed] every 10 minutes. Under Related diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . THE indication for use was upset stomach, and under Additional Directions was typed, give one dose now and recheck bs [blood sugar] in 10 minutes. May repeat dose if needed. At 9:59 pm reflected a second physician's order for [MEDICATION(S)] one mg/ml PRN [equals one prefilled injection] For BS < 60 [less than]. Use if resident is unresponsive. Notify MD. According to the Geriatric Handbook, page 827, Detemir is a long acting insulin that begins to lower blood sugar in three to four hours after injection, peak effectiveness in three to nine hours and may last up to 23 hours. On page 846 [MEDICATION(S)] 70/30 is an intermediate acting insulin that starts to lower blood sugar in 10 to 20 minutes after injection, peaks in two hours, and keeps working for up to 24 hours. [CONDITION(S)] is the most common side effect of Detemir and [MEDICATION(S)] 70/30, and its use may delay recovery from [CONDITION(S)]. Profound and prolonged episodes of [CONDITION(S)] may result in convulsions, unconsciousness, temporary or permanent brain damage or even death. A review of the electronic medical record dated 1/12 21 reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the eMAR for R10 reflected they received their 70/30 dose of insulin in the morning and the 70/30 and Detemir insulins at bedtime. Blood sugars from 1/12/21 to 1/14/21 were as follows: before breakfast blood sugars ranged from 145 to 112. Before dinner blood sugars were 183 on 1/13/21 and 97 on 1/14/21, the same night R10 has no documented intake for dinner or bedtime snack. The first [MEDICATION(S)] injection was documented at 7:09 am, and the second injection was documented at 10:10 am. A review of the electronic FAR (food acceptance record) for R10 reflected: On 1/12/21 resident refused breakfast and lunch, ate 50% of dinner and had the bedtime snack. On 1/13/21 R10 refused breakfast and lunch, ate 10% of his dinner and refused the bedtime snack. On 1/14/21 R10 ate 65% of breakfast, refused lunch and nothing was documented, including refusals, for dinner or bedtime snack on 1/14/15. According to the facility's electronic Speech Therapy Evaluation and Plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the electronic medical record titled SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress notes - V3, dated 1/15/21 at 1:33 pm, reflected documentation of vital signs at times ranging from 1:00 am to 1:38 pm. The resident had already left the building. Under nursing notes was documented At 0650 [6:50 am] this morning, routine blood sugar was found to be 25. [MEDICATION(S)] one ml administered in left thigh. Blood sugar rechecked in 30 minutes with result of 51. Rechecked in one hour with result of 57. NP [nurse practitioner] at bedside and ordered 2nd dose of [MEDICATION(S)]. Blood sugar continues to stay in the 50's and resident is unresponsive. Attempts at starting a peripheral IV were unsuccessful. Orders to transfer to the hospital emergency for eval and treat. 911 notified. A review of the electronic record titled Transfer Details, dated 1/15/21 at 10:00 am, reflected R10 was transported to the hospital at 9:51 am. A review of the EMS (emergency medical service) Patient Care Report for R10, they received the call for transport on 1/15/21 at 9:38 am, arrived at the facility at 9:42 am and left the facility with R10 at 10:02 am. His blood sugar was 86 after a third [MEDICATION(S)] injection given just prior to transport. R10 had blood in his mouth, his jaw was clenched, he was arousable to painful stimuli only, his eyes were to the right and he would not move his head in any direction. The ambulance diverted to the closest hospital due to being unsure about stroke symptoms. A review of the progress notes dated 1/15/21 at 9:45 am documented by Staff T reflected, Blood glucose level this am at 0650 [6:50 am] was 25. after 2 [MEDICATION(S)] injections and over 2 hours, blood sugar still at 57. Nurse practitioner and unit manager unable to start IV. Resident sent to hospital emergency for eval and treat. A review of the progress notes dated 1/15/21 at 9:12 am documented by Staff T reflected, 0700 [7:00 am] blood sugar 28 had already received 1 dose of [MEDICATION(S)]. 0705 blood sugar 33, blood pressure 201/89, heart rate 104 bpm [beats per minute. 0710 blood sugar 42. 0730 blood sugar 51. blood pressure 172/111, heart rate 118 bpm. On 5/12/21 at 1:45 pm, Nurse Practitioner (NP) U was interviewed as follows: NP U entered the building between 8 and 8:30 am, went straight to the bedside and asked for the IV to give glucose and a second [MEDICATION(S)]. NP U said the nurses probably had to run to the medication (med) box in the med room. When asked about their understanding of the facility's [CONDITION(S)] protocol, NP U said check blood sugars frequently, aim for a blood glucose greater than 80. Staff U was not aware it had been 1.5 hours since the first [MEDICATION(S)] was given. If a call was made to the on-call provider, said NP U, I did not get it. [MEDICATION(S)] was supposed to work rapidly. On 5/12/21 at 2:00 pm, Staff V was interviewed. They had a huge number of blood sugars to do on 1/15/21 am. R10's blood glucose was very low and I went to get Staff T for help, and we discussed oral glucose. The night shift Staff L was still there helping me with blood sugars. Staff T was in with R10 for 20 - 30 minutes and came out. Staff V waited about 15 minutes, after Staff T went back to her area. Staff V I checked R10's sugar - it was still low. Staff U came into the room, and Staff V said she was irritated that Staff T left. We were unable to start an IV, and sent him to the hospital. when asked what kind of monitoring was supposed to happen in cases of extremely low blood sugar, Staff V said recheck the sugar until it goes up. On 5/12/21 at 2:00 pm, Staff V was interviewed about staffing. The nurse that works the charge cart had fewer residents and was supposed to help other nurses in the facility. The charge nurses rarely come to the long term care side. The charge nurse often stays on the ventilator side unless we ask. clean resident's up. When asked who took R10's first blood sugar the morning of 1/15/21, Staff V believed it was Staff L. On 5/12/21 at 2:25 pm Staff T was interviewed. They said Staff V asked them for help. Staff T checked R10's sugar and noted he was unresponsive and his eyes were fluttering under his eyelids. We're supposed to give orange juice, but R10 was unresponsive. Injecting [MEDICATION(S)] was next. Recheck blood sugars every 15 minutes. Staff T could not recall how long it took to get his blood sugar up to 57. When asked, believed R10 went to the hospital between 8 and 8:30 am. Doesn't know how long this took. Believes sent out around 8 - 8:30. Staff T recalled his color was OK, R10 was not ashen, and did not recall R10 was sweating When asked, Staff T thought the night aide discovered him the way he was. On 5/13/21 at 8:00 am, Staff W was interviewed. Staff W was unable to recall anything about the low blood sugars, but seemed to recall there was some concern and discussion among nurses about his not eating well and his insulin doses, probably during report. On 5/13/21 at 3:55 pm, Director of Nurses (DON) B was interviewed. When asked about how to use [MEDICATION(S)] and assessing blood sugars during a low blood sugar incident, DON B said they would have to look it up. DON B also said they would find out what time R10 actually left for the hospital on 1/15/21. On 5/13/21 at 4:15 pm, Doctor (Dr) X was interviewed. Dr X said the facility made him aware of R10 and his low blood sugars. Dr. X was not aware that R10 had eaten very little, and nothing was documented for supper or bed time snack on 1/14/21. Dr X said NP Y was on call and the log showed the call came in at 6:51 am about low blood sugars for R10. On 5/12/21 at 8:00 am, Staff L was interviewed. Staff Q reported to Staff L that R10 was different or sleepy. Staff L asked for vital signs, but states did not document these. No blood sugar was checked at that time. After report, Staff V came out of R10's room and said the blood sugar was very low. Staff V needed help, so Staff L told Staff V that R10 needed to drink orange juice or get [MEDICATION(S)], and call the doctor on-call. then, Staff T came to help. Staff L said they did not see R10 after Staff Q reported, and believed Staff W did checks between 4:00 and 6:00 am. R10 was fine at bedtime when I gave the insulins to him. Staff L was not aware that supper and bedtime snack intake was not documented. On 5/12/21 at 11:34 am, Staff Q was interviewed. When asked, Staff Q said the last time they rounded on R10 was probably 5:00 to 5:30 am. Staff Q worked 10:00 pm to 6:00 am in January. Staff Q checked R10's brief and he wasn't responding, so called R10's name and still to response. Staff Q checked his oxygen level and it was good:. When asked, believes he told Staff L R10 was not waking up and not really responsive. Staff Q was unable to recall if they checked R10's vital signs. Staff L came and looked at R10 while Staff Q was still in the room. R10 didn't wake up for Staff L. When asked if he had known R10 prior to the morning of 1/15/21, Staff Q said yes for a day or two. Staff Q said they talked with R10 at the beginning of the shift, sometime after 10:00 pm. R10's speech was clear. Staff Q doesn't remember if anyone checked R10's blood sugar. On 5/12/21 at 10:00 am, NP U was interviewed. NP U did not remember a call about R10 that morning, and he did not know R10. When asked what was usually done with severe low blood sugar, NP U said the nurses gave [MEDICATION(S)] SQ immediately if the resident was unresponsive, then called 911. I usually get the call after the nurse have called 911, said NP U. I've never had a blood sugar that low. On 5/12/21 at 12:05 am, Assistant Director of Nursing (ADON) Z was interviewed. When asked, ADON Z couldn't remember much about R10. When asked how [MEDICATION(S)] was usually given, ADON Z said that it was given after 15 - 20 minutes if the blood sugar didn't come up. On 5/12/21 at 12:15 pm, Staff AA was interviewed. NP U came into the room shortly after. The ambulance had been called, and Staff AA was unsure if a second [MEDICATION(S)] had been given. and didn't know who discovered him. When asked, Staff AA said [MEDICATION(S)] was based on Dr. order, and the nurse usually checks a blood sugar 15 minutes later. If the Resident was no better, a second [MEDICATION(S)] was given. In report, we were told R10 couldn't drink juice. When I saw R10 during the IV attempts, They were making noise and moving their head. On 5/12/21 at 1:15 pm. Family R was interviewed about R10. They believed R10;s blood sugar was 25 in the emergency room . Family R said R10 was always asleep at the facility when he called. After the hospitalization following the low blood sugar, R10 mumbled and they could barely understand his speech, R10 was a 'liquid' diet, then said puree food sounded correct. Family R said they were told R10 had seizures after arrival in the emergency roiagnom on [DATE]. Family R said that other people checked on R10 and found a full meal sitting on his bed table, uneaten and R10 asleep. R10 was alert and talking normal before coming to the facility. R10 was discharged to another facility, and passed on 2/12/21.

This citation is related to intakes: MI 713 & MI 759 Based on observation, interview and record review the facility failed to A) Use assistive devices during transfers for 2 of 5 sampled residents (Resident #3 and Resident #5) and failed to B) Use required assistance of 2 staff-persons during transfer for 1 of 5 sampled residents (Resident #5) resulting in falls, an [MEDICATION(S)] hematoma, a subfalcine herniation, a left occipital bone fracture, pain, the need for hospital transport, a possible left mastoid fracture, and the potential for additional injuries related to manual transfer from the floor to the bed after a fall with head injury. Findings Include: Resident #3 (R3) The Electronic Medical Record (EMR) on 02/25/20 at 09:28 AM reflected R3 was admitted to the facility on [DATE] with diagnoses that included: Anorexia Nervosa, protein calorie malnutrition, [CONDITION(S)], muscle weakness, nutritional [CONDITION(S)], chronic embolism and [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], hypercalcemia, [CONDITION(S)], major depressive disorder, abdominal pain and urinary incontinence. The admission Minimum Data Set (MDS: resident assessment tool) for R3 reflected she was cognitively intact, required extensive assistance of 2 persons for transfers, bed mobility, dressing and hygiene. Dietary notes dated 01/17/20 reflected R3 was 70 pounds. The facility's incident/occurrence report dated 01/23/20 at 09:45 PM, reflected R3 was going to the rest-room with 1 staff person holding her hands, her knees buckled, she fell backwards and banged her head. The fall resulted in a hematoma/bruise to the back left side of her head, and no mobility devices were checked as being used. Certified Nursing Assistant (CNA C) was identified as the staff who assisted R3 on 01/23/2020. The facility's Quality Assessment & Assurance Investigation Report reflected, Walker not used. Care plan interventions prior to the fall/accident reflected, 1 staff assist with transfers, use of walker with transfers. The Activity of Daily Living (ADL) care plan for R3 revised on 12/27/19 reflected the following interventions: -Ambulation: In room and hallway 1 PA (person assistance) & FWW (front wheeled walker) with cuing for hand placement and facilitation of core control. Date initiated 01/21/2020 -Ambulation: In room and hallway with wheelchair and 1 staff assist, stand and pivot. Date initiated 01/21/2020 Revision on 01/24/2020. -Transfer with 1 PA with pivot transfer to wheelchair. Date initiated 01/20/2020 Revision on 01/24/2020. The Falls care plan focus for R3 reflected: -The resident is at risk for falls related to: Acute Process, Gait/balance problems, [CONDITION(S)]. Date initiated 12/12/2019 Revision on 01/20/2020 Interventions for the Fall care plan included: -Use gait belt for transfers/walking. Date initiated 01/07/2020 -Stand pivot to wheelchair for transfer. Date initiated 01/20/2020 Revision on 01/24/2020 -Use gait belt for transfers/walking and FWW. Date initiated and revised on 01/20/2020 The Kardex for R3 used by CNA's reflected under Safety: -Ambulation: In room and hallway with 1 PA & FWW with cuing for hand placement and facilitation of core control. Under Mobility reflected: -Use gait belt for transfers/walking and FWW. Under Transferring reflected: -Transfers 1 PA with FWW. The care plans nor Kardex listed above for R3 reflected she should be transferred with 1 PA while holding her hands. The facility's June 2018 Falls policy reflected that based on the assessment a care plan will be developed and implemented to address identified risk. This will be revised as necessary. The Fall Investigation Report signed by the Administrator (ADM A) and the Director of Nursing (DON B) reflected the root cause of the fall to be: Staff did not use walker or gait belt with transfer. The intervention to prevent future falls were described as: Education to staff, downgraded Res transfer status, referral to therapy. On 01/24/2020 the Performance Improvement Forms reflected DON B issued two written warnings to CNA C with a hire date of 09/30/2019. 1.The reason for counseling/corrective action reflected: 01/23/20 did not follow care plan/Kardex when transferring resident from bed to bathroom. Kardex called for use of gait belt and FWW. Has this concern been previously discussed with the employee was a question on the form? The answer reflected, Yes-Upon hire education provided to read Kardex prior to care & follow care plans/Kardex each resident for cares. 2.The reason for counseling/corrective action reflected: 01/27/20 did not follow care plan/Kardex when transferring resident from bed to bathroom. Kardex called for use of gait belt. After fall/incident residents are not to be moved until after nurse completes evaluation and approves transfer. At that point being a no lift facility a Hoyer would be used to get the resident off the floor. Has this concern been previously discussed with the employee was a question on the form? The answer reflected, Yes-Upon hire education provided to read Kardex prior to care & follow care plans/ Kardex each resident for cares, and facility is a no lift facility and Hoyer's are to be used to get residents up from the floor. CNA C was interviewed by phone on 02/05/20 at 11:19 AM and was asked to recall R3's fall on 01/23/2020. CNA C revealed, That night it was close to 10 PM I was called to south, because her light was on. I did not have the hall she was on and was walking pass. The nurse said R3 needed her food. When I entered R3 stated she was waiting for her food, but they probably didn't tell you I had to go to the bathroom. CNA C was asked if he knew R3's transfer status, revealed she was a 1 PA, but he had not checked before he went in to help her. CNA C continued, We get up to go to the bathroom, she takes 4-5 steps, I check my back to make sure I don't run into anything, that's when she fell to the ground and hit her head. She cried to get back in bed and I placed her back in bed. CNA C revealed he was holding her hands, when he turned around and had a grip on her up to her elbows but may have loosened his grip a little because R3 was fragile. Also, that her legs were stable when walking, when he turned around her legs gave out and she fell back and that it happened quickly. CNA C revealed he should not have moved R3 after the fall, but in the midst of it she was crying, and he was trying to put her in bed immediately. When asked how R3 was after the fall CNA C revealed, R3 was grabbing her head, asking how big the knot was on her head, complained about it hurting and was tearful. CNA C revealed he then went and got Registered Nurse (RN D), RN D had him get a bag of ice for R3's head. On 02/05/2020 at 2:40 PM DON B was interviewed about R3's fall. She was asked if holding a resident's hands/arms was the standard for transfer of someone with an unstable gait. DON B revealed, They are to follow their care plan, the one that is developed for them. If for example they are a 2 PA stand pivot, they should always be a 2 PA stand pivot and not a 1 PA. When asked what was R3's transfer status at the time of the fall DON B revealed, She was a 1 PA with walker and a gait belt. When asked if the transfer assistive devices were used at the time of fall, DON B revealed she was told No. In addition she revealed, that when CNA's come on shift, they are to review the residents Kardex. When asked if a resident falls, were staff to move them DON B replied, No. DON B revealed she was notified of the fall in the morning, went in to assess R3 at around 08:15 AM, R3 looked white, she was looking up in the ceiling, the way she responded to the questions were concerning and that she told R3 she needed to go out. When asked what was the policy if someone fell and developed a hematoma? DON B revealed they should go out. When she told me no, I told her she did not have an option, but she had to go to the hospital. Minutes after interviewing the DON, R3's father (R3F) was interviewed by phone at 02:42 PM. R3F revealed R3 was malnourished, was weak, and had no muscle strength. R3 could walk as long as she was supported with a gait belt at all times with a wheelchair, and that she had never walked on her own without the support of a walker. Later the same day at 4:12 PM Occupational Therapist (OT W) was interviewed about R3's mobility and recent treatment. OT W revealed that if all the pillows, sheets and blankets were cleared off R3's bed and she was given 15-20 minutes along with the remote bed control and bed enablers, R3 could go from a lying flat, to sitting up at the edge of bed most of time. Yet when sitting up, she almost always 95% of the time, needed physical assistance to scoot her hips forward toward the edge of the bed. When you get her to sit to stand from the edge of the bed, it was a max assist of 1 person. Once standing she pretty much locked her joints in place and could stand, fair minus balance, which means she needs to hold onto something, and she (OT W) would hold on to her just in case with a gait belt. The therapy care plan communication sheet by occupational therapy signed by OT W and DON B dated 01/07/2020 reflected: -Transfers 1 assist -Set up for front closure shirts/jackets, dependent lower body dressing. Staff to position wheelchair next to it with resident reaching for grab bars and staff assisting from back side and using gait belt or -Assist resident from front with staff holding gait belt which is positioned at waist level On 02/05/2020 at 4:21 PM Physical Therapy Assistant (PTA X) was interviewed and asked about R3's level of transfer. PTA X revealed with transfers, R3 from the edge of the bed or from her wheelchair to walker needed 25% help. R3 was to always use a gait-belt with walker because she had no core control. When asked if it would be a good idea to walk R3 holding her hands? PTA X stated, Oh God no. I once had to talk to CNA about walking her with a gait belt and walker and about using a wheelchair as well, because of her lack of core strength. PTA X revealed R3 did not have strength in her core to maintain an upright position. When asked how she felt R3 should be ambulated, PTA X revealed the gait-belt, walker and wheelchair were the most recent recommendations for transfer prior to discharge. The therapy care plan communication sheet by physical therapy signed by an PTA and DON B reflected: -1 assist for transfers, toileting, bed mobility and limited assist for ADL's. -Ambulate in room with FWW, 1 PA stand in room -Ambulate in hallway with FWW, 1 PA minimum assist with curing for hand placement and facilitation of core control. On 02/05/2020 at 05:28 PM with permission, R3 was interviewed at a local hospital she had been admitted to. R3 appeared to be emaciated, she had a kerlix bandage covering the top of her head, blood products were infusing in her intravenous line, and she had a nasogastric tube in her nose. R3 was asked to recall the fall incident on 01/23/2020. R3 revealed she had been waiting a long time to go to the bathroom and get her dinner, it was late at night and she was tired. Usually when taken to the bathroom, staff used the walker, the wheelchair and a gait-belt. R3 stated CNA C stood her up, was not close to her, did not use a gait-belt, and her legs immediately gave out on her. Her legs went down to the side, it hit hard on her legs and it hurt so bad. Next thing I remember, I was laying down holding my head. I remember saying to my mom that they dropped me. I don't remember anything else after that. When asked where she hit her head? R3 revealed, The back of my head (and touched the occipital bone on the left side of her head). It was the worst pain I ever felt in my entire life. It hurt so bad. When asked to rate the pain on a 0-10-point pain scale (0=no pain to 10=sever pain) R3 revealed it was a 20 and piercing. The occipital bone forms the base of the skull at the rear of the cranium. R3 then pointed to the back of her head (the same area she earlier touched), revealed her legs hurt too, but the main thing she remembered most was her head. R3 denied recalling how she got back in the bed and could not remember if she was offered to go to the hospital. When asked how her pain was currently R3 replied, It always hurts. It's like a constant pain. I can't hear out of my left ear. It's pressure inside of my ear, and the back of my head always hurts, and I can only lay on this side (R3 was laying on her right side). My neck hurts all the time ever since the fall, my left arm won't go up much. R3 then raised her left arm, and was observed to only raise it to a 90-degree angle from her body. R3 then raised her right arm, and was observed to raise it up to approximately 135 degrees from her body. When asked to rate her pain currently on a 0-10 point pain scale, R3 stated a 8 and pointed again to the left occipital bone area. CNA Z was called on 02/06/2020 at 09:49 AM. CNA Z denied working with R3 on the day of her fall, however she did reveal she had transferred R3 before. When asked how was R3 to be transferred CNA Z revealed, with a gait belt, and with a walker that is to be in her room. Also, when she transferred R3, she used a gait-belt and wheelchair. CNA CC was interviewed on 02/06/2020 at 01:03 PM and asked about R3 transfer status. CNA CC revealed, she had transferred R3 out of bed to the bathroom on third shift. CNA CC revealed R3 sits at the edge of bed, CNA CC used a gait-belt to stand and pivot R3 to the wheelchair, and used the same method with the wheelchair to bathroom with a gait-belt to pick her up. CNA CC revealed R3 knees locked, and she had strength to stand. When asked if she would ever transfer R3 holding her hands and letting her walk CNA CC replied, Absolutely not, any resident who needs assistance is to have a gait belt. If a mechanical lift is not used, you must use a gait belt. A CNA who desired to remain anonymous was interviewed during the survey from 02/05/2020-02/11/2020. When asked about R3's transfer status the CNA revealed, initially R3 was transferred with a gait-belt and 2 PA, then R3 was transferred with a gait-belt, walker or wheelchair. R3 preferred to go in the bathroom with the wheelchair with gait-belt. When asked if she would transfer R3, by letting her walk while holding her hands? The CNA replied, I would not have transferred her by hand. I would have told her No. I would go by the transfer Kardex. On 02/06/2020 at 03:50 PM RN D was interviewed and asked to recall R3's 01/23/2020 fall. RN D revealed the CNA told him R3 fell backwards onto her head. He went to check on her, she was in the bed, and had a lump on her head half the size of a ping pong ball. They got an ice pack to her head and did a set of neurological (neuro) checks that were within normal limits (WNL). RN D talked to the Nurse Practitioner (NP AA), and updated him with R3's status and neuro checks. At the beginning RN D told R3 she had a big lump, he was concerned, she was sick and to consider going to the emergency room (ER), but she declined a total of 3 times (after the fall, before the Administrator (ADM A) arrived, after ADM A arrived in front of her parents, and also during the night when her mother went to the bathroom). RN D revealed he checked R3's mentation away from the mother, because it actually changed when her mother was there. When her mom was there, she seemed more confused. However, R3 was alert and oriented x 4 (person, place, time and situation) with all neuro checks and at 03:00 AM. There was a notable change in the level of orientation when her mother was present. Through the night when RN D checked her pupils and even until he left at 06:00 AM, he revealed R3's pupils were brisk, reactive and equal. At 06:00 AM the lump on R3' head had significantly decreased from the initial impact, and the ping pong ball size disappeared, and it was only swelling at the area. At 03:00 AM the size of the area, was the same as 06:00 AM, with generalized swelling no huge lump with bruising. When queried about transfer status before the fall, RN D revealed R3 was a 1 PA with a walker. As a result of the fall we changed her to wheelchair with staff assist. RN D was asked if a gait-belt was to be used with R3's transfers and replied, The CNA's are to wear the gait-belt as a part of their standard uniform and are to use it as well. Absolutely not, was the response RN D gave when asked if he thought it was appropriate to transfer R3 by her hands. RN D was asked if R3 complained of pain. RN D revealed R3 did complain of pain and that was why he got her the ice pack and gave her Tylenol. When asked if she described the pain RN D revealed R3 stated, It really really hurts bad. Progress/Nursing notes reviewed from 01/23/2020 09:45 PM (the previous note was written by NP AA dated 01/23/2020 at 04:04 PM, but was actually created on 01/27/2020 at 04:05 PM as a late entry) to 01/24/2020 at 06:02 AM reflected the following: 1/24/2020 06:02 AM Nurses' Notes Note Text: Resident neuro checks completed and pupils are equal, brisk and reactive, hand grasps are equal and moderately strong, resident is alert and oriented times four at this time and making a joke, will continue to monitor her today. 1/24/2020 03:40 AM Nurses' Notes Note Text: Residents pupils checked at this time and they continue to be equal and reactive, pupils are brisk in response to light from flashlight, left back of head still tender to touch, [CONDITION(S)] in area has diminished at this time from ice pack. 1/23/2020 22:09 PM Nurses' Notes Note Text: After fall resident was questioned if she wanted to go to the hospital and she refused, parents were not present at this time, resident was alert and oriented times four when questioned by this writer when this question was asked. 1/23/2020 21:45 PM Pertinent Charting-Falls Note Text: Date of Fall: 01/23/2020 Situation Details: Resident was being assisted to use the restroom by staff holding her hands and her knees buckled and she she fell backwards and hit her head, a golf ball sized lump was noted on the left back side of her head, she was assisted back to bed and vitals were taken, NP AA was notified that her pupils are equal and reactive, father was also notified of the fall and DON. Assessment: All vital signs were stable and pupils have been brisk, equal and reactive, no bruises noted on her body, no lacerations noted, hematoma noted on the left back of her head. Hematoma was noted on left back part of head about the size of a half of a ping pong ball, ice was applied at this time. Mitigating Factors: walker was not used for transfer at this time by staff. Environmental Factors: none. Interventions: Use of walker and one staff to assist, no use of walker until cleared by PT. MD Notification: NP AA was notified 2230 PM Responsible Party Notification: R3F father notified at 2215 PM Comments: none Documentation and/or assessment of R3's hematoma was noted only twice, at 09:45 PM and 03:40 AM. The January Medication Administration Records (MAR) was negative for Tylenol and/or any [MEDICATION(S)] medication given at and/or after R3's fall on 01/23/2020. The neurological flow sheet for R3 reflected, neuro checks were WNL performed at the following times: 01/23/2020: 9:45 PM, 10:00 PM, 10:15 PM, 10:30 PM, 10:45 PM, 11:15 PM. On 01/24/2020: 12:15 AM, 01:15 AM, 1st (time unknown), 2nd (time unknown). LPN N's witness statement dated on 01/24/2020 reflected she received report from RN D last night, and evaluated R3 around 07:00 AM, however no neuro checks were noted completed by LPN N after taking over for RN D to indicate LPN N assessed R3 for any changes in her neuro status. All of the neuro checks had a Glasgow coma scale of 15 and were documented as performed by RN D, minus the one completed at 12:15 AM by unknown nursing staff. A Situation, Background, Assessment, Recommendation (SBAR) form was created for R3 on 01/24/2020 at 09:30 AM. R3 was checked as having increased confusion, decreased consciousness and slurred speech. Nursing Notes on the form reflected: Resident had a witnessed fall on night shift. Large hematoma to left rear scalp with serous drainage. Mental status is altered with new onset confusion. The Transfer form for R3 dated 01/24/2020 reflected she was transferred to a local hospital at 09:33 AM. On 02/06/20 at 04:02 PM DON B was queried about nursing staff gait-belt use. DON B revealed all CNA nursing staff receive a gait-belt during in-service at their date of hire. DON B was asked what did the in-service entail and responded, staff should use their gate-belt and follow residents care plan. DON B was then asked when were nursing staff supposed to use the gait-belt and replied, When they transfer the resident, if plan of care list resident is not stable, and when moving a resident that is not independent. They are issued the gait-belt training on hire, and are to have it on them, they're to use it if resident is not independent. DON B was asked if a resident is a 1 PA, that means they are not independent? DON B stated, Correct. CNA Y was interviewed on 02/07/2020 at 11:39 AM, she denied witnessing R3's fall, but saw a silver dollar sized lump on her head that ice was applied to. When asked about R3's transfer status CNA Y revealed, R3 would hold her arms when standing, CNA Y would use the gait-belt and wheelchair next to her, or have somebody help her transfer R3 to the bathroom. CNA Y revealed she used the gait-belt for safety and denied she would transfer R3 holding her arms while letting her walk. Records obtained for the local hospital where R3 was admitted on [DATE] reflected: The Computed Tomography (CT) of R3's brain/head performed on 01/24/20 findings reflected: -Large [MEDICATION(S)] hematoma measuring at 10 x 3.9 x 10 centimeters (cm). -Subfalcine herniation to the right measuring 7 millimeters (mm). -Non-displaced fracture of the left occipital bone. -The possibility of extension of the fracture into the left mastoid air cells. The MedicineNet 2020 online medical reference referred to an [MEDICATION(S)] hematoma as: A hematoma between the skull and the brain's tissue-like covering, which is known as the dura. [MEDICATION(S)] hematoma is usually caused by a full-on blow to the head and is often associated with skull fracture The National Center for Biotechnology Information (NCBI) 2020 online medical reference reflected the following for herniation and subfalcine herniation: Herniation occurs when brain tissue is displaced across a structure within the cranium. The most common form of intracranial herniation occurs when brain tissue is displaced under the falx cerebri and is aptly named a subfalcine herniation. The WebMD 2020 online medical reference reflected a non-displaced fracture as: In a non-displaced fracture, the bone cracks either part or all of the way through, but does move and maintains its proper alignment. According to the hospital records, after anti-coagulation reversal (due to prescribed [MEDICATION(S)]/Apixaban: blood thinner for a history of embolism and [CONDITION(S)]) and blood [CONDITION(S)], R3 underwent a left frontal, temporal, occipital, CRANIOTOMY for evacuation of a subdural hematoma on 01/27/2020. The WebMD 2019 online medical reference reflected a subdural hematoma as: A subdural hematoma is a collection of blood outside the brain. Subdural hematomas are usually caused by severe head injuries. Resident #5 (R5) On 02/06/2020 at 10:50 AM, R5 was observed sitting in her wheelchair in her room, during the same observation it was noted R5 was not wearing knee supports on both knees to support her knees during transfers, as instructed on her 10/02/2012 Activities of Daily Living (ADL) care plan implemented on 03/21/2019. During an interview on the same date and time R5 stated she did not wear knee supports because they did not fit her. R5's Minimum Data Set (MDS) dated [DATE] introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 15 (Scale 13-15 Cognitively Intact). The same MDS assessment revealed R5 was admitted to the facility on [DATE], did not exhibit any physical, verbal or other behavioral symptoms during the look back period. The same MDS indicated R5 did not reject evaluation or care (e.g., blood work, taking medications, ADL assistance) that was necessary to achieve the resident's goals for health and well-being during the look back period. R5's 12/13/2019 MDS indicated she required limited assistance of staff for transfers, walking, and toilet use. The same MDS assessment indicated R5 was not steady, only able to stabilize with staff assistance in moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off toilet, and for surface-to-surface transfer (transfer between bed and wheelchair). The same MDS revealed R5 had diagnoses including [CONDITION(S)] disorder, heart failure, hypertension, anxiety and depression. In review of R5's ADL care plan dated 10/03/2012, as of 01/21/2020, she required the assistance of two staff for tilting. R5's pain care plan dated 01/13/2018, she had chronic knee pain, left shoulder, and back pain. The same care plan indicated R5 often chose not to wear knee braces as ordered and had the diagnoses of difficulty walking, abnormal posture, and history of falls. Incident Report dated 01/29/2020 at 7:30 PM revealed R5 was assisted to the toilet by CNA V, R5 had a [CONDITION(S)] and fell from the toilet onto her knee. Redness was noted to both of R5's knees. The attached investigation report revealed CNA V did not use a gait belt when she transferred R5 from her wheelchair to the toilet. The same report indicated CNA V was educated to use a gait belt and R5's was care plan was updated to reflect two persons assist with bathing, toileting and transfers. There was no mention of R5's knee supports being on as care planned. In review of R5's incident and accident report dated 02/04/2020 at 7:00 PM, two nurses were in the hallway counting medications and a loud noise was heard. R5 was observed on one knee at the entrance of her bathroom and attempting to get herself up from the floor. The nurse observed seizures [MEDICATION(S)] one to two seconds after finding R5 on the floor. R5's call light was not turned on prior to the fall, and she was re-educated to use her call light for assistance. The same report indicated R5 had redness to both knees. There was no mention of R5's knee supports being on as care planned. In review of R5's incident and accident reports on 02/05/2020 at 8:45 PM, R5 was assisted to the bathroom by CNA Q, CNA Q stayed in the bathroom with R5, R5 stood up, lost her balance and fell on the floor. The same document revealed CNA Q received re-education and suspension pending investigation. The attached investigation report indicated R5 stated her right knee gave up. The same investigation report indicated R5's care plan was not followed as evidenced by gait belt was not used and R5 was a two person assist. The same report indicated CNA Q was educated on the importance of using a gait belt and reading the care plan. The same report did not indicate that R5 was not wearing her knee supports. The same 02/05/2020 at 8:45 PM incident report indicated R5 was incontinent at the time of the fall, the toilet was checked and found to be absent of urine/feces. During an interview on 02/06/2020 at 2:20 PM, CNA Q stated on 02/05/2020 at 8:45 PM, she had answered R5's call light, R5 stood up from the toilet, her knee gave out, and she fell to her buttocks. CNA Q indicated during the same interview she was under the impression R5 was a one person assist for transfers and didn't have time to don a gait belt prior to R5's fall. CNA Q stated she was sent home after R5's fall when they had been working short that evening. During an interview on 02/06/2020 at 3:00 PM, Licensed Practical Nurse (LPN) P stated she saw CNA Q in the R5's bathroom when she was in the hallway prior to R5's fall on 02/05/2020 at 8:45 PM. LPN P stated she interviewed CNA Q and determined she did not follow R5's care plan prior to R5's fall in the bathroom. LPN P stated she was certain CNA Q did not answer R5's call light because LPN P was in the hallway prior to the fall and did not observe the call light on. LPN P stated the call light was not on following the fall. LPN P stated CNA Q took R5 to the bathroom, did not use a gait belt and did not ensure two people assisted her per R5's care plan. Director of Nursing (DON) B was interviewed on 02/06/2020 at 3:55 PM and did not know how long R5's knee support did not fit and was not aware the knee supports were on R5's care plan, initiated 03/21/2019. On 02/07/2020 at 8:35 AM, DON B confirmed R5's knee supports did not fit and stated she had a history of refusing to wear the supports. DON B was not sure if she refused the knee supports due to the fit. DON B stated in the same interview a therapy order was obtained for therapy to evaluate R5 for knee supports. On 02/07/2020 at 10:44 AM, Restorative CNA K stated R5 was in a restorative walking program for quite a while and was not aware R5 had knee supports. During an interview on 02/11/2020 at 12:09 PM, DON B stated the entire care plan was reviewed following a fall. In review of the Falls- Clinical Protocol policy, dated April 2016, revealed if the resident continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that had already been identified) and will re-evaluate the continued relevance of current interventions.

This citation pertains to intake MI 874. Based on interview, and record review, the facility failed to provide an environment free from neglect for 11 residents (#2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) of 11 reviewed for abuse and neglect when Licensed Practical Nurse was allowed to work while impaired during two shifts, and did not provide her residents with ordered medications and treatments. Findings include: Review of the Performance Improvement Form dated 8/29/19 revealed that LPN T was discharged from employment. Reason for Counseling/Corrective Action: Violating the Company's policies, including but not limited to conflict of interest, harassment, discrimination, violence prevention, drug-free workplace, confidentiality, criminal conviction, safety and security, computer, Internet and e-mail, and the Company's Code of Conduct. Employee was scheduled from 6pm-6am on 8/27/2019. Employee was visualized by multiple staff and members of leadership showing signs of working under the influence such as unsteady balance, lethargic, and slurred speech. Employee was offered and declined to take a drug test 2x, once while being driven home at 0600 as well as later in the afternoon of 8/28/2019. Review of LPN T's Resident assignment sheet, which was provided to the surveyor by Nursing Home Administrator (NHA) A revealed that on the evening of 8/27/19 LPN T was responsible for the care and wellbeing of Residents #2, 3, 4, 5, 6, 7, 9, 10, 11 and 12. Review of the Medication and Treatment Administration Records for the residents affected, revealed that there were multiple medications and treatments that were not documented as being administered and/or completed. Review of the work schedule dated 8/27/19 revealed that LPN T and Registered Nurse (RN) G were assigned to work the ventilator unit. Review of a statement written by Registered Nurse (RN) G, signed and dated 8/28/19 revealed, At approximately 0100 (1:00 a.m.) I noticed the nurse (LPN T) eating at the desk. Her motor skills seemed to be slowed down. Her behavior made me pay attention to her, but she appeared to be functioning ok at this time. Around 0200-0300 (2:00-3:00 a.m.) nobody was able to locate (LPN T) for an extended period of time. I took a break around 0400 (4:00 a.m.), when I returned to the floor at 0430 (4:30 a.m.) I observed (LPN T) struggling to walk straight, she was stumbling and bouncing into the wall. Her speech was very slurred, and she seemed confused. A staff member was confronting her about her behavior and the DON (Director or Nursing (former) U) notified. (LPN T) gave her cart keys to another nurse and did not provide any patient care from that point. During a telephone interview 9/10/19 at 1:15 p.m., when asked about her statement and about LPN T's behavior during the night shift on 8/27/19, RN G stated, The beginning of the shift I did not notice anything with (LPN T's) behavior, I took my lunch around 10-1030 (p.m.) and I gave her the keys to my (medication) cart to cover me while I was on lunch. Around 1 or 2 (a.m.) she was eating a snack and was acting really slow, she could have been just tired, it just kind of caught my attention. Then a little later she was coming back from break and she was slamming into the wall, slurring her words, could barely walk, there was something wrong. This is not the first time. This happened another night too, and (Nursing Home Administrator (NHA) A) was made aware. It was towards the end of her shift again, she was on the south unit that night, it was (LPN H) that told (NHA A) about it. I know that night (LPN T) took a break and then that is when she began acting different. When asked if she was aware if LPN T'S residents received all of their treatments and medications, RN G stated, I know that nothing was charted. During a telephone interview on 9/10/19 at 1:26 p.m., when asked if she had ever witnessed LPN T act impaired, LPN H stated, Yes, I did see this before and I told the NHA, it was probably 3-4 weeks before this incident (the one on 8/27/19) .It would have been the night of the third (8/3/19), it was during the night shift, I was approached by 3 different CNAs (Certified Nursing Assistant) came to me, I was on the other side of the building, and I went down to talk to her (LPN T). I was working charge nurse that night and (LPN T) was working south end. I was working on admission for the north unit, when the CNAs came and got me. They had said that (LPN T) had been gone for a while. I took Respiratory Therapist (RT K) with me to see what was going on with (LPN T) When we got down to her unit, LPN T was slow moving, her behavior was really off, she was talking about things that did not make sense. The back of her pants was wet because she said she sat in pee, but there were no chairs with pee in them. She could not keep her eyes open; she was way way off, she was not able to answer any questions. I was wondering if she had a medical condition and she got really mad. I told (LPN T) that I did not think her residents were safe with her taking care of them, so I called (NHA A) and I told (NHA A) what was going on. (NHA A) talked with (LPN T) on the phone and (LPN T) started screaming that this was 'BS'. After the phone call, she was going to go take a break. I called (NHA A) and she said she was going to go take a break and calm down and was fine to work. When asked if she felt LPN T was impaired and possibly under the influence, LPN H stated, Yes, she was impaired, I would think she was under the influence of something. When asked if she was aware of residents that LPN T was caring for not getting their medications or treatments the evening, LPN H stated, I was there until 10:00 a.m., I know a nurse stated that the narcotic count was all messed up. The day shift nurse (RN I) said that (Resident #8) told a nurse that he had not gotten his pain meds (medications) at 4am for the past 2 nights and he filed a report with (RN L) because he said he did not get his meds .It was (RN I) that stated the narc count was all messed up and she told (Former DON U) that she was not going to take the medication cart keys because the cart was messed up (the narcotic counts were messed up). When asked who the Respiratory therapist was that also witnessed LPN T's behaviors, LPN H stated, I took (RT K) with me, she was pretty upset about the way LPN T was. It just seemed like (LPN T) was drugs or something, I did not smell any alcohol. During a telephone interview on 9/12/19 at 1:46 p.m., when asked about LPN T's behavior on both 8/3/19 and 8/27/19, RT K stated, She is fairly new, so I don't know her that well. I work on the vent (ventilator) side and I was asked to go to the other side with (LPN H) and just see (LPN T) and see if she looked ok because there was some complaints from the CNAs that (LPN T) was acting strangely and she was leaving the building. So, when she came back they asked us to go down there and investigate. LPN H was the head nurse that night so I just went to observe. I did think there was something wrong with LPN T, and that she needed to get checked out .she made me feel uncomfortable, and at that point I didn't think that her patients were safe with her taking care of them. I didn't know if (LPN T) was taking medication and I asked her if she had maybe accidentally took too much medications that would cause her to act this way. I know she was acting different, and that she was not right. We did contact (Former DON U) and she did not answer the phone and so we called (NHA A). (NHA A) spoke with (LPN T) over the phone and her conclusion was for her to take a break and then continue to work. RT K continued, The next time I worked with (LPN T) she was on the vent side on a cart and she disappeared for what seemed like a couple of hours. I did go looking for her because one of her patients (Resident #11) was asking for medications. We have residents that are off their vents (ventilators) during the day, and then on during the night. Before we put them on the vent at night, some of them get medications, and that is why I was looking for (LPN T), but she was no where to be found, so I put them on the vent anyways. When (LPN T) did come back she was not walking straight and slurring her words and would not open her eyes when she was talking. I stood next to (LPN E) when she called (Former DON U) and I suggested that we call 911 to have (LPN T) checked out and (Former DON U) said no, not to do that. In my opinion they should have called 911 to make sure that (LPN T) was ok. We were not sure what we should have done because we were told by our management to let (LPN T) work, she (Former DON U) kind of trumps us on what we say and do. We suggested calling 911 because we were worried about (LPN T), I am not a doctor so I can't tell exactly what is going on and we were put in a bad spot. During this same interview, when asked if she felt LPN T was impaired, RT K stated, Yes, there was something wrong with her, and I was concerned with her being able to take care of the patients. When asked if she was aware of any cares or medications not being provided to LPN T's residents, RT K stated that she did not have time to make sure that LPN T's work was being done, but stated, I do know that I looked for (LPN T) to give (Resident #11) his meds, he asked for them, and I looked for her to give him the medications, and could not find her. No, he did not get the drops and I don't know if there was anything else, he was supposed to get at that time. I know that drops are supposed to help his secretions when he is on the vent. I don't believe he got his drops, and it seemed like there was something else he was supposed to get but I don't remember, I had no idea where (LPN T) was. I know that for at least 2 hours I noticed that (LPN T) was not available. Review of Resident #11's Medication Administration Record [REDACTED]. Resident #11 was not available for interview. During the same interview, RT K stated, (Resident #12) told me that he did not get some medications that he was supposed to get. I told (LPN E) that (Resident #12) stated he was not getting medications that is all I know as it was being handled by the person in charge at the time. RT K continued, Both times (LPN T) was acting the same way, I was asked to write up a statement. When asked if anyone had contacted her about the first time LPN T's behavior was brought to the attention of management, RT K stated, No, never. I was actually kind of offended that they did not ask me about the situation. I heard through (LPN H), she too felt offended that they were not taking action on the concerns. I feel that management should have looked at the first situation and that this incident (8/27/19) could have been prevented. When asked if there was anything else that she wanted to add about this concern, RT K stated, In my opinion when I looked at her (LPN T), she was impaired, and not able to take care of her residents. There were two CNAs for sure that had the same concerns about (LPN T) that evening (8/3/19). Review of the medical record and MDS assessment dated [DATE] revealed that Resident #12 was a [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #12 had clear speech, was independent with decisions regarding task of daily living and required staff supervision for ADLs. During an interview on 9/10/19 at 2:25 p.m. Resident #12 was observed lying in his bed, and when asked about the evening that he stated that he did not get some of his morning medications, Resident #12 stated, Yes, I do remember. It was the night that (LPN T) worked, she was kind of a new nurse, she took my [MEDICATION NAME] and one other med, I can't remember. She was wasted, I mean wasted. She was slurring her words. The beginning of the shift she was fine, she came in and gave me a back massage, then she was gone for like an hour and a half and when she came back, she was wasted. She was stumbling, couldn't talk, couldn't keep her eyes open, I mean she was wasted. She sat at the end of my bed and was just babbling about stuff, couldn't even understand her, then she left. I kept telling them (staff) that she took my meds, Director or Respiratory Services told me that the DON or (NHA A) would probably come and talk to me, but nobody ever did. When asked if he felt LPN T took his medications, Resident #12 stated, Yes, I think she stole my meds. Review of Resident #12's MAR indicated [REDACTED] --[MEDICATION NAME] ([MEDICATION NAME], a benzodiazepine medication) Tablet 0.5 MG Give 1 tablet by mouth at bedtime related to ANXIETY DISORDER, UNSPECIFIED --[MEDICATION NAME] Tablet 3 MG Give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] --[MEDICATION NAME] Tablet (Metaxalone) Give 400 mg by mouth every 12 hours for pain --[MEDICATION NAME] Tablet 800 MG Give 1 tablet by mouth every 8 hours for pain . During an interview on 9/10/19 at 2:05 p.m., when asked about the narcotic count being messed up on 8/3/19, RN I stated, I was taking over the cart from (LPN T) and when we were going through the cart she kept saying that she forgot to sign out a medication and then sign it out. (LPN T) was looking at the count sheet and would call out the number of pills that were left, and it would not match the sheet. We would stop and then she would correct it after looking at the medical record. After about the third one I told (LPN T) that she had to go through this and make sure it is right, and then I would come back. I told (Former DON U) about my concerns. When asked if there were any residents that showed signs or symptoms or complained of not getting their medications that evening, RN I stated, I know that night, I want to say (Resident #8) said he did not get his pain med that night. When asked if this has happened before with this resident, RN I stated, No, this is not a behavior for him. I did tell (Former DON U) about that. Review of the Quality Assistance Form dated 8/4/19 at 4:15 p.m. revealed that Resident #8 had brought forth a concern that, I do not receive my [MEDICATION NAME] (narcotic pain medication) last 2 nights. Under the Details section is stated, See back for details. Review of the back revealed, Resident c/o (complaint of) not receiving his 0400 (4:00 a.m.) dose of [MEDICATION NAME] this am and yesterday 8/3/19 & 8/4/19. Further review of this form revealed that it was completed by RN L and was assigned to Former DON U to review. Under the findings it stated, Resident states that he did not receive scheduled [MEDICATION NAME] last 2 nights. Under the Plan/Actions it stated, Review MAR (Medication Administration Record [REDACTED]. Review of the Medical Record and Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #8 was a [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#8 was mostly independent for his Activities of Daily Living and was cognitively intact. Review of the MAR indicated [REDACTED]. During an interview on 9/10/19 at 2:20 p.m., when asked if there was a night that he did not get pain medications, Resident #8 stated, Yes. He put up two fingers and stated, Two nights, Saturday and Sunday, I did not get pain meds. Resident further stated that he did tell a nurse about this and that he had bad pain. During a telephone interview on 9/11/19 at 9:57 a.m., when asked about the concern that Resident #8 brought forward about getting his 4:00 a.m. pain meds, RN L stated, (Resident #8) had told me that he was having a lot of pain that morning, and he had said that he did not get is 4 am dose of medication. When asked if Resident #8 appeared to be in more pain than normal, RN L stated, Yes, he was very painful, it was definitely more than he normally had, he had grimacing and other signs of increased pain, he was very painful. When asked if he had ever seen him like this before, RN L stated, No, not like this. When asked if Resident #8 was known to be med seeking RN L stated, No, he has legitimate pain, if he doesn't get his meds on the scheduled times, he does have increased pain. I know that his pain is normally 3-4. RN L further stated that he filled out a concern form and, I put it in her (Former DON U's) mailbox. When asked if anyone had followed up with you about this concern RN L stated, No, no one did. RN L further stated, I care for (Resident #8) about 3 days a week, it was that whole weekend he was having issues with increased pain. The first day I thought that maybe it was just a unique issue, but then when it was the second day and it was worse, then I got concerned about it. He was very concerned about it and was upset about it. He was cussing about it and was very upset that he did not get his pain meds those mornings. During an interview on 9/10/19 at 9:37 a.m., when asked about LPN T's behavior during the 8/27/19-8/29/19 shift, LPN D stated, I was coming in early to do my (online training). I punched in at 501 (5:01 a.m.), I was walking in and LPN [NAME] was the nurse that was working north, the one that I was going replace, and I told her that I was going to be doing my (training) I was doing my stuff, and (LPN E) came over to me and said can I count the cart with me. When asked why she was asked to count the cart with LPN E, LPN D stated, There was a nurse that seemed to not be able to have the keys, so (LPN E) took the keys from her (LPN T), and before that nurse was leaving the building (LPN E) wanted to have the count. LPN D stated, When i walked in and (LPN T) was sitting there up front, I briefly talked to her later on, I definitely felt that she should not have the keys (to the medication cart). I would have to say that she was under the influence of something. She was definitely different then when she came on the night before at 6 p.m When asked if there were any identified concerns when the narcotic medication count was completed with LPN E, LPN D stated, Yes there were discrepancies on the narc count cards, I would say at least a handful of the cards (controlled drug record) When asked if any of the discrepancies stuck out, LPN D stated, Yes, one of them was a 2 mg [MEDICATION NAME], and this one would have been one that she was supposed give. When asked who the resident was that was supposed to receive that medication LPN D stated, It was a 2mg [MEDICATION NAME] for (Resident #10). There was a dose at 4 am that was missing but (LPN T) was not here, so she could not have given it to him. I was told that (LPN T) had left the building for a couple of hours, (LPN E) said that (LPN T) wasn't here at 4 am .(LPN E) then text (Former) DON to tell her that she thinks there was a missing dose of [MEDICATION NAME]. During an interview on 9/10/19 at 9:52 a.m., when asked about LPN T's behaviors during the 8/27/10-8/28/19 shift, LPN [NAME] stated, That night was working north cart (the other side of the building), (LPN T) was working front part of the vent unit. All of a sudden (CNA N and RT K) came and asked if anyone had seen (LPN T) and I said no, and I kept an eye out for her. Then about 45 minutes later they were asking for her again, and then still did not see her, it was about 1:45 a.m., then another staff said she has not seen her since 1200 a.m. Someone went outside and said she was in her car, so I went out and she was vaping outside, I told her that she was needed inside. A little while later, the same CNA came back down and said that (LPN T) just came out of the bathroom and her back of the pants were wet and that (LPN T) was stumbling, so I text (Former DON U, and told her that there was an issue. Former DON U called me back and told me that she talked to (LPN T) and that she seemed fine, and to just keep an eye on her, so I went about my business. Come about 4-4:30 a.m., I was going back to the north vent unit and staff couldn't find (LPN T) again, and then two other CNAs said that they saw (LPN T) stumbling around the car. The social worker was also aware of this, and she saw (LPN T) stumbling and not keeping her eyes open. At this time, I was going to take the (medication cart) keys from (LPN T) and she couldn't even get the keys out of her pocket she was swaying all over the place. LPN [NAME] further stated, We were not going to let (LPN T) drive home, we called her boyfriend to pick her up and he never came. (LPN T) was not like that at the beginning of the shift, and then it got bad. Everything seemed fine and then between around 12 (a.m.) and 2:30 a.m. (LPN T) was out of the building. The second time she left the building, I do not know when she went out, but she came back in around 4:30 (a.m.), and that was when the CNAs saw her outside at her car. During this same interview, when asked about counting the narcotics on the chart with LPN D, LPN [NAME] stated, I did not count them when I took the keys because there was no one here to count with .then when (LPN D) came in we did the cart count at that time .There were meds that were not accounted for on (LPN T's) shift and I highlighted what was missing, and I told (Former DON U) that there were meds missing and I told her that it was mostly midnight shift, it was a mess. When asked if there were any residents that would have appeared that they did not get their medications, LPN [NAME] stated, Yes, this guy that was storming (Commonly referred to as storming, [DIAGNOSES REDACTED] Sympathetic [MEDICAL CONDITION] (PSH) is a nervous system disorder that affects 15 to 33 percent of people who have sustained a severe [MEDICAL CONDITION] (TBI). The sympathetic refers to the fight or flight portion of our autonomic nervous system.), (Resident #10). Normally when he gets his meds is, he is calm, and he was just storming at this time. If he did not have his meds, they called it storming, neurologically something was not working. With the [MEDICATION NAME] he is fine, but when he does not get it, he storms. I found that even if the [MEDICATION NAME] is even a little late, he will storm, and when I looked at in the morning, when we did the counts, he was storming pretty bad. LPN [NAME] further stated that Resident #10 should have gotten a 4:00 a.m. dose of [MEDICATION NAME]. LPN [NAME] further stated that it appeared that this dose was taken from the medication card but, I am sure she could not have even give him this med, she was not even able to pull the keys out of her pocket. There was no way she was coordinated enough at that time, he is a peg (referring to getting his medications through a tube that is inserted into the stomach), she would have had to crush it, stop the tube feed, give the med, then start the tube feed back up. (LPN T) should have been sent to the ER, but my DON (Former DON U) said no, we are going to just wait and someone will pick her up, and then (DON U) came and picked her up and took her home. When asked to clarify that the ambulance was not to be called for LPN T, LPN [NAME] stated, We were told by the DON (Former DON U) not to call an ambulance. Review of the medical record and MDS assessment revealed that Resident #10 was a male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #10 required a ventilator for breathing. Review of the MDS dated [DATE] revealed that Resident #10 was severely impaired cognitively and totally dependent on staff for cares. Review of the MAR indicated [REDACTED] --[MEDICATION NAME] HCl Tablet 200 MG Give 1 tablet via PE[DEVICE] every 6 hours related to [MEDICAL CONDITION] --Natural Balance Tears Solution 0.4 % (Hypromellose) Instill 1 drop in both eyes every 6 hours for dry eyes --[MEDICATION NAME] Tablet 5-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet enterally every 6 hours for pain related to [MEDICAL CONDITION] --[MEDICATION NAME] Tablet 2 MG ([MEDICATION NAME]) Give 1 tablet enterally every 4 hours for [MEDICAL CONDITION] related to OTHER [MEDICAL CONDITION] (2 doses) --[MEDICATION NAME] Solution 1 % Place and dissolve 2 drop [MEDICATION NAME] every 4 hours for secretions related to DISTURBANCES OF SALIVARY SECRETION (2 doses) Review of typed statement dated 8/28/19 and signed by Former DON U revealed, (Received) text message at approx. 3:15am from (LPN E) that she had rec'd (received) reports from staff that (LPN T) was acting strange. I called (LPN T) and spoke to her for >5 minutes. She sounded normal and was able to recall her night so far. I explained to her about the concerns that were told to me and told her that she needed to work at 100% capacity as we care for a vulnerable population. She stated that she understood and ensured me that she was and would continue to do so. I rec'd a phone call from (Social Services V) just before 5 am and she stated that (LPN T) was acting impaired. She stated that staff had approached her and she herself observed (LPN T) slurring her words. I asked her to have a nurse obtain the cart keys from (LPN T) and count off the narcotics together in order to secure the cart and ensure the safety of our residents. I then asked her to stay with (LPN T) and to make sure she did not drive home. I asked her to contact (LPN T's) emergency contact to come and pick her up. I was called again a few minutes later and informed that we did not have emergency contact information available and (LPN T) was refusing to give (Social Services V) the name, contact number, or address. I informed (Social Services V) that I would be leaving home to come to the facility. I arrived at approx. 6am and as I got out of my car (LPN T) was standing at the front door with (Social Services V) present. I told (LPN T) to get into my car so I could drive her home. She did so after asking her to twice. During the drive she refused to give me her address. She directed me which way to turn. She sat in the passenger seat and refused to use her seatbelt, had the window down and using her vape cigarette. I at no time smelled any alcohol. (LPN T) was slurring her words occasionally and very angry with the situation. She was unhappy that we would not allow her to drive herself home. During the drive I offered to drive her to get a drug test and she refused stating that she just wanted to go home. I explained to her that she could contact me later to obtain her car keys. I turned into the driveway she told me to and she got out of my car, walked around the back and began to walk down the street. She was not stumbling or swaying. Upon returning to the facility, (Social Services V) handed me (LPN T's) car keys. I walked to the back lot to ensure that her car was locked and secure and held the keys in my office until (LPN T) could pick them up. Review of a statement dated 8/28/19, written and signed by RT K revealed, (LPN T) was gone off floor for approximately two hours. When she returned to the floor, she was slurring her words and talking with her eyes shut . Review of a statement dated 8/28/19, written and signed by RT W revealed, At 0020 (12:20 a.m.) I went into the resident's room (Resident #12) because the resident wanted to be placed on the ventilator. He told me he needed to see the nurse because he thought she had not given him his [MEDICATION NAME] and [MEDICATION NAME]. I tried to find (LPN T) his nurse to ask her to talk to the patient I did not see her until around 3:30 a.m. at this time I told (LPN T) that (Resident #12) wanted to talk to her because he wasn't sure if she had given him his medications. The nurse went and talked to the resident. At (5:00 a.m.) I went into (Resident #12's) room and he told me that he thought (LPN T) 'must have been taking something'. I was also unable to find [NAME] from (3:50 a.m. until 4:45 a.m.) Review of a statement dated 8/28/19 at 6:18 a.m., written and signed by CNA X revealed, Dear (Former DON U), Around 12am (LPN T) had left the floor and was nowhere to be seen. At 3:15 am . I went on a 15 minute break and came back to the parking lot and observed abnormal behavior from (LPN T). She was cleaning her car and could barely walk. I did not see her on the floor from 12am-5am approximately. She was slurring her words and not making any sense as if she was high. (LPN T) was saying she didn't have a car, but I seen her enter and sit in a maroon car. Review of a statement dated 8/28/19, written and signed by CNA M revealed, 3:45 am I went outside to take a break & seen (LPN T) outside. She was staggering slurring her words barely able to keep her eyes open. I assumed maybe she was under the influence of something. I went and reported it to (Social Services V) . Review of a statement dated 8/28/19, written and signed by CNA O revealed, We noticed the nurse (LPN T) was having hard time walking and her speech was blur. So therefore, something was wrong. She was gone almost the whole shift . During a telephone interview on 9/12/19 at 3:35 p.m., when asked about (LPN T's) behavior on the night of 8/27/19-8/28/19, CNA O stated, We have seen her out of character before, she went out (of the building) then came back and she was gone for a long time, I would say an hour and half, and then she came back, she was working on south (this was 8/3/19) and her residents were asking for their meds and then when she got back she was slow in everything, and closing her eyes, we asked the charge nurse to come down and figure out what is going on with her because she was not acting right .and she was so defensive. I was busy doing my thing. Her eyes were not open enough to see people and to get the meds out for the residents. Some reason the charge nurse tried to call management at like 3 or 4 in the morning, that was the first incident. Then the last incident (8/27/19-8/28/19) she left the building for a long time, I went outside to find her and I did not see her car, she was sitting in another car, and I told her that I was looking for her, it was hours after I seen her. She couldn't even make it into the building by herself, she had to have someone help her in, she couldn't put a coat on, she couldn't even talk properly, she couldn't walk properly she couldn't even open the cart, she was not safe enough to care for the residents, it was bad. She was very impaired; she couldn't even use a key to open the bathroom. I told them she should go to the ER (emergency room ). When asked if the residents got cared for that night, CNA O stated, She did midnight med pass, then after that she was not able to care for anyone. I actually felt that her car and med cart keys should be taken from her because she was so bad. During this same interview, when asked if anyone had followed up about the first incident, CNA O stated, No, nobody did. When asked if during the first incident if any residents stated that they did not get their medications, CNA O stated, Yes, there were residents that did not get their meds, one resident needed and wanted his breathing treatment, and he never got it, I told the resident that I could not f

This citation pertains to intake MI 874. Based on interview and record review, the facility failed to thoroughly investigate multiple allegations of neglect, abuse and misappropriation of medications for 11 residents (#2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) of 11 reviewed for abuse and neglect, resulting in an allegations of neglect and misappropriation that were not thoroughly investigated allowing the same License Practical Nurse (LPN T) to later again neglect residents. Findings include: Review of the facility's Abuse Prevention Program Policy revised 2/22/18 revealed, Our residents have the right to be free from abuse, neglect, misappropriation of resident property .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED].Timely and thorough investigations of all reports and allegations of abuse. The reporting and filling of accurate documents relative to incidents of abuse . Should an incident or suspected incident of resident abuse, mistreatment, neglect .be reported, the Administrator (Nursing Home Administrator (NHA) A), or his/her designee, will appoint a member of management to investigate the alleged incident .The individual conducting the investigation will, at a minimum .Interview the person(s) reporting the incident; Interview any witnesses to the incident, Interview the resident .Interview staff members (on all shifts) who have had contact with the resident during the period of alleged incident .Interview other residents to whom the accused employee provides care or services; and Review all events leading up to the alleged incident . Review of the Performance Improvement Form dated 8/29/19 revealed that LPN T was discharged from employment. Reason for Counseling/Corrective Action: Violating the Company's policies, including but not limited to conflict of interest, harassment, discrimination, violence prevention, drug-free workplace, confidentiality, criminal conviction, safety and security, computer, Internet and e-mail, and the Company's Code of Conduct. Employee was scheduled from 6pm-6am on 8/27/2019. Employee was visualized by multiple staff and members of leadership showing signs of working under the influence such as unsteady balance, lethargic, and slurred speech. Employee was offered and declined to take a drug test 2x, once while being driven home at 0600 as well as later in the afternoon of 8/28/2019. During a telephone interview on 9/10/19 at 1:26 p.m., when asked if she had ever witnessed LPN T act impaired, LPN H stated, Yes, I did see this before and I told the NHA, it was probably 3-4 weeks before this incident (the one on 8/27/19) .It would have been the night of the third (8/3/19), it was during the night shift, I was approached by 3 different CNAs (Certified Nursing Assistant) came to me, I was on the other side of the building, and I went down to talk to her (LPN T). I was working charge nurse that night and (LPN T) was working south end. I was working on admission for the north unit, when the CNAs came and got me. They had said that (LPN T) had been gone for a while. I took Respiratory Therapist (RT K) with me to see what was going on with (LPN T) When we got down to her unit, LPN T was slow moving, her behavior was really off, she was talking about things that did not make sense. The back of her pants was wet because she said she sat in pee, but there were no chairs with pee in them. She could not keep her eyes open; she was way way off; she was not able to answer any questions. I was wondering if she had a medical condition and she got really mad. I told (LPN T) that I did not think her residents were safe with her taking care of them, so I called (NHA A) and I told (NHA A) what was going on. (NHA A) talked with (LPN T) on the phone and (LPN T) started screaming that this was 'BS'. After the phone call, she was going to go take a break. I called (NHA A) and she said she was going to go take a break and calm down and was fine to work. When asked if she felt LPN T was impaired and possibly under the influence, LPN H stated, Yes, she was impaired, I would think she was under the influence of something. When asked if she was aware of residents that LPN T was caring for not getting their medications or treatments the evening, LPN H stated, I was there until 10:00 a.m., I know a nurse stated that the narcotic count was all messed up. The day shift nurse (RN I) said that (Resident #8) told a nurse that he had not gotten his pain meds (medications) at 4am for the past 2 nights and he filed a report with (RN L) because he said he did not get his meds .It was (RN I) that stated the narc count was all messed up and she told (Former DON U) that she was not going to take the medication cart keys because the cart was messed up (the narcotic counts were messed up). When asked who the Respiratory therapist was that also witnessed LPN T's behaviors, LPN H stated, I took (RT K) with me, she was pretty upset about the way LPN T was. It just seemed like (LPN T) was drugs or something, I did not smell any alcohol. During a telephone interview on 9/12/19 at 1:46 p.m., when asked about LPN T's behavior on 8/3/19, RT K stated, She is fairly new, so I don't know her that well. I work on the vent (ventilator) side and I was asked to go to the other side with (LPN H) and just see (LPN T) and see if she looked ok because there was some complaints from the CNAs that (LPN T) was acting strangely and she was leaving the building. So, when she came back, they asked us to go down there and investigate. LPN H was the head nurse that night so I just went to observe. I did think there was something wrong with LPN T, and that she needed to get checked out .she made me feel uncomfortable, and at that point I didn't think that her patients were safe with her taking care of them. I didn't know if (LPN T) was taking medication and I asked her if she had maybe accidentally took too much medications that would cause her to act this way. I know she was acting different, and that she was not right. We did contact (Former DON U) and she did not answer the phone and so we called (NHA A). (NHA A) spoke with (LPN T) over the phone and her conclusion was for her to take a break and then continue to work. During the same interview, when asked if anyone had contacted her about LPN T's behavior on 8/3/19, which was brought to the attention of management, RT K stated, No, never. I was actually kind of offended that they did not ask me about the situation. I heard through (LPN H), she too felt offended that they were not taking action on the concerns. I feel that management should have looked at (this) situation and that the incident (on 8/27/19) could have been prevented. When asked if there was anything else that she wanted to add about this concern, RT K stated, In my opinion when I looked at her (LPN T), she was impaired, and not able to take care of her residents. There were two CNAs for sure that had the same concerns about (LPN T) that evening (8/3/19). Review of the Quality Assistance Form dated 8/4/19 at 4:15 p.m. revealed that Resident #8 had brought forth a concern that, I do not receive my [MEDICATION NAME] (narcotic pain medication) last 2 nights. Under the Details section is stated, See back for details. Review of the back revealed, Resident c/o (complaint of) not receiving his 0400 (4:00 a.m.) dose of [MEDICATION NAME] this am and yesterday 8/3/19 & 8/4/19. Further review of this form revealed that it was completed by RN L and was assigned to Former DON U to review. Under the findings it stated, Resident states that he did not receive scheduled [MEDICATION NAME] last 2 nights. Under the Plan/Actions it stated, Review MAR (Medication Administration Record [REDACTED]. Review of the Medical Record and Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #8 was a [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#8 was mostly independent for his Activities of Daily Living and was cognitively intact. Review of the MAR indicated [REDACTED]. During an interview on 9/10/19 at 2:20 p.m., when asked if there was a night that he did not get pain medications, Resident #8 stated, Yes. He put up two fingers and stated, Two nights, Saturday and Sunday, I did not get pain meds. Resident further stated that he did tell a nurse about this and that he had bad pain. During a telephone interview on 9/11/19 at 9:57 a.m., when asked about the concern that Resident #8 brought forward about getting his 4:00 a.m. pain meds, RN L stated, (Resident #8) had told me that he was having a lot of pain that morning, and he had said that he did not get is 4 am dose of medication. When asked if Resident #8 appeared to be in more pain than normal, RN L stated, Yes, he was very painful, it was definitely more than he normally had, he had grimacing and other signs of increased pain, he was very painful. When asked if he had ever seen him like this before, RN L stated, No, not like this. When asked if Resident #8 was known to be med seeking RN L stated, No, he has legitimate pain, if he doesn't get his meds on the scheduled times, he does have increased pain. I know that his pain is normally 3-4. RN L further stated that he filled out a concern form and, I put it in her (Former DON U's) mailbox. When asked if anyone had followed up with you about this concern RN L stated, No, no one did. RN L further stated, I care for (Resident #8) about 3 days a week, it was that whole weekend he was having issues with increased pain. The first day I thought that maybe it was just a unique issue, but then when it was the second day and it was worse, then I got concerned about it. He was very concerned about it and was upset about it. He was cussing about it and was very upset that he did not get his pain meds those mornings. This surveyor asked for the complete investigation file regarding Resident #8's allegation of not receiving his pain medications on 8/3/19 and 8/4/19. The facility provided this surveyor with the Quality Assistance Form. There was no other documentation pertaining to this concern. There were no statements from other staff nor from other residents. During an interview on 9/10/19 at 3:15 p.m., when asked if there was any other documentation pertaining to the concern brought forth by Resident #8, NHA A stated that there was not. When asked if any other residents were interviewed about missing medications, or if any other staff members were questioned about other residents not receiving their medications, NHA A stated that she did not complete the investigation, that Former DON U was the individual that completed the investigation. NHA A further stated that she was not sure what Former DON U did as far as the investigation. NHA A was not able to provide any other documentation pertaining to this investigation. During a telephone interview on 9/12/19 at 3:35 p.m., when asked about (LPN T's) behaviors on the night of 8/3/19, CNA O stated, We have seen her out of character before, she went out (of the building) then came back and she was gone for a long time, I would say an hour and half, and then she came back, she was working on south (this was 8/3/19) and her residents were asking for their meds and then when she got back she was slow in everything, and closing her eyes, we asked the charge nurse to come down and figure out what is going on with her because she was not acting right .and she was so defensive. I was busy doing my thing. Her eyes were not open enough to see people and to get the meds out for the residents. Some reason the charge nurse tried to call management at like 3 or 4 in the morning, that was the first incident. When asked if the residents got cared for that night, CNA O stated, She did midnight med pass, then after that she was not able to care for anyone. I actually felt that her car and med cart keys should be taken from her because she was so bad. During this same interview, when asked if anyone had followed up about this incident, CNA O stated, No, nobody did. When asked if during this incident if any residents stated that they did not get their medications, CNA O stated, Yes, there were residents that did not get their meds, one resident needed and wanted his breathing treatment, and he never got it, I told the resident that I could not find the nurse. There were other residents that didn't get meds either that night, it was a long time ago I can't really remember who, but I know there were other residents that did not get their meds. During an interview on 9/10/19 at 3:15 p.m., when asked about the neglectful actions of LPN T that took place on 8/3/19 and if she was notified about them, NHA A stated, I did have a concern brought forward one night, maybe (LPN H) about (LPN T)? She was making a comment about a chair being wet, I talked to (LPN T) on the phone and that she had stated that she started her period and that she had to run home and get new pants. When asked if any other staff were questioned about LPN T's behavior on the night of 8/3/19, NHA A stated, No I do not believe so. When asked if she remembered anything else from the phone call she received from LPN H about LPN T's behaviors, NHA A stated, (LPN H) said that (LPN T) said her pants were wet. I don't remember the rest of the conversation. NHA A was not able to provide any documentation pertaining to any kind of investigation regarding the allegations that were brought forward that LPN T was impaired on 8/3/19 and not able to perform her duties. NHA A stated that she spoke with LPN T on the phone and determined from that phone conversation that LPN T was able to carry out her duties. During the survey, former DON U was unavailable for interview. Review of the medical record and MDS assessment dated [DATE] revealed that Resident #12 was a [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #12 had clear speech, was independent with decisions regarding task of daily living and required staff supervision for ADLs. During an interview on 9/10/19 at 2:25 p.m. Resident #12 was observed lying in his bed, and when asked about the evening (8/27/19-8/28/19) that he stated that he did not get some of his morning medications, Resident #12 stated, Yes, I do remember. It was the night that (LPN T) worked, she was kind of a new nurse, she took my [MEDICATION NAME] and one other med, I can't remember. She was wasted, I mean wasted. She was slurring her words. The beginning of the shift she was fine, she came in and gave me a back massage, then she was gone for like an hour and a half and when she came back, she was wasted. She was stumbling, couldn't talk, couldn't keep her eyes open, I mean she was wasted. She sat at the end of my bed and was just babbling about stuff, couldn't even understand her, then she left. I kept telling them (staff) that she took my meds, Director or Respiratory Services told me that the DON or (NHA A) would probably come and talk to me, but nobody ever did. When asked if he felt LPN T took his medications, Resident #12 stated, Yes, I think she stole my meds. During an interview on 9/10/19 at 9:37 a.m., when asked about LPN T's behavior during the 8/27/19-8/29/19 shift, LPN D stated, I was coming in early to do my (online training). I punched in at 501 (5:01 a.m.), I was walking in and LPN [NAME] was the nurse that was working north, the one that I was going replace, and I told her that I was going to be doing my (training) I was doing my stuff, and (LPN E) came over to me and said can I count the cart with me. When asked why she was asked to count the cart with LPN E, LPN D stated, There was a nurse that seemed to not be able to have the keys, so (LPN E) took the keys from her (LPN T), and before that nurse was leaving the building (LPN E) wanted to have the count. LPN D stated, When I walked in and (LPN T) was sitting there up front, I briefly talked to her later on, I definitely felt that she should not have the keys (to the medication cart). I would have to say that she was under the influence of something. She was definitely different then when she came on the night before at 6 p.m When asked if there were any identified concerns when the narcotic medication count was completed with LPN E, LPN D stated, Yes there were discrepancies on the narc count cards, I would say at least a handful of the cards (controlled drug record) When asked if any of the discrepancies stuck out, LPN D stated, Yes, one of them was a 2 mg [MEDICATION NAME], and this one would have been one that she was supposed give. When asked who the resident was that was supposed to receive that medication LPN D stated, It was a 2mg [MEDICATION NAME] for (Resident #10). There was a dose at 4 am that was missing but (LPN T) was not here, so she could not have given it to him. I was told that (LPN T) had left the building for a couple of hours, (LPN E) said that (LPN T) wasn't here at 4 am .(LPN E) then text (Former) DON to tell her that she thinks there was a missing dose of [MEDICATION NAME]. During an interview on 9/10/19 at 9:52 a.m., when asked about LPN T's behaviors during the 8/27/10-8/28/19 shift, LPN [NAME] stated, That night was working north cart (the other side of the building), (LPN T) was working front part of the vent unit. All of a sudden (CNA N and RT K) came and asked if anyone had seen (LPN T) and I said no, and I kept an eye out for her. Then about 45 minutes later they were asking for her again, and then still did not see her, it was about 1:45 a.m., then another staff said she has not seen her since 1200 a.m. Someone went outside and said she was in her car, so I went out and she was vaping outside, I told her that she was needed inside. A little while later, the same CNA came back down and said that (LPN T) just came out of the bathroom and her back of the pants were wet and that (LPN T) was stumbling, so I text (Former DON U, and told her that there was an issue. Former DON U called me back and told me that she talked to (LPN T) and that she seemed fine, and to just keep an eye on her, so I went about my business. Come about 4-4:30 a.m., I was going back to the north vent unit and staff couldn't find (LPN T) again, and then two other CNAs said that they saw (LPN T) stumbling around the car. The social worker was also aware of this, and she saw (LPN T) stumbling and not keeping her eyes open. At this time, I was going to take the (medication cart) keys from (LPN T) and she couldn't even get the keys out of her pocket she was swaying all over the place. LPN [NAME] further stated, We were not going to let (LPN T) drive home, we called her boyfriend to pick her up and he never came. (LPN T) was not like that at the beginning of the shift, and then it got bad. Everything seemed fine and then between around 12 (a.m.) and 2:30 a.m. (LPN T) was out of the building. The second time she left the building, I do not know when she went out, but she came back in around 4:30 (a.m.), and that was when the CNAs saw her outside at her car. Review of typed statement dated 8/28/19 and signed by Former DON U revealed, (Received) text message at approx. 3:15am from (LPN E) that she had rec'd (received) reports from staff that (LPN T) was acting strange. I called (LPN T) and spoke to her for >5 minutes. She sounded normal and was able to recall her night so far. I explained to her about the concerns that were told to me and told her that she needed to work at 100% capacity as we care for a vulnerable population. She stated that she understood and ensured me that she was and would continue to do so. I rec'd a phone call from (Social Services V) just before 5 am and she stated that (LPN T) was acting impaired. She stated that staff had approached her and she herself observed (LPN T) slurring her words. I asked her to have a nurse obtain the cart keys from (LPN T) and count off the narcotics together in order to secure the cart and ensure the safety of our residents. I then asked her to stay with (LPN T) and to make sure she did not drive home. I asked her to contact (LPN T's) emergency contact to come and pick her up. I was called again a few minutes later and informed that we did not have emergency contact information available and (LPN T) was refusing to give (Social Services V) the name, contact number, or address. I informed (Social Services V) that I would be leaving home to come to the facility. I arrived at approx. 6am and as I got out of my car (LPN T) was standing at the front door with (Social Services V) present. I told (LPN T) to get into my car so I could drive her home. She did so after asking her to twice. During the drive she refused to give me her address. She directed me which way to turn. She sat in the passenger seat and refused to use her seatbelt, had the window down and using her vape cigarette. I at no time smelled any alcohol. (LPN T) was slurring her words occasionally and very angry with the situation. She was unhappy that we would not allow her to drive herself home. During the drive I offered to drive her to get a drug test and she refused stating that she just wanted to go home. I explained to her that she could contact me later to obtain her car keys. I turned into the driveway she told me to, and she got out of my car, walked around the back and began to walk down the street. She was not stumbling or swaying. Upon returning to the facility, (Social Services V) handed me (LPN T's) car keys. I walked to the back lot to ensure that her car was locked and secure and held the keys in my office until (LPN T) could pick them up. Review of a statement dated 8/28/19, written and signed by RT W revealed, At 0020 (12:20 a.m.) I went into the resident's room (Resident #12) because the resident wanted to be placed on the ventilator. He told me he needed to see the nurse because he thought she had not given him his [MEDICATION NAME] and [MEDICATION NAME]. I tried to find (LPN T) his nurse to ask her to talk to the patient I did not see her until around 3:30 a.m. at this time I told (LPN T) that (Resident #12) wanted to talk to her because he wasn't sure if she had given him his medications. The nurse went and talked to the resident. At (5:00 a.m.) I went into (Resident #12's) room and he told me that he thought (LPN T) 'must have been taking something'. I was also unable to find [NAME] from (3:50 a.m. until 4:45 a.m.) During an interview on 9/11/19 at 11:35 a.m., when asked about the incident that took place on the night shift 8/27/19-8/28/19, Unit Manager, RN R stated, I got here about 8 that morning, and (Former DON U) was already doing the camera review, she called me in to tell me what was going on, and I wanted to go down on my unit and make sure that everything was ok. I just wanted to follow up with the unit, (LPN F) was in that morning and she was running around trying to catch up because she was behind from the previous shift (LPN T's shift). I did my morning rounds to make sure that they were ok, by the time I got here, they had everything cleaned up pretty well. When asked who performed the duties that LPN T was supposed to perform, RN R stated, I know that the tube feeds were hung, as far as meds, I do not know, I was not physically here, if it is not documented it is not done. When asked if she did anything to investigate if the residents did not get medications or treatments during the night shift, RN R stated, No, I just laid my eyes on the residents and rooms. When asked about Resident #10, and if she was aware of his storming incident, RN R stated, (LPN F) made the comment that he was storming, and she gave him the medications and then he was better. LPN F said that (Resident #10) was the first person she went to take care of because of the storming. I know that he has the issues, so I really wanted to check on him . During an interview in 9/10/19 at 3:15 p.m., when asked about LPN T's behaviors during the 8/27/19-8/28/19 night shift, NHA A stated, I received a phone call from (Social Services V) who stated that (LPN T) was acting strange and she had concerns. I asked if she had talked to (Former DON U) about this and she said no. I asked her to call her. (Former DON U) ended up telling the staff to take keys to the med cart and (Former DON U) ended up coming in and taking (LPN T) home. When I came in (Former DON U) stated that they were going through and looking a narcs and trying to figure out what they did give. (LPN T) came in later and she was asked if she would take a drug test, and that she declined. She stated that she had delivered the medications. When asked about the investigation into this incident, NHA A stated, I did not do any of the investigations. When asked if LPN T having these strange behaviors and not being able to perform her duties, would consider neglect, NHA A stated, Not if she provided cares for her residents. When asked if she was aware that there were multiple treatments and medications that were not documented as being completed, NHA A did not answer. When asked if she was aware that there were controlled medications that were missing from cards and not documented as being pulled from the cards, nor documented as being administered, NHA A stated, (Former DON U) confirmed to me that the meds were reconciled. When asked if she was aware of Resident #12 stating that he did not get medications during the evening, NHA A stated that she was not aware of that. When asked about an investigation regarding Resident #12's missing medications, NHA A stated she was not aware of an investigation taking place.

This citation pertains to intake MI 874. Based on interview and record review, the facility failed to immediately report allegations of neglect for 11 residents (#2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) of 11 reviewed for abuse and neglect, resulting in allegations of neglect/abuse that were not reported to the the State Agency timely for further neglect/abuse to go unreported, and not thoroughly investigated. Findings include: Review of the facility's Abuse Prevention Program Policy revised 2/22/18 revealed, Our residents have the right to be free from abuse, neglect, misappropriation .Our facility will not condone resident abuse by anyone .The Administrator must be immediately notified of alleged abuse/neglect or incidents of abuse/neglect. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such incident .When an alleged or suspected case of mistreatment, neglect, injuries of unknown source or abuse is reported, the facility Administrator, DON (Director of Nursing), or individuals designated will immediately .notify the following persons or agencies of such incident: 1. The State licensing/certification agency responsible for surveying/licensing the facility . Review of the Performance Improvement Form dated 8/29/19 revealed that LPN T was discharged from employment. Reason for Counseling/Corrective Action: Violating the Company's policies, including but not limited to conflict of interest, harassment, discrimination, violence prevention, drug-free workplace, confidentiality, criminal conviction, safety and security, computer, Internet and e-mail, and the Company's Code of Conduct. Employee was scheduled from 6pm-6am on 8/27/2019. Employee was visualized by multiple staff and members of leadership showing signs of working under the influence such as unsteady balance, lethargic, and slurred speech. Employee was offered and declined to take a drug test 2x, once while being driven home at 0600 as well as later in the afternoon of 8/28/2019. Review of LPN T's Resident assignment sheet, which was provided to the surveyor by Nursing Home Administrator (NHA) A revealed that on the evening of 8/27/19 LPN T was responsible for the care and wellbeing of Residents #2, 3, 4, 5, 6, 7, 9, 10, 11 and 12. Review of the Medication and Treatment Administration Records for the residents affected, revealed that there were multiple medications and treatments that were not documented as being administered and/or completed. Review of the work schedule dated 8/27/19 revealed that LPN T and Registered Nurse (RN) G were assigned to work the ventilator unit. Review of a statement written by Registered Nurse (RN) G, signed and dated 8/28/19 revealed, At approximately 0100 (1:00 a.m.) I noticed the nurse (LPN T) eating at the desk. Her motor skills seemed to be slowed down. Her behavior made me pay attention to her, but she appeared to be functioning ok at this time. Around 0200-0300 (2:00-3:00 a.m.) nobody was able to locate (LPN T) for an extended period of time. I took a break around 0400 (4:00 a.m.), when I returned to the floor at 0430 (4:30 a.m.) I observed (LPN T) struggling to walk straight, she was stumbling and bouncing into the wall. Her speech was very slurred, and she seemed confused. A staff member was confronting her about her behavior and the DON (Director or Nursing (former) U) notified. (LPN T) gave her cart keys to another nurse and did not provide any patient care from that point. During a telephone interview 9/10/19 at 1:15 p.m., when asked about her statement and about LPN T's behavior during the night shift on 8/27/19, RN G stated, The beginning of the shift I did not notice anything with (LPN T's) behavior, I took my lunch around 10-1030 (p.m.) and I gave her the keys to my (medication) cart to cover me while I was on lunch. Around 1 or 2 (a.m.) she was eating a snack and was acting really slow, she could have been just tired, it just kind of caught my attention. Then a little later she was coming back from break and she was slamming into the wall, slurring her words, could barely walk, there was something wrong. This is not the first time. This happened another night too, and (Nursing Home Administrator (NHA) A) was made aware. It was towards the end of her shift again, she was on the south unit that night, it was (LPN H) that told (NHA A) about it. I know that night (LPN T) took a break and then that is when she began acting different. When asked if she was aware if LPN T'S residents received all of their treatments and medications, RN G stated, I know that nothing was charted. During a telephone interview on 9/10/19 at 1:26 p.m., when asked if she had ever witnessed LPN T act impaired, LPN H stated, Yes, I did see this before and I told the NHA, it was probably 3-4 weeks before this incident (the one on 8/27/19) .It would have been the night of the third (8/3/19), it was during the night shift, I was approached by 3 different CNAs (Certified Nursing Assistant) came to me, I was on the other side of the building, and I went down to talk to her (LPN T). I was working charge nurse that night and (LPN T) was working south end. I was working on admission for the north unit, when the CNAs came and got me. They had said that (LPN T) had been gone for a while. I took Respiratory Therapist (RT K) with me to see what was going on with (LPN T) When we got down to her unit, LPN T was slow moving, her behavior was really off, she was talking about things that did not make sense. The back of her pants was wet because she said she sat in pee, but there were no chairs with pee in them. She could not keep her eyes open; she was way way off, she was not able to answer any questions. I was wondering if she had a medical condition and she got really mad. I told (LPN T) that I did not think her residents were safe with her taking care of them, so I called (NHA A) and I told (NHA A) what was going on. (NHA A) talked with (LPN T) on the phone and (LPN T) started screaming that this was 'BS'. After the phone call, she was going to go take a break. I called (NHA A) and she said she was going to go take a break and calm down and was fine to work. When asked if she felt LPN T was impaired and possibly under the influence, LPN H stated, Yes, she was impaired, I would think she was under the influence of something. When asked if she was aware of residents that LPN T was caring for not getting their medications or treatments the evening, LPN H stated, I was there until 10:00 a.m., I know a nurse stated that the narcotic count was all messed up. The day shift nurse (RN I) said that (Resident #8) told a nurse that he had not gotten his pain meds (medications) at 4am for the past 2 nights and he filed a report with (RN L) because he said he did not get his meds .It was (RN I) that stated the narc count was all messed up and she told (Former DON U) that she was not going to take the medication cart keys because the cart was messed up (the narcotic counts were messed up). When asked who the Respiratory therapist was that also witnessed LPN T's behaviors, LPN H stated, I took (RT K) with me, she was pretty upset about the way LPN T was. It just seemed like (LPN T) was drugs or something, I did not smell any alcohol. During a telephone interview on 9/12/19 at 1:46 p.m., when asked about LPN T's behavior on both 8/3/19 and 8/27/19, RT K stated, She is fairly new, so I don't know her that well. I work on the vent (ventilator) side and I was asked to go to the other side with (LPN H) and just see (LPN T) and see if she looked ok because there was some complaints from the CNAs that (LPN T) was acting strangely and she was leaving the building. So, when she came back they asked us to go down there and investigate. LPN H was the head nurse that night so I just went to observe. I did think there was something wrong with LPN T, and that she needed to get checked out .she made me feel uncomfortable, and at that point I didn't think that her patients were safe with her taking care of them. I didn't know if (LPN T) was taking medication and I asked her if she had maybe accidentally took too much medications that would cause her to act this way. I know she was acting different, and that she was not right. We did contact (Former DON U) and she did not answer the phone and so we called (NHA A). (NHA A) spoke with (LPN T) over the phone and her conclusion was for her to take a break and then continue to work. RT K continued, The next time I worked with (LPN T) she was on the vent side on a cart and she disappeared for what seemed like a couple of hours. I did go looking for her because one of her patients (Resident #11) was asking for medications. We have residents that are off their vents (ventilators) during the day, and then on during the night. Before we put them on the vent at night, some of them get medications, and that is why I was looking for (LPN T), but she was no where to be found, so I put them on the vent anyway. When (LPN T) did come back she was not walking straight and slurring her words and would not open her eyes when she was talking. I stood next to (LPN E) when she called (Former DON U) and I suggested that we call 911 to have (LPN T) checked out and (Former DON U) said no, not to do that. In my opinion they should have called 911 to make sure that (LPN T) was ok. We were not sure what we should have done because we were told by our management to let (LPN T) work, she (Former DON U) kind of trumps us on what we say and do. We suggested calling 911 because we were worried about (LPN T), I am not a doctor so I can't tell exactly what is going on and we were put in a bad spot. During this same interview, when asked if she felt LPN T was impaired, RT K stated, Yes, there was something wrong with her, and I was concerned with her being able to take care of the patients. When asked if she was aware of any cares or medications not being provided to LPN T's residents, RT K stated that she did not have time to make sure that LPN T's work was being done, but stated, I do know that I looked for (LPN T) to give (Resident #11) his meds, he asked for them, and I looked for her to give him the medications, and could not find her. No, he did not get the drops and I don't know if there was anything else, he was supposed to get at that time. I know that drops are supposed to help his secretions when he is on the vent. I don't believe he got his drops, and it seemed like there was something else he was supposed to get but I don't remember, I had no idea where (LPN T) was. I know that for at least 2 hours I noticed that (LPN T) was not available. During the same interview, RT K stated, (Resident #12) told me that he did not get some medications that he was supposed to get. I told (LPN E) that (Resident #12) stated he was not getting medications that is all I know as it was being handled by the person in charge at the time. RT K continued, Both times (LPN T) was acting the same way, I was asked to write up a statement. When asked if anyone had contacted her about the first time LPN T's behavior was brought to the attention of management, RT K stated, No, never. I was actually kind of offended that they did not ask me about the situation. I heard through (LPN H), she too felt offended that they were not taking action on the concerns. I feel that management should have looked at the first situation and that this incident (8/27/19) could have been prevented. When asked if there was anything else that she wanted to add about this concern, RT K stated, In my opinion when I looked at her (LPN T), she was impaired, and not able to take care of her residents. There were two CNAs for sure that had the same concerns about (LPN T) that evening (8/3/19). Review of the medical record and MDS assessment dated [DATE] revealed that Resident #12 was a [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #12 had clear speech, was independent with decisions regarding task of daily living and required staff supervision for ADLs. During an interview on 9/10/19 at 2:25 p.m. Resident #12 was observed lying in his bed, and when asked about the evening that he stated that he did not get some of his morning medications, Resident #12 stated, Yes, I do remember. It was the night that (LPN T) worked, she was kind of a new nurse, she took my [MEDICATION NAME] and one other med, I can't remember. She was wasted, I mean wasted. She was slurring her words. The beginning of the shift she was fine, she came in and gave me a back massage, then she was gone for like an hour and a half and when she came back, she was wasted. She was stumbling, couldn't talk, couldn't keep her eyes open, I mean she was wasted. She sat at the end of my bed and was just babbling about stuff, couldn't even understand her, then she left. I kept telling them (staff) that she took my meds, Director or Respiratory Services told me that the DON or (NHA A) would probably come and talk to me, but nobody ever did. When asked if he felt LPN T took his medications, Resident #12 stated, Yes, I think she stole my meds. Review of the Quality Assistance Form dated 8/4/19 at 4:15 p.m. revealed that Resident #8 had brought forth a concern that, I do not receive my [MEDICATION NAME] (narcotic pain medication) last 2 nights. Under the Details section is stated, See back for details. Review of the back revealed, Resident c/o (complaint of) not receiving his 0400 (4:00 a.m.) dose of [MEDICATION NAME] this am and yesterday 8/3/19 & 8/4/19. Further review of this form revealed that it was completed by RN L and was assigned to Former DON U to review. Under the findings it stated, Resident states that he did not receive scheduled [MEDICATION NAME] last 2 nights. Under the Plan/Actions it stated, Review MAR (Medication Administration Record [REDACTED]. Review of the Medical Record and Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #8 was a [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#8 was mostly independent for his Activities of Daily Living and was cognitively intact. Review of the MAR indicated [REDACTED] During an interview on 9/10/19 at 2:20 p.m., when asked if there was a night that he did not get pain medications, Resident #8 stated, Yes. He put up two fingers and stated, Two nights, Saturday and Sunday, I did not get pain meds. Resident further stated that he did tell a nurse about this and that he had bad pain. During a telephone interview on 9/11/19 at 9:57 a.m., when asked about the concern that Resident #8 brought forward about getting his 4:00 a.m. pain meds, RN L stated, (Resident #8) had told me that he was having a lot of pain that morning, and he had said that he did not get is 4 am dose of medication. When asked if Resident #8 appeared to be in more pain than normal, RN L stated, Yes, he was very painful, it was definitely more than he normally had, he had grimacing and other signs of increased pain, he was very painful. When asked if he had ever seen him like this before, RN L stated, No, not like this. When asked if Resident #8 was known to be med seeking RN L stated, No, he has legitimate pain, if he doesn't get his meds on the scheduled times, he does have increased pain. I know that his pain is normally 3-4. RN L further stated that he filled out a concern form and, I put it in her (Former DON U's) mailbox. When asked if anyone had followed up with you about this concern RN L stated, No, no one did. RN L further stated, I care for (Resident #8) about 3 days a week, it was that whole weekend he was having issues with increased pain. The first day I thought that maybe it was just a unique issue, but then when it was the second day and it was worse, then I got concerned about it. He was very concerned about it and was upset about it. He was cussing about it and was very upset that he did not get his pain meds those mornings. During an interview on 9/10/19 at 9:37 a.m., when asked about LPN T's behavior during the 8/27/19-8/29/19 shift, LPN D stated, I was coming in early to do my (online training). I punched in at 501 (5:01 a.m.), I was walking in and LPN [NAME] was the nurse that was working north, the one that I was going replace, and I told her that I was going to be doing my (training) I was doing my stuff, and (LPN E) came over to me and said can I count the cart with me. When asked why she was asked to count the cart with LPN E, LPN D stated, There was a nurse that seemed to not be able to have the keys, so (LPN E) took the keys from her (LPN T), and before that nurse was leaving the building (LPN E) wanted to have the count. LPN D stated, When I walked in and (LPN T) was sitting there up front, I briefly talked to her later on, I definitely felt that she should not have the keys (to the medication cart). I would have to say that she was under the influence of something. She was definitely different then when she came on the night before at 6 p.m When asked if there were any identified concerns when the narcotic medication count was completed with LPN E, LPN D stated, Yes there were discrepancies on the narc count cards, I would say at least a handful of the cards (controlled drug record) When asked if any of the discrepancies stuck out, LPN D stated, Yes, one of them was a 2 mg [MEDICATION NAME], and this one would have been one that she was supposed give. When asked who the resident was that was supposed to receive that medication LPN D stated, It was a 2mg [MEDICATION NAME] for (Resident #10). There was a dose at 4 am that was missing but (LPN T) was not here, so she could not have given it to him. I was told that (LPN T) had left the building for a couple of hours, (LPN E) said that (LPN T) wasn't here at 4 am .(LPN E) then text (Former) DON to tell her that she thinks there was a missing dose of [MEDICATION NAME]. During an interview on 9/10/19 at 9:52 a.m., when asked about LPN T's behaviors during the 8/27/10-8/28/19 shift, LPN [NAME] stated, That night was working north cart (the other side of the building), (LPN T) was working front part of the vent unit. All of a sudden (CNA N and RT K) came and asked if anyone had seen (LPN T) and I said no, and I kept an eye out for her. Then about 45 minutes later they were asking for her again, and then still did not see her, it was about 1:45 a.m., then another staff said she has not seen her since 1200 a.m. Someone went outside and said she was in her car, so I went out and she was vaping outside, I told her that she was needed inside. A little while later, the same CNA came back down and said that (LPN T) just came out of the bathroom and her back of the pants were wet and that (LPN T) was stumbling, so I text (Former DON U, and told her that there was an issue. Former DON U called me back and told me that she talked to (LPN T) and that she seemed fine, and to just keep an eye on her, so I went about my business. Come about 4-4:30 a.m., I was going back to the north vent unit and staff couldn't find (LPN T) again, and then two other CNAs said that they saw (LPN T) stumbling around the car. The social worker was also aware of this, and she saw (LPN T) stumbling and not keeping her eyes open. At this time, I was going to take the (medication cart) keys from (LPN T) and she couldn't even get the keys out of her pocket she was swaying all over the place. LPN [NAME] further stated, We were not going to let (LPN T) drive home, we called her boyfriend to pick her up and he never came. (LPN T) was not like that at the beginning of the shift, and then it got bad. Everything seemed fine and then between around 12 (a.m.) and 2:30 a.m. (LPN T) was out of the building. The second time she left the building, I do not know when she went out, but she came back in around 4:30 (a.m.), and that was when the CNAs saw her outside at her car. Review of typed statement dated 8/28/19 and signed by Former DON U revealed, (Received) text message at approx. 3:15am from (LPN E) that she had rec'd (received) reports from staff that (LPN T) was acting strange. I called (LPN T) and spoke to her for >5 minutes. She sounded normal and was able to recall her night so far. I explained to her about the concerns that were told to me and told her that she needed to work at 100% capacity as we care for a vulnerable population. She stated that she understood and ensured me that she was and would continue to do so. I rec'd a phone call from (Social Services V) just before 5 am and she stated that (LPN T) was acting impaired. She stated that staff had approached her and she herself observed (LPN T) slurring her words. I asked her to have a nurse obtain the cart keys from (LPN T) and count off the narcotics together in order to secure the cart and ensure the safety of our residents. I then asked her to stay with (LPN T) and to make sure she did not drive home. I asked her to contact (LPN T's) emergency contact to come and pick her up. I was called again a few minutes later and informed that we did not have emergency contact information available and (LPN T) was refusing to give (Social Services V) the name, contact number, or address. I informed (Social Services V) that I would be leaving home to come to the facility. I arrived at approx. 6am and as I got out of my car (LPN T) was standing at the front door with (Social Services V) present. I told (LPN T) to get into my car so I could drive her home. She did so after asking her to twice. During the drive she refused to give me her address. She directed me which way to turn. She sat in the passenger seat and refused to use her seatbelt, had the window down and using her vape cigarette. I at no time smelled any alcohol. (LPN T) was slurring her words occasionally and very angry with the situation. She was unhappy that we would not allow her to drive herself home. During the drive I offered to drive her to get a drug test and she refused stating that she just wanted to go home. I explained to her that she could contact me later to obtain her car keys. I turned into the driveway she told me to and she got out of my car, walked around the back and began to walk down the street. She was not stumbling or swaying. Upon returning to the facility, (Social Services V) handed me (LPN T's) car keys. I walked to the back lot to ensure that her car was locked and secure and held the keys in my office until (LPN T) could pick them up. Review of a statement dated 8/28/19, written and signed by RT K revealed, (LPN T) was gone off floor for approximately two hours. When she returned to the floor, she was slurring her words and talking with her eyes shut . Review of a statement dated 8/28/19, written and signed by RT W revealed, At 0020 (12:20 a.m.) I went into the resident's room (Resident #12) because the resident wanted to be placed on the ventilator. He told me he needed to see the nurse because he thought she had not given him his [MEDICATION NAME] and [MEDICATION NAME]. I tried to find (LPN T) his nurse to ask her to talk to the patient I did not see her until around 3:30 a.m. at this time I told (LPN T) that (Resident #12) wanted to talk to her because he wasn't sure if she had given him his medications. The nurse went and talked to the resident. At (5:00 a.m.) I went into (Resident #12's) room and he told me that he thought (LPN T) 'must have been taking something'. I was also unable to find [NAME] from (3:50 a.m. until 4:45 a.m.) Review of a statement dated 8/28/19 at 6:18 a.m., written and signed by CNA X revealed, Dear (Former DON U), Around 12am (LPN T) had left the floor and was nowhere to be seen. At 3:15 am . I went on a 15 minute break and came back to the parking lot and observed abnormal behavior from (LPN T). She was cleaning her car and could barely walk. I did not see her on the floor from 12am-5am approximately. She was slurring her words and not making any sense as if she was high. (LPN T) was saying she didn't have a car, but I seen her enter and sit in a maroon car. Review of a statement dated 8/28/19, written and signed by CNA M revealed, 3:45 am I went outside to take a break & seen (LPN T) outside. She was staggering slurring her words barely able to keep her eyes open. I assumed maybe she was under the influence of something. I went and reported it to (Social Services V) . Review of a statement dated 8/28/19, written and signed by CNA O revealed, We noticed the nurse (LPN T) was having hard time walking and her speech was blur. So therefore, something was wrong. She was gone almost the whole shift . During a telephone interview on 9/12/19 at 3:35 p.m., when asked about (LPN T's) behavior on the night of 8/27/19-8/28/19, CNA O stated, We have seen her out of character before, she went out (of the building) then came back and she was gone for a long time, I would say an hour and half, and then she came back, she was working on south (this was 8/3/19) and her residents were asking for their meds and then when she got back she was slow in everything, and closing her eyes, we asked the charge nurse to come down and figure out what is going on with her because she was not acting right .and she was so defensive. I was busy doing my thing. Her eyes were not open enough to see people and to get the meds out for the residents. Some reason the charge nurse tried to call management at like 3 or 4 in the morning, that was the first incident. Then the last incident (8/27/19-8/28/19) she left the building for a long time, I went outside to find her and I did not see her car, she was sitting in another car, and I told her that I was looking for her, it was hours after I seen her. She couldn't even make it into the building by herself, she had to have someone help her in, she couldn't put a coat on, she couldn't even talk properly, she couldn't walk properly she couldn't even open the cart, she was not safe enough to care for the residents, it was bad. She was very impaired; she couldn't even use a key to open the bathroom. I told them she should go to the ER (emergency room ). When asked if the residents got cared for that night, CNA O stated, She did midnight med pass, then after that she was not able to care for anyone. I actually felt that her car and med cart keys should be taken from her because she was so bad. During this same interview, when asked if anyone had followed up about the first incident, CNA O stated, No, nobody did. When asked if during the first incident if any residents stated that they did not get their medications, CNA O stated, Yes, there were residents that did not get their meds, one resident needed and wanted his breathing treatment, and he never got it, I told the resident that I could not find the nurse. there were other residents that didn't get meds either that night, it was a long time ago I can't really remember who, but I know there were other residents that did not get their meds. Review of a statement dated 8/28/19, written and signed by CNA N revealed, The nurse (LPN T) was outside in her car when I went outside. She walked inside and then I walked inside. She was coming out of the back bathroom. She was falling into the wall. I told (LPN E) to call (Former DON U) she was not safe to be passing pills she could not even stand without swaying. After (LPN T) got off the phone with (Former DON U) she left again her car was gone for a while. When I went outside for a last break (LPN T) was yelling on the phone leaning on the building. Then I saw her try to get in the building and could not figure out how to even get in. After that I just went to do my last round. Review of a statement dated 8/28/19, written and signed by CNA Y revealed, I noticed (LPN T) was stumbling all over the place when (CNA X) and I got back from our 15-minute break . Review of an incident Statement of Witness dated 8/28/19 at 4:45 a.m. and signed by Social Services V revealed, I was approached by (CNA M) and was told (LPN T) was stumbling around & slurring her words. Went out back to see what was going on .I observed (LPN T) leaning against the wall by the back door trying to get in while on the phone slurring words. I contacted (NHA A) & (Former DON U) immediately I had (LPN T) come inside with me. (LPN E) and I got her vitals & was able to sit her down for a moment. I got her cart & car keys from her. She did laps around inside of the building, running into things & talking very loud. She was cussing at me because I wouldn't let her alone. She walked from the front to the back multiple times forgetting she didn't have her keys. As she was doing laps around the inside of the facility she got loud & cussed numerous times while running into walls .She also had a very hard time keeping her eyes open & would hit her vape pen inside & wouldn't listen. Review of an incident Statement of Witness dated 8/28/19 and signed by RN G revealed, At approximately 0100 (1:00 a.m.) I noted the nurse (LPN T), eating at the desk. Her motor skills seemed to be slowed down. Her behavior made me pay attention to her, but she appeared to be functioning ok at this time. Around 0200-0300 (2:00 a.m.-3:00 a.m.) nobody was able to locate (LPN T) for an extended period of time. I took a break around 0400 (4:00 a.m.), when I returned to the floor at 0430 (4:30 a.m.) I observed (LPN T) struggling to walk straight, she was stumbling & bouncing into the wall. Her speech was very slurred and she seemed confused. A staff member was confronting her about her behavior and (Former DON U) was notified. (LPN T) gave her cart keys to another nurse and did not provide any patient care from that point. During an interview on 9/11/19 at 11:35 a.m., when asked about the incident that took place on the night shift 8/27/19-8/28/19, Unit Manager, RN R stated, I got here about 8 that morning, and (Former DON U) was already doing the camera review, she called me in to tell me what was going on, and I wanted to go down on my unit and make sure that everything was ok. I just wanted to follow up with the unit, (LPN F) was in that morning and she was running around trying to catch up because she was behind from the previous shift (LPN T's shift). I did my morning rounds to make sure that they were ok, by the time I got here, they had everything cleaned up pretty well. When asked who performed the duties that LPN T was supposed to perform, RN R stated, I know that the tube feeds were hung, as far as meds, I do not know, I was not physically here, if it is not documented it is not done. When asked if she did anything to investigate if the residents did not get medications or treatments during the night shift, RN R stated, No, I just laid my eyes on the residents and rooms. When asked about Resident #10, and if she was aware of his storming incident, RN R stated, (LPN F) made the comment that he was storming, and she gave him the medications and then he was better. LPN F said that (Resident #10) was the first person she went to take care of because of the storming. I know that he has the issues, so I really wanted to check on him . During an interview in 9/10/19 at 3:15 p.m., when asked about LPN T's behaviors during the 8/27/19-8/28/19 night shift, NHA A stated, I received a phone call from (Socia

This Citation Pertains To MI 796. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy as a result of the facility's failure to prevent the elopement and ensure the safety of 2 residents (#1 and #2) out of six residents reviewed for the potential of elopement who exited the facility and traveled to the closest cross street resulting in the likelihood of injury and possibly death if/when they crossed the street in their wheelchairs and were hit by traffic. Immediate Jeopardy (IJ) is identified at F-689. The IJ began on 6/26/19 when R1 exited the facility without supervision, was identified as an IJ on 7/25/19 and was removed on 7/25/19. Findings include: On 7/16/19, an anonymous complaint was received which stated on 6/26/19 R1 left the facility and was trying to cross a street at a cross light by herself. She rolled herself to the traffic light by herself in her wheelchair. Resident #1 Resident #1 (R1) was admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnoses: [REDACTED]. R1 required extensive assistance with activities of daily living. On 7/24/19, an observation of the exterior of the facility and the location of the gas station and restaurant located across Lake Lansing road revealed the following information: · R1 left the facility unsupervised and was alone at the corner of Lake Lansing Rd and Haggadorn when R1 was seen by a facility employee who was passing by in a car on the way to the facility. R1 was going to cross the street to a local restaurant. Two facility staff assisted R1 back to the facility. · Lake Lansing Road is a busy street which is controlled by a traffic light at the intersection with Haggadorn. R1 would have attempted to cross that intersection in a non-electric wheelchair which she would propel with her feet. R1 had a [DIAGNOSES REDACTED]. There is the likelihood R1 could have a [MEDICAL CONDITION] while crossing the street which would cause her to lose consciousness and put her at risk of being hit by a passing car causing injury and/or death. · There was no investigation regarding: how and why R1 was able to leave the facility and navigate down the driveway to the corner by the crosswalk at the traffic light. There is no current plan in place with interventions to prevent another occurrence. There is no documentation or Incident/accident report concerning the elopement. The care plan was not updated. There is no assessment to determine if R1 is/was an elopement risk after the resident was found at the traffic light. On 7/24/19, a record review of R1's electronic medical record was done. Progress notes were reviewed and there was no documentation that R1 had eloped from the facility on 6/26/19. A record review of the quarterly evaluation done on 3/7/19 indicated R1, even with her cognitive impairment and frequent [MEDICAL CONDITION], was not an elopement risk. The next elopement evaluation was done on 6/11/19 with the same result. There was no elopement evaluation done on or after 6/26/19. On 7/24/19 at 11:45 AM, an interview was done with Registered Nurse (RN) H. According to RN H, she was in Administrator As office when she saw R1 wheel out of the facility and then out of the parking lot. RN H stated she told Administrator A that R1 had left the facility property. RN H said she thought either someone from social services or the resident advocate went to bring R1 back to the facility but did not know for sure. On 7/24/19 at 1:50 PM, Administrator A was interviewed. When Administrator A was asked if she reported that R1 eloped from the facility, she stated she did not report that R1 eloped to the state agency. In addition, she stated there was no investigation into R1 leaving the facility and no elopement assessment was done after R1 was returned to the building. On 7/24/19 at 2:15 PM, Director of Nursing (DON) B was interviewed. DON B stated that she (DON B) was reportedly alerted by a staff member from Human Resources (HR D) that, as she was returning to the facility by car, HR D observed that R1 was on the corner (of Lake Lansing Rd. and Haggadorn Rd.). A resident's brother (RB C) had taken his sister in her wheelchair across the street to the local restaurant and left R1 in her wheelchair on the corner. He did not come back to get her. On 7/24/19 at 3:00 PM, Resident's Brother (RB) C: was interviewed by telephone. When he was asked if he escorted R1 down to the traffic light, RB C stated he did not see R1 when he wheeled his sister to the local restaurant. R1 did not leave the building with RB C and he stated he definitely did not leave R1 alone on the corner by the traffic light. He stated She (R1) can't leave the building by herself. On 7/25/19 at 10:00 AM, an interview was done with Licensed Practical Nurse (LPN) F. When asked if R1 can leave the facility alone, LPN F stated R1 can self-propel w/c and is cognitively aware. LPN F was asked if R1 had [MEDICAL CONDITION]. LPN F stated typically she slumps over (during [MEDICAL CONDITION]), her eyes have a glaze and look different if she is having or had a [MEDICAL CONDITION]. It would make me highly nervous if she was crossing the street (when having [MEDICAL CONDITION]). LPN F was asked if it was reported to her that R1 left the building without supervision would she complete an incident and accident report? LPN F stated I would call the Nursing Home Administrator and ask for direction. I would also do a progress note. On 7/25/19 at 10:15 AM, an observation of R1 occurred. R1 was in her wheelchair which had a seatbelt fastened across her abdomen. R1 was wearing a padded helmet on her head. Conversation was difficult as R1 had long pauses in her sentences as she tried to come up with the words to respond to surveyor's questions. R1 was asked if she remembered leaving the facility and going to the traffic light at the end of June. R1 said she remembered sitting on the corner at the light. R1 denied attempting to cross the street and said she just sat there. R1 said she did not sign out of the facility on the Leave of Absence (LOA) form because the form was full. On 7/25/19, a record review of the LOA signout sheet was done. Two sheets were provided. One sheet was completely full to the bottom. However, review of the form showed R1 never signed herself out on the LOA form for any time she left the facility but had other people do so. According to the OBRA Assessment form, dated 6/10/19, R1 had limited ability to read and write. On 7/25/19 at 2:40 PM, R1's Guardian (R1G) J was interviewed via telephone. According to R1G J, R1 was very headstrong and didn't want to follow any rules. R1 still is experiencing [MEDICAL CONDITION] and can't go anywhere without assistance. R1G agreed if R1 started crossing the street and had a [MEDICAL CONDITION] while in the street, there was the likelihood R1 would be injured. R1G J indicated the facility was aware R1 has to have supervision when she leaves the facility. On 7/25/19 at 3:15 PM, Human Resources (HR) D was interviewed. She stated she was coming back to the facility from the bank in her car and saw R1 on the corner by the traffic light pushing the button on the traffic light in order to cross the street. HR D said she was concerned as HR D never saw R1 by herself away from the facility. HR D immediately parked her car, went to the corner by the traffic light, got R1 and brought her back to the building. On 7/25/19, a record review of the OBRA (Omnibus Reconciliation Act) Level II Assessment for R1, dated (MONTH) 10, 2019, revealed the following information: R1 was diagnosed with [REDACTED]. A psychological evaluation confirmed R1 had difficulties sustaining attention, concentration and mental control. Perceptual reasoning (ability to think and reason using visual information) and working memory fell in the extremely low range. R1 was able to understand and engage in simple conversation. With more complex items, she (R1) has more difficulty answering and will often stop engaging. R1 had uncontrolled [MEDICAL CONDITION] and had a vagal nerve stimulator in place to interrupt the [MEDICAL CONDITION]. R1 wears a helmet on her head to protect her from head trauma when out of bed secondary to uncontrolled [MEDICAL CONDITION] activity. R1 required extensive assistance with bed mobility (positioning while in bed), transfer (moving from one surface to another), dressing, toilet use, personal hygiene and was totally dependent with bathing. The following is the recommendation as a result of the assessment: Recommend continues nursing facility placement . She continues to require 24 hour skilled nursing care, supervision and extensive assistance with the majority of her activities of daily living. She (R1) continues to experience [MEDICAL CONDITION] activity sporadically which occur without warning and requires nursing facility staff to intervene and assist. She has a significant history of falling and injuries with her [MEDICAL CONDITION] activity and wears a padded helmet on her head when out of bed for her protection. R1 exhibits deficits in intellectual functions including reasoning, problem solving, planning, abstract thinking, judgment, academic learning and learning from experience. She has deficits in adaptive functioning that has resulted in the failure to meet developmental and socioculteral standards for personal independence and social responsibility. The assessment of any supportive devices indicated: Although she (R1) remains in her wheelchair and does not walk, she is still at risk for injuries if she were to have a [MEDICAL CONDITION] seated. On 7/30/19, a record review of R1's progress notes, dated 7/28/19 at 8:30 AM, indicated R1 had a 7 minute [MEDICAL CONDITION] while sitting on the toilet. RN M, who was assigned to care for R1 on 7/28/19 was interviewed. He stated R1 was having a [MEDICAL CONDITION] and described the [MEDICAL CONDITION] as - R1 was leaning forward and was limp, had tremors to her arms and trunk. Then R1 leaned backward then forward but had no response to verbal stimuli. On 7/16/19, an anonymous complaint was received which stated on 7/3/19 R2 was found across the street at the gas station. Resident #2 Resident #2 (R2) was admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnoses: [REDACTED]. According to her most recent Minimal Data Set evaluation, dated 6/30/19, R2 had a Brief Interview for Mental Status (BIMS) Score of 10 which indicated mild cognitive impairment. On 7/24/19, a record review of R2's electronic medical record was done. Progress notes were reviewed and there was no documentation that R2 had eloped from the facility on 7/3/19. A record review of the care plan indicated no documentation that R2 had attempted to elope and there were no interventions in place regarding elopement. An incident and accident form was not completed. On 7/24/19 at 10:50 AM, R2's guardian L was interviewed by telephone. According to the guardian L, an unknown person at the facility contacted her on 7/3/19 to let her know that R2 had left the facility without supervision and went to the gas station across the street from the facility. On 7/24/19 at 11:02 AM, R2 was observed lying in bed with her eyes closed. She opened her eyes and greeted the surveyor when the surveyor spoke to her. R2 does not remember how long she has been at the facility but thought she was in the facility previous to the current facility. R2 stated that she came here from her home because she was not able to care for herself. When asked who R2 lived with at home, she stated that it was just her and her cat. She stated that she came to this building directly from home, where she lived with her cat. When asked what the name of this facility was, she stated the name of the previous facility. Surveyor told R2 the name of the current facility. R2 was asked if she remembered living at (name of previous facility) and being transferred to the current facility, R2 did not remember living at another facility and being transferred to this facility. When asked how she liked it here at the current facility, she stated that it was nice but not as good as previous facility. R2 denied that she has gone out of the building since she has been here. R2 did not recall going outdoors at all to obtain cigarettes. On 7/25/19 at 9:00 AM, an interview was done with certified nursing assistant (CENA)/resident advocate E. According to CENA E, R2 liked to go outside and her guardian was OK with R2 going outside. On 7/3/19 at an unknown time, CENA [NAME] was informed by unknown residents in the facility that R2 was looking for cigarettes so CENA [NAME] began to look for R2. Since CENA [NAME] had seen R2 outside the facility on the porch, she went outside to look for her. When CENA [NAME] checked the parking lot, she spotted R2 across the street at the gas station. CENA [NAME] went and assisted R2 back to the facility as R2 looked hot and her face was red. When R2 was brought back to the facility, she was given ice water. No vital signs were taken and no physical assessment was done. On 7/25/19 at 9:40 AM, Social Services Director (SS) G was interviewed. SS G was asked if she was aware R2 had left the building on 7/3/19 without notifying staff. According to SS G, R2 was across the street at the gas station looking around. SS G stated R2 looked hot so SS G helped R2 back to the facility. SS G informed Administrator A and DON B that R2 was across the street at the gas station. SS G did not document assisting R2 back to the facility in the electronic medical record. SS G did not feel the need to do an incident and accident report and did not feel a need to document R2's elopement in the progress notes. SS G stated she did not know how long R2 was outside. However, when SS G went to assist R2 back to the facility, R2's face was red and R2 appeared hot. On 7/25/19 at 11:00 AM, a second interview with R2's guardian L revealed the guardian did not feel comfortable with R2 leaving the facility alone and crossing the street at the traffic light without supervision. The guardian L stated she was never contacted by the facility asking for permission to allow R2 to leave the property by herself. If she had been contacted, she would not have approved R2 leaving the facility alone. On 7/29/19 at 2:00 PM, Attending Physician (AP) for R1 and R2 was interviewed by phone. When he was asked if he felt either R1 and/or R2 were elopement risks, he stated prior to this phone call, he had no strong feelings about either resident being an elopement risk. Currently, after being updated by management at the facility that both residents had left the facility without supervision, he was aware both residents had the potential to elope. On 7/30/19, a record review of the Unsafe Wandering & Elopement Prevention Protocol, revised date of (MONTH) (YEAR), revealed the following information: Every effort will be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. In addition, the following information was listed under the title Nursing Service Duties Upon Return of Missing Resident: a. Examine the resident for injuries b. Contact the Attending Physician c. Notify the resident's responsible party e. Complete and file an incident report f. Complete an elopement assessment g. Make appropriate entries into the resident's medical record The abatement plan submitted by the facility on 7/25/19 included the following: On 7/25/19, the DON, Administrator, and 10 other staff members participated in this action plan. On 7/25/19, Resident #1's guardian was contacted by the Director of Nursing and the preference for the resident to leave the facility independently was validated. · On 7/25/19 at 11:48 am, the Administrator placed a staff member at the only unsecured door. This staff member will remain in place until compliance is attained. · On 7/25/19 Resident #1 had an elopement assessment completed and was determined to not be at risk and care plan updated. · On 7/25/19, Resident #1 was assessed by the licensed nurse for [MEDICAL CONDITION] activity including neuro-check, and there were no concerns identified. · On 7/25/19, 79 residents that reside in the facility had a Risk for Elopement Assessment completed by the Unit Managers with care plans updated as indicated. 7 of 79 residents have been assessed as at risk for elopement. · On 7/25/19, the 7 residents residing in the facility who were identified as being at risk for elopement were reviewed by the nursing leadership to review current elopement risk, orders requiring documentation, care plan, and Kardex to ensure appropriate assessment and intervention were in place. · An audit was completed on 7/25/19 of the elopement book to verify that all residents at risk for elopement had an elopement photo sheet in place. · On 7/25/19, the DON/designee reviewed the last 30 days of progress notes for 79 residents that reside in the facility to ensure that incidents occurring in the facility were identified and an incident report/investigation has been completed and there were no concerns identified. · Signs were placed before entering the front door, viewable upon entrance and exit, as well as at the nursing station alerting persons that exit the facility not to assist resident s outside without checking with the nurse. · On 7/25/19, the Administrator, DON, and IDT were re-educated on the Unsafe Wandering & Elopement Prevention Protocol-Missing Resident Protocol and Accidents and Incidents- Investigating and Reporting. · The Unsafe Wandering & Elopement Prevention Protocol-Missing Resident Protocol and Accidents and Incidents- Investigating and Reporting, was reviewed by the NHA and DON on 7/25/19, and deemed appropriate. · An Ad Hoc QAPI meeting was held on 7/25/19 to review the Unsafe Wandering & Elopement Prevention Protocol-Missing Resident Protocol and Accidents and Incidents-Investigating and Reporting and this plan. The Medical Director reviewed the plan with the Administrator on 7/25/19 via telephone and he agreed with the plan. · Beginning 7/25/19, re-education was provided to staff including; nursing, housekeeping, dietary, maintenance, and therapy, by the DON/designee related to the Unsafe Wandering & Elopement Prevention Protocol-Missing Resident Protocol. No employee will be allowed to work without receiving education. 81 out of 150 employees have been reeducated by the DON/Designee. · Beginning 7/25/19, re-education was provided by the DON/Designee to the licensed nurses regarding Accidents and Incidents- Investigating and Reporting. No employee will be allowed to work without receiving education. 10 out of 35 nurses have been re-educated. · Beginning 7/25/19, new admissions will have a risk for elopement assessment completed. Those determined to be at risk will have their care plans and Kardex updated with appropriate interventions. These assessments will be reviewed during the next scheduled clinical meeting, M-F, to ensure that they are accurate and that interventions are in place to meet the resident's needs. Although the Immediate Jeopardy was removed on 7/29/19 at 11:00 AM, when it was verified that the facility implemented the action plan, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

This citation includes complaint intake MI 44. Based on interview, and record review, the facility failed to provide adequate supervision for 1 (Resident #3) of 2 reviewed for falls and transfers, resulting in Resident #3 sustaining a fall with fracture. Findings include Review of the medical record and Minimum Data Set (MDS) assessment, Resident #3 was a [AGE] year old male resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #3 had clear speech, sometimes understood, sometimes understands was severely impaired cognitively and had disorganized thinking present that fluctuated. Further review of the MDS revealed Resident #3 required extensive physical assistance of 2 staff members for activities of daily living to include toilet use. Review of the Medical Record revealed Resident #3 had falls on 4/20/19, 4/23/19, 4/28/19 and 4/29/19. Review of the fall incident report dated 4/20/19, completed by Registered Nurse (RN :J) revealed, (Resident #3) has been very agitated for several weeks. (Resident #3) was agitated and in his room alone wanting to be dressed and helped to his chair. He states that he slid out of bed .care plan intervention is to not leave this resident alone in his room when he is agitated . Further review of this report reveled that a falls team meeting was completed, and that Unit Manager (UM) G had documented the following notes under this section, Pt in his bed calling out, staff found (Resident #3) on his floor next to his bed, Conclusion: Pt fell on to floor from bed. Additional Care Plan / Nurse Aide Assignment Updates: When patient is yelling out and agitated, offer to assist him into his wheelchair and check to see if he is incontinent. Review of the facility's fall incident report dated 4/29/19, and completed by Registered Nurse (RN J) revealed, Lodger (Resident #3) was found in Room by N.P. (nurse practitioner) .Lodger was found face down on floor .obvious bloody head wound .Lodger was on floor face down, bleeding from serious gash on forehead .This nurse called EMS (Emergency Medical Services) and prepared transfer paperwork. Lodger transferred to (name of hospital) Review of the Hospital's Trauma Services Discharge Summary dated 4/29/19 revealed Resident #3 was, admitted to the hospital after a fall form his wheelchair .CT showed nasal bone fractures .Type II C2 (cervical) fracture . Further review of the fall incident report dated 4/29/19 revealed, Lodger (Resident #3) has been agitated more than usual for several weeks .Lodger had a fall from bed the day previous and has a history of falls. Lodger has been showing a higher level of agitation for some three weeks .Lodger has a history of falls and has often been observed engaging in unsafe practices, such as reaching for items on the floor while seated in his wheelchair. This fall was unobserved. During an interview on 6/5/19 at 11:40 a.m., when asked about Resident #3's fall, RN J stated, (Resident #3) had been up an very agitated for several weeks and would be up for large part of the night, and that was the situation that day .He is not allowed to be in his room by himself, we have it care planned to not be in his bed if he is agitated because he will fall out .I was shocked, I had never seen him fall out of his chair before . When asked why he fell , what was he trying to do, RN J stated, I really do not know. Review of the Five Whys Tool for Root Cause Analysis, undated and unsigned, revealed that the Root Cause of Resident #3's fall on 4/29/19 was, Pt (Resident #3) needed to be toileted. Review of Resident #3's ADL care plan revealed the intervention, TOILET USE: 2 person assist with easy stand Date Initiated: 07/10/2018. Review of Resident #3's schizo-affective disorder care plan revealed the intervention of, If (Resident #3) is noted as yelling, approach him calmly and quietly. Offer to assist him to a quiet place and monitor to ensure safety During an interview on 6/5/19 at 1:08 p.m., when asked about Resident #3's fall and the incident report, Unit Manager (UM) G stated, I do the wrap up of the investigation. When asked what the investigation showed, UM G stated, That he (Resident #3) was in activities and was yelling out and then activities assisted him to outside his room. She (Activities Director (AD) F) notified staff member that he (Resident #3) had to use the the bathroom, and then he was found face down in his room. When asked who the staff member was that AD F notified, UM G stated, I was not given a name, that would be a question for (Director of Nursing) (DON) B). When asked why staff would not have just taken Resident #3 to the bathroom when he said he had to go, UM G stated that she agreed. When asked about the Root Cause Analysis tool, and the fact that the root cause of the fall was determined to be that the Resident needed to be toileted, UM G agreed and stated that she was the individual that completed that form. UM G agreed that it appeared that Resident #3 had to use the bathroom, and a staff member, rather than helping him to use the bathroom, pushed him to his doorway, and left him there to have someone else care for his needs. Review of the Statement of Witness form dated 5/1/19 revealed UM G was the person that conducted the interview and AD F was the Name of Witness. Review of this statement revealed, (Resident #3) was in activities after breakfast being disruptive yelling out. (AD F) asked (Resident #3) to use a quiet voice because he was scaring the ladies .(AD F) went to a meeting, once returned from meeting around 10 (am), (AD F) saw (Resident #3) in the hallway .yelling out, I have to[***] (AD F) assisted (Resident #3) to his room and left him outside his room in the doorway. Further review of this witness statement revealed an Addendum which was documented by DON B which stated, (AD F) states that she assisted resident to room and notified a staff member that he needed to use the bathroom. During an interview on 6/5/19 at 12:50 p.m., when asked about the statement of witness form, AD F stated, I was the one that took (Resident #3) to his room. (Resident #3) was in the activities doorway and was kind of agitated and was yelling. I asked him to use a nicer voice. I went to my morning meeting and then when I came back, he was in the hallway, I then took him down to his room, left him outside the entrance of his door, I went in turned the call light on, the first aide I saw, I told them that (Resident #3) had to go number 2. I don't remember the name of the person I told, but yes for sure it was an aide. Review of the complete fall incident report failed to reveal that any staff member had knowledge, other than AD F, that Resident #3 had to use the bathroom. Furthermore, review of the witness statements, and interviews with staff members involved would indicate that 2 (CNAs C and D) of the 4 aides that were working that section, were at lunch during the time of the fall, CNA H was interviewed and stated that she was not made aware or Resident #3's need to use the bathroom. CNA I was not available for interview, but her statement of witness indicated that she was not aware of Resident #3's need to use the bathroom, and also indicated that Resident #3's call light was not on at time of fall or prior to fall. During an interview on 6/5/19 at 1:30 p.m., when asked about Resident #3's fall on 4/29/19, and who the staff member was that AD F notified, DON B stated, When we asked the CNAs (Certified Nursing Assistants) they could not remember if someone told them that (Resident #3) had to go to the bathroom or not .When I talked to the two (CNAs H and I), they both said they were helping other residents on the hall, and the patient advocate was not on the floor either, at that time. Review of the Statement of Witness form dated 5/1/19 revealed UM G was the person that conducted the interview and Activities Aide (AA E) was the Name of Witness. Review of this statement revealed, After breakfast (Resident #3) came to activities, (Resident #3) was disruptive yelling out. (Resident #3) had a cookie and then wheeled out of activities into the hallway between activities doorway and hall. (Resident #3) was yelling that he needed to use the bathroom and (AD F) took him to his room. During an interview on 6/5/19 at 12:40 p.m., AA [NAME] read her witness statement and than said, (Resident #3) was stating that he had to use the bathroom, but I know I did not want to take him to his room, so I was trying to keep him occupied until the aides came to get him. When asked why she did not want him to go to his room, AA [NAME] stated, He had been agitated and was yelling and I didn't want him to fall. Surveyor asked AA [NAME] , So you felt that at that time (Resident #3) needed supervision? and AA [NAME] stated, Yes. During an interview on 6/5/19 at 12:05 p.m., when asked about Resident #3's fall on 4/29/19, CNA C stated, Yes, I was his (Resident #3's) aide that morning. When he fell I was at lunch, when I went to lunch he was in the activity room and when I came back, the paramedics were in the room with him. CNA C stated that she gets a 30 minute lunch. When asked who would have been covering her assignment while she was at lunch, CNA C stated, It would have been any of the other aides, we work as team, it would have been (CNA I or D) During an interview on 6/5/19 at 12:27 p.m., when asked about Resident #3's fall, CNA D stated, I was at lunch at the time of the fall. When asked if it was normal for 2 aides to be at lunch at the same time, CNA D stated, Yes, there are 3 (CNAs) on central and one on the middle of central .everybody is responsible to cover when we go to lunch. When asked who would have been aides that day, CNA D stated it would have been herself, CNA C, H and I During an interview on 6/5/19 at 1:57 p.m., CNA H was provided her witness statement which stated, did not see anything was caring for another pt (Resident) at the time of fall. CNA H agreed that was her statement regarding the fall. When asked if prior to Resident #3's fall if anyone informed her that Resident #3 had to use the bathroom, CNA H, with a puzzled look on her face, stated, No, nobody did. If you look at the care plan, it states that he should not be in his room by himself. We try to keep him out of the room all the time, we try to distract him with activities. This surveyor attempted to contact CNA I during the survey, but no return call was received. Review of CNA I's statement of witness dated 4/30/29, and completed by UM G, revealed, All morning (Resident #3) was yelling out and was not redirectable .NP saw me in the hall and asked me to help her because (Resident #3) was on the floor. (Resident #3) call light was not on at time of fall or prior to fall.

This citation pertains to intake MI 750. Based on observation, interview and record review the facility failed to accurately assess, and document a resident's skin integrity, and update interventions to prevent the development and worsening of pressure ulcers for 1 (Resident #2) of 3 residents reviewed for pressure wounds from a total of 5 sampled residents resulting in Resident #2 being hospitalized [MEDICAL CONDITION], and osteo[DIAGNOSES REDACTED] (infection of the bone). Findings include: Review of the Admission Record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was a [AGE] year old female that was originally admitted to the facility on [DATE], was sent to the hospital on [DATE], was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #2 had no speech, was rarely/never understood, rarely/never understands, was severely impaired cognitively, required extensive assistance of two staff for Bed mobility, to include, moving to and from lying position, turning side to side and positioning body while in bed, was totally dependent on 2 staff for transfers from bed, required extensive assistance of 2 staff for hygiene, and was admitted with a stage II pressure ulcer (localized damage to the skin and underlying soft tissue; partial-thickness skin loss with exposed dermis). Review of the nurses note dated 1/6/18 revealed, (Resident #2) transferred to (Name of hospital) ED (Emergency Department) .(Resident #2) was transported to (Name of Hospital ED) at 7:30 a.m. Review of the hospital's ED notes dated 1/6/18 revealed, 8:50 a.m .Patient febrile (having a fever) .Large sacral decubitus ulcer found on exam .wound shows exposed muscle and stage 4 ulcer (full thickness tissue loss with exposed bone, tendon or muscle) .Paged for admission [MEDICAL CONDITION] (secondary) to UTI (urinary tract infection) vs. decubitus ulcer . Further review of the ED notes revealed, Large stage 4 sacral decubitus ulcer. ~ 15 x 15 cm (centimeters) area of necrosis (dead body tissue). ~ 7x 5 cm area of exposed adipose muscle. Yellow discharge present. 2nd ulcer present on posterior aspect of left thigh. Review of the hospital History and Physical dated 1/6/18 revealed, Chief Complaint: decubu ulcers (decubitus ulcers-bedsores, or pressure ulcers), UTI, lethargy .Pt (patient) is non-verbal at baseline .Pt is residing at (name of facility) long-term She has been more lethargic and clammy .She was sent for thoughts of UTI .On review of pt in Ed. She was noted to have multiple, deep ulcers to buttocks and back and surgery was notified and will do debridement (removal of damaged tissue from a wound) .Very large, deep wound to right buttock encompassing almost the entire right buttock cheek; smaller, deep ulcer left buttock; more superficial wounds to upper shoulder/midline .Plan: Admit to inpatient:[MEDICAL CONDITION] (body's overwhelming and life-threatening response to infection) due to high grade decubitus ulcers on buttocks and back, UTI (urinary tract infection) . Review of the Surgery Consult Note dated 1/6/18 revealed, (Resident #2) .presents from (name of facility) for concern [MEDICAL CONDITION] .and they are suspected of UTI. On arrival to ER (emergency room ) patient found to have large deep pressure ulcers therefore general surgery consulted for possible debridement .Per chart review, sacral decubitus ulcer in (MONTH) (YEAR) was a stage 2 and healed while in inpatient setting. Per ED, there was concern for neglect and APS (Adult Protection Services) consulted .Sacral decubitus ulcer approximately 15 cm x 10 cm likely stage 4 and malodorous (foul-smelling), left posterior thigh decubitus ulcer, stage 3 (full thickness skin loss, fat is visible), upper back with stage 1 ulcers (intact skin with localized area of non-blanchable skin) .On exam, patient with multiple decubitus ulcer with stage 4 decubitus ulcer to sacrum, stage 3 to left posterior thigh in need of debridement . Review of the Debridement of Sacral Ulcer Operative Note dated 1/7/18 revealed, Debridement of skin, subcutaneous tissue and muscle from sacral decubitus ulcer measuring 19x12x2 cm .debridement of necrotic tissue of sacral decubitus ulcer .Stage 4 sacral decubitus ulcer, necrotic skin, fat and muscle debrided .Evidence of Infection: Yes: necrotic infected tissue . Review of the Infectious Disease Consult Note dated 1/6/18 revealed, Surgery and wound care have seen (Resident #2) and she is likely to go for debridement either tomorrow or Monday ID (Infectious Disease) consulted for possible osteo[DIAGNOSES REDACTED] of the sacrum .worsening wound on her buttock/sacrum .large sloughing (to shed dead skin) escar (sp.) (dry dark dead skin) on her sacrum with additional wounds in buttox, no visible bone but can't see under escar (sp.) .Plan: Await surgical debridement . Review of the Hospitalist Service progress note dated 1/22/18 revealed, (Resident #2) was admitted and surgery consulted for debridement of ulcer and pt (patient) underwent debridement and surgical cultures sent on 1/7 .ID was consulted .Pt underwent debridement on 1/8 .On 1/9 .on examination of wound now felt to possibly involve bones .debridement done on 1/10/19 and taken to OR on 1/11 .MRI ordered of the sacrum to rule out [DIAGNOSES REDACTED]-it was positive . Review of the Hospital's Wound Flowsheet dated 1/6/18 revealed, Pressure wound 1/6/18 Stage III Gluteal fold/upper thigh .Date first assessed 1/6/18 .pink yellow slough . Review of the facility's wound documentation for Resident #2 revealed that on 1/2/18, Resident #2's sacrum wound was measured length/width/depth of 11.0/20.0/0.1 cm and was staged as a Stage II pressure ulcer .further review of this wound assessment revealed, Wound Bed: Granulation (new vascular tissue in granular form on an ulcer, the healing process of a wound) .Tissue Type: Granulation. Review of the facility's 2nd wound documentation for Resident #2 revealed that on 1/2/18, Resident #2's left inner thigh wound measured 4.0/2.8/0.1 cm and was not called a pressure ulcer, rather Type of wound: brief trauma . During an interview on 2/14/18 at 1:00 p.m., when asked about the facility's wound assessments on 1/2/18, Director or Nursing (DON B) stated, Yes, on the 2nd I rounded with (DR J) it was me, (Registered Nurse (RN) I) and (DR J). He was not staging or measuring the wounds, he was letting us do that. When asked why there was such a huge discrepancy in the assessment of the wounds compared to the facility and the hospital, DON B stated, I know that the day (Resident #2) left here (1/6/18) the wound looked identical to what they looked like on the 2nd, the gluteal fold was a surface abrasion from the edge of the brief, it was never a pressure ulcer, it was more of a shearing from the brief. The sacrum was never more than a Stage II, but I can't speak for what happened between here and the hospital. When asked to confirm that the base of the sacrum wound was visible and was only 0.1 cm deep, DON B stated, Yes, it was superficial. When asked if DR J was wound certified, DON B stated, I can not answer that. When asked if RN I was wound certified, DON B stated, No, I am and I taught (RN I) how to assess wounds. During an interview on 2/14/18 at 10:00 a.m. when asked about the facility having a wound doctor, DON B stated that they did have a wound doctor, and he ended his service at the facility on 12/15/17. DON B further stated that they now have a new wound doctor, who started about 3 weeks ago. DON B further stated that (RN I and RN K) both rounded with the wound doctor and documented the wounds in the (name of the wound documentation software). Review of a progress note from the previous wound doctor dated 12/13/17 revealed, The patient had community acquired stage II wound of the sacrococcygeal area which has now progressed to a deep tissue unstageable situation. The wound is 11 x 18 with poor blanching in the central portion. On the edges, there is some blanching .There is still a central area of approximately 8 x 12 at the skin that could not be removed and is still darkened. The surrounding area still does not blanch well except at the very periphery .SKIN: approximately 10 x 15 mm ulcerative lesion on the inferior aspect of the left gluteal region; covered in a clean/dry/intact dressing; no significant surrounding [DIAGNOSES REDACTED], [MEDICAL CONDITION], color, or drainage. Review of the corresponding wound note that was documented by (RN K) dated 12/13/17 revealed, Length / Width / Depth: 11.0 / 18.0 / 0.1 cm .Stage 2 .Tissue Type: Granulation .Wound Bed: Granulation . In the General Comments and Observations section of this note, it appears that the doctor's description was copied and pasted to this section. Review of the Nursing Evaluation Data that was completed upon Resident #2's readmission on 11/22/17 revealed, that it was documented that Resident #2 had a Pressure Ulcer on her coccyx. There was no staging or measurement of this wound. Review of the Norton Plus Pressure Ulcer Scale (a tool used to assess the risk of developing pressure ulcers) dated 11/22/17, Revealed that Resident #2 was High Risk scoring a 2.0 (10 and below is high risk). Further review of this scale revealed that Resident #2 was immobile Review of the MDS assessment dated [DATE] revealed that the Care Area Assessment for Pressure Ulcers was triggered, and required a decision to be made about care plan for pressure ulcers. Review of the at risk for pressure ulcer development initiated on 10/27/17 revealed the following 2 interventions that were in place on 11/22/17, after Resident #2 was readmitted to the facility with a Stage II pressure ulcer, and was assessed as being high risk for the development of pressure ulcers: -Evaluate nutritional status. Serve diet as ordered, monitor intake and record. -Follow facility policies/protocols for the prevention/treatment of [REDACTED].>Further review of Resident #2's care plan failed to reveal any type of repositioning intervention was put into place until 1/4/18 when the intervention of, Yellow dot program was added to Resident #2's care plan. During an interview on 2/14/18 at 1:00 p.m., when asked what the yellow dot program was, DON B Stated, It means that staff is to round every two hours and turn people. When asked what the difference is between the Yellow dot program and Reposition every two hours, DON B stated, no difference. When asked what the standard of care was for repositioning residents, DON B stated, It depends on their Norton score. When asked how often residents that are not care planned for the yellow dot program or to be turned every two hours, are to be repositioned, DON B stated that those residents would be able to reposition themselves and therefore would not need to be careplanned to be repositioned. When asked at what score on the Norton scale, should residents be repositioned, DON B responded, There is no set Norton score to indicate when they should be turned. While DON B looked at the medical record stated, I see it was 1/12/18 when the resident had the intervention of being turned every two hours was put into place. DON B further stated, I see a yellow dot on 1/4/18. Review of the physician note dated 11/27/17 revealed, Functional [MEDICAL CONDITION] .Frequent turns. Pressure point offloading. Review of the Physician Wound Care Note dated 11/29/17 revealed, .She is seen today for community-acquired wound .continue with offloading per call per the facility's standard . Review of the Physician Wound Care Note dated 12/6/17 revealed, She is obese and came in with community acquired stage II wound which is showing signs of some moisture trapping and macerated skin .continue offloading as best as possible .Functional [MEDICAL CONDITION] Notes: Frequent turns. Pressure point offloading. Review of the Physician Wound Care Note dated 12/13/17 revealed, The patient had community acquired stage II wound of the sacrococcygeal area which has now progressed to a deep tissue unstageable situation. The wound is 11 x 18 with poor blanching in the central portion. On the edges, there is some blanching .There is no significant bogginess at this time and hopefully this will resolve. It is important to perform religiously turning side to side every few hours to offload this area completely . During an observation made on 2/13/18 at 1:15 p.m., Resident #2's pressure measured approximately 11 cm (centimeters) wide by 20 cm long. The wound had a wound vac dressing in place and therefore could not be completely visualized.

This citation pertains to intake MI 750. Based on interview and record review the facility failed to ensure timely action was taken for an abnormal lab for 1 of 3 residents (Resident #2) reviewed for lab results in a total sample of 5 residents resulting in Resident #2 not being treated for [REDACTED]. Findings include: Review of the Admission Record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was a [AGE] year old female that was originally admitted to the facility on [DATE], was sent to the hospital on [DATE], was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #2 had no speech, was rarely/never understood, rarely/never understands, was severely impaired cognitively, required extensive assistance of two staff for Bed mobility, to include, moving to and from lying position, turning side to side and positioning body while in bed, was totally dependent on 2 staff for transfers from bed, required extensive assistance of 2 staff for hygiene, and was admitted with a urinary catheter. Review of the hospital emergency department notes dated 1/6/18 revealed, History of Present Illness: (Resident #2) .presents to the ED (emergency department) from (name of facility) with CC (chief complaint) of UTI (urinary tract infection) .Foley placed. Cloudy urine present in Foley .Chart review performed shows urine culture performed on 1/2/18 growing [DIAGNOSES REDACTED] pneumonia (type of bacteria) .Paged for admission [MEDICAL CONDITION] (secondary) UTI .Vanc ([MEDICATION NAME], an antibiotic) and [MEDICATION NAME] (another antibiotic) started . Review of the hospital History and Physical dated 1/6/18 revealed, Chief Complaint: decubu ulcers (decubitis ulcers-bedsores, or pressure ulcers), UTI, lethargy .Pt (patient) is non-verbal at baseline .Pt is residing at (name of facility) long-term She has been more lethargic and clammy .She was sent for thoughts of UTI . Further review of the History and Physical revealed, Plan: Admit to inpatient:[MEDICAL CONDITION] (body's overwhelming and life-threatening response to infection) due to high grade decubitus ulcers on buttocks and back, UTI (urinary tract infection) . Review of the At risk for return to hospital related to LACE (index identifies patients that are at risk for readmission or death within thirty days of discharge) score 10 (0-4 is low; 5-9 is moderate and > or =10 is high risk) initiated on 11/28/17 revealed the intervention of, Labs as ordered and report to MD (doctor) Review of the Nurse Practitioner (NP) note dated 1/1/18, from NP G revealed, For her leukocytosis (is when the white blood cells are above the normal range in the blood. It is frequently a sign of an [MEDICAL CONDITION] response, most commonly the result of infection) .we will order a chest x-ray and a urinalysis to identify source of infection . Review of the urinalysis lab report dated 1/4/18 revealed that Resident #2 had a urinary infection. The report also included the culture and sensitivity (identification of the causative bacteria and what medications can be used). Review of the complete medical record failed to reveal that the urinalysis with culture an sensitivity dated 1/4/18 was ever relayed to the ordering nurse practitioner, nor was it reported to any other physician, and therefore no treatment could be started. During a telephone interview on 2/14/18 at 11:16 a.m., NP G accessed Resident #2's electronic medial chart, and reviewed the urinalysis with culture and sensitivity dated 1/4/18. NP G stated, I did not see it until Monday (1/8/18), I was hot, it should have been reported to us on the 4th. When asked if she would have started any type of treatment if she was made aware of the urinalysis with culture and sensitivity dated 1/4/18, NP G responded, Looks like I would have started her on an antibiotic. I would admit there is a problem with the lab system because I would have started her on something on the 4th.

This citation pertains to MI 736: Based on interview and record review, the facility failed to prevent a significant medication error for (Resident #1 and #4) from a total sample of 4 residents reviewed for medication errors, resulting in Resident #1 receiving unprescribed anti-epileptic and [MEDICAL CONDITION] medications, was sent to the hospital, Resident #4 receiving unprescribed insulin, and the potential for [DIAGNOSES REDACTED]. Findings include: Resident #1 Review of the Admission Record and Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was an [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #1 had clear speech, usually understood others, usually understands and was cognitively intact. Review of the Nurses' Note dated 1/19/2018 at 10:31 a.m. revealed, (Resident #1) was given medications this AM (morning) for his room mate . Review of the Medication Error Report dated 1/19/18 at 10:00 a.m. revealed, Description of error (include medication, dose, route and time administered) [MEDICATION NAME] 100 mg (milligrams), [MEDICATION NAME] 300 mg, [MEDICATION NAME] 300 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 250 mg, [MEDICATION NAME] 30 mg, [MEDICATION NAME] 1750 mg. Review of the Nurse Practitioner's Progress Note dated 1/19/2018 at 2:08 p.m. revealed, History of Present Illness Details: (Resident #1) is an [AGE] year-old gentleman with a history of dementia, debility, [MEDICAL CONDITION] arthritis, seen today after the patient accidentally received his roommate's medications. The patient received a couple of his roommate's anticonvulsant's which included [MEDICATION NAME], and [MEDICATION NAME]. The patient is currently in his room at this time. The patient is normally verbal. At this time, he is not. He does appear to be lethargic. The nurse's aide states that she would try to sit him up to dress him and the patient would just immediately fall back on to the bed .I did advice the nurse to send the patient over to the emergency room for further evaluation and for possible charcoal to inactivate the medications that the patient ingested. Review of drugs.com, revealed the following information pertaining to some of the medications that Resident #1 received inadvertently: [MEDICATION NAME]: An anti-epileptic drug; it works by slowing down impulses in the brain, common side effects include dizziness, drowsiness, confusion, loss of balance or coordination; recommended starting dose is 100 mg, Resident #1 received 160 mg [MEDICATION NAME]: An anti-epileptic drug; is used together with other drugs, common side effects include dizziness, shakiness and unsteady walk, sleepiness or unusual drowsiness, unsteadiness, trembling, other problems with muscle control or coordination; normal initial dose is 100 mg 2 times a day, Resident #1 received 300 mg. [MEDICATION NAME]: An anticonvulsant drug, used to treat [MEDICAL CONDITION]; common side effects include numbness, dizziness, drowsiness, tired feeling and slow reactions; normal starting dose for [MEDICATION NAME] is 25 mg twice a day, Resident #1 received 300 mg [MEDICATION NAME]: An anti-epileptic drug used to treat [MEDICAL CONDITION]; common side effects include dizziness, drowsiness and weakness; normal initial dose is 500 mg twice a day, Resident #1 received 1750 mg. During a telephone interview on 1/29/18 at 1:11 p.m., when asked about the medication error involving Resident #1, Registered Nurse (RN) D stated, I was in the middle of my morning med pass (medication pass), I had pulled medications for (Resident #1's) roommate, my cart was in between that room and another room, another resident's call light went on, I went to answer it then came back, I pulled the med's that I had in the cup and then gave (Resident #1) (Resident #2's) medications . During an interview on 1/29/18 at 11:23 a.m., when asked about the morning that he received the wrong medications, Resident #1 stated, I don't even remember it. From what I'm told, I went to the hospital and everything. I just don't remember. During an interview on 1/29/18 at 12:15 p.m., when asked about the effects of the medication error, Resident #1's wife stated, He was just given the medications of his roommate. He did go to the hospital, and is ok now, but it took him about 3 days to come out of his stupor. Resident #4 Review of the Admission Record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #4 had clear speech, was understood, understands and was severely impaired cognitively. Review of the Medication Error Report dated 12/28/17 revealed, Description of error: Bed 2 instead of Bed 1. Was asked to administer insulin for another nurse. Misunderstood which resident and gave to incorrect resident. Review of the complete medical record and Medication Error Report failed to reveal what type and how much insulin was given to Resident #4, and therefore can not be documented in this report. During an interview on 1/29/18 at 1:35 p.m., when asked about administering insulin to Resident #4 in error, Licensed Practical Nurse (LPN) E stated, I was outside smoking a cigarette with (Name of other nurse),(Resident #4)'s nurse, she said she was going to get something to eat and asked me to give her resident some insulin, she had it predrawn, I gave it to the wrong resident. Review of the Transcribed Progress Note dated 12/29/17 revealed, .The patient had received her roommate's long-acting insulin after she was admitted to the facility yesterday afternoon. We have checked her blood sugars on the hour since then. Her blood sugars have since stabilized .

This citation has 2 Deficient Practice Statements (A and B). This citation pertains to MI 433. Findings include: A. Based on observation, interview, and record review, the facility failed to prevent mistreatment for one of 5 residents reviewed for mistreatment (Resident #2), from a total of 7 sampled residents, resulting in continued aggression from an unauthorized use of a non-medical device as a restraint with the potential for psychological harm, injury and/or death and placing an additional 20 Residents, deemed by the facility at risk for unauthorized use of restraint, at risk for increased aggression, psychological harm, injury and/or death. Review of Resident #2's Minimum Data Set, dated dated [DATE], revealed he was a [AGE] year old man, admitted to the facility on [DATE], who had severe cognitive impairment, severe vision impairment, no range of motion impairments, ambulated with limited assistance, was in Hospice, and had [DIAGNOSES REDACTED]. On 1/19/17 at 12:10 AM and on 1/24/17 at 11:20 AM, this Surveyor observed Resident #2 laying quietly in bed, apparently sleeping. According to Intake Information, dated 1/03/17, On 12/23/16, a mid-night nurse or CNA (Nurse Aide) tied (Resident #2) to his wheelchair with a sheet that was wrapped around his stomach, then knotted in the back of his wheelchair. They tied him up so he could not get out. In an interview, on 1/19/17 at 12:14 PM, MDS Coordinator I reported she entered the facility on 12/23/16 at approximately 5:15 AM and saw Resident #2 in a wheelchair with a sheet tied around back of the wheelchair. MDS Coordinator I said, (RN/Registered Nurse E) said they put the sheet on Resident #2 because he had been 'combative, hitting, spitting'. (RN H) came and untied (Resident #2) .I stayed with him. He kept getting up, hitting and grabbing me. We had been noticing hallucinations and a pattern of being more combative (with Resident #2). MDS Coordinator I stated this was definitely, ignorance on their part (referring to RN E and H). They should have called (Resident #3's RP/Responsible Party O) first then 911 to ship him (send to the hospital). At 6:15 AM an ambulance came, but he was calm by then. The hospital sent him right back. When (LPN/Licensed Practical Nurse AA) from first shift, came in, she has a good rapport with (Resident #2), and he calmed right down. When the DON/Director of Nursing (B) and Administrator (A) got here, seven-ish (approximately 7:00 AM), I let them know what happened. Other nurses approached me about it; they were upset it happened. There should have been an Incident Report. I knew it was wrong and could be considered abuse. It was a physical restraint. They did it to restrain him. They didn't call Hospice or the DON (B). I'm not sure who tied him. Review of Resident #2's Care Plans revealed there was no restraint intervention for Falls or Behaviors. However, according to Resident #2's Activities Care Plan, dated 10/24/16, .Lodger likes to listen to organ music .offer (Resident #2) car magazines to look at .provide a unhurried pace .prefers the following TV channels: news and Lawrence Welk . And his Behavior Care Plan, dated 5/09/16, revealed, .understands consistent, simple, directive sentences Stop and return if agitated .Engage .in simple, structured activities . (12/21/16) - If .noted as being agitated and observed approaching other patients, please re-direct or observe to ensure safety .If refusing care, ensure safety and re-approach in 10-15 minutes. If this continues not to work, use a different caregiver .(5/09/16) - Keep .routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion .Provide .look at pictures of his cat .interactive cat, and eat his own snacks (that his niece or hospice has provided) .really likes Coca-Cola, cookies, ice cream, juice, hot cocoa, coffee .Reminisce with .using photos of family and friends . In an interview, on 1/19/17 at 12:32 PM, LPN/Licensed Practical Nurse K reported Resident #2, likes to stand and walk around. Not safe without 1:1. Does not use call light. LPN K said she worked full-time days and had never seen Resident #2 hit anyone. In an interview, on 1/19/17 at 12:52 PM, ADON/Assistant Director of Nursing C acknowledged the incident with Resident #2 being tied to a wheelchair on 12/23/16 did occur but, said she did not think the incident was abuse, . because they didn't intend to abuse him . In an interview, on 1/19/17 at 1:00 PM, Resident #2's RP/Responsible Party O said Resident #2 was very verbally abusive' but not like this before I put him there (facility). RP O said the facility had not called her, but, On 12/23/6), the hospital called and said they were sending him back to the facility that there was nothing wrong with him RP O said, Maybe (RN E) couldn't handle him. In a telephone interview, on 1/19/17 at 1:23 PM, RN E (assigned to Resident #2 on 12/22/16 from 6:00 PM - 12/23/16 at 6:30 AM) - reported she and 3 other staff (herself, RN H, and Nurse Aides F and G) restrained Resident #2 because he was aggressive, stumbling and she was afraid he would fall. (According to Federal Regulations, restraint use is not justified to prevent falls.) RN E said, He was spitting, calling names, hitting. RN E said she took him to his room and he took a Christmas ornament and hit her in the face with it. RN E said, I took him in the hallway and told him 'You have to be still'. RN E reported Resident #2's [MEDICATION NAME] gel (anti-anxiety medication) was not available and Resident #2 spit out his oral [MEDICATION NAME] (0.5 mg scheduled at 11:00 PM) and 0.5 mg 2 tablets/10 mg (prn/as needed) given at 4:33 AM was spit out too.He kept spitting out the pills. RN E said she had tried to reach the physician on call (Medical Director J) 3 times but he did not return her calls and so around 4:00 AM, One of the Nurse Aides suggested we wrap something around him to keep him down . I was there when she (Nurse Aide G) was doing it. He was still trying to get up out of the wheelchair at 5:00 AM with the sheet tied. When asked if she had been educated or disciplined, RN E said, DON told me to call 911 if it happens again .we can only use restraints for desperate measures. When asked if she had been educated on the facility policy, RN E said, No, but I took a copy for myself and read it. When asked if she learned anything about physician order [REDACTED]. According to a Witness Statement, dated 12/30/16 (7 days after the incident), RN E documented, .around 4 AM in the morning (4:00 AM), (Resident #2) woke up from sleep and was walking the hallway stumbling .also entering other resident's room .The CNA (Nurse Aide G) assigned to (Resident #2) followed (Resident #2) with his wheelchair preventing him from falling. (Resident #2) became very violent and refused to get into his wheelchair .he started kicking, punching and scratching staff. He was uncontrollable. I then administered his prn [MEDICATION NAME] two tablets which he took with the intension (intention) of spitting it on Call lights were on. Other residents needed help, so I asked the CNA to wheel him to the hallway .The other nurse from the North wing (RN H) had to intervene (intervene) .He became more physically and verbally aggressive, calling us 'Black monkeys' So we decided to keep him in his wheelchair and used a fitted bed sheet to confine (Resident #2) .He was confined in his wheelchair for 20 (minutes) for his own safety and the safety of staff and other residents. Resident was a danger to himself, staff and other residents .the MDS Co-ordinator (I) asked me to send him to the hospital .(Resident #2) was a severe danger to himself if left alone in the hallway because there were a lot of extra wheelchairs and hoyers (mechanical lifts) left in the hallways. There were also only four CNAs working during the time all this happened (sic). A Performance Improvement Form was submitted to Surveyor as evidence of discipline of RN E, however, it was not dated and not signed by anyone other than RN E. Per the form, On 12-23-16 A make shift seat belt was made to prevent a resident from falling when displayed very disruptive, abusive behavior towards self and others. Staff .were trying to prevent the resident from further injury .(sic) Attached to the form, was a letter without a title, dated 12/23/16, and signed by DON B and Administrator A in which they documented, .(MDS Coordinator I) noticed that there was a sheet used as a belt restraint while (Resident #2) was sitting in the w/c (wheelchair) .(MDS Coordinator I) had educated both nurse's that were involved, (RN E and H) to not resort to a make shift restraints and if unable to get a hold of the attending physician to send him out to the hospital. The staff involved did not act in any malicious manner in their attempt to prevent the resident from further harming himself. This was purely out of desperation .(sic) In an interview, on 1/19/17 at 2:40 PM, DON/Director of Nursing B was asked if she currently considered the staff restraining Resident #2 to be mistreatment or abuse, and she replied, Absolutely not, abuse. They tried everything. It was desperate measures . It was not their intent to punish. When asked when staff were last educated on restraint use, DON B said there was no evidence of education because, We don't use restraints. In an interview, on 1/19/17 at 3:20 PM, Unit Manager D reported, (Resident #2) is a handful and needs 1:1 at times. The doctor on call (Medical Director J) wears a [MEDICAL CONDITION] (a machine used to assist breathing) and sometimes doesn't hear the phone. Regarding the [MEDICATION NAME] cream, Unit Manager D said, Hospice could overnight it. There was no backup [MEDICATION NAME] cream here. In a telephone interview, on 1/19/17 at 3:54 PM, Nurse Aide F, who was working at the time of the incident on 12/23/16, stated I saw it on (Resident #2) around 5:00 AM; she said she knew it was wrong for staff to have applied the sheet as a restraint but said she did not call DON B because, I saw no option. When asked what she would do in the future if a similar situation arose, Nurse Aide F said, I'd remove myself from the situation. I'm not sure what I'd do. In an interview, on 1/19/17 at 4:10 PM, Nurse Aide G, who was the Nurse Aide assigned to Resident #2 at the time of the incident on 12/23/16, stated, (Resident #2) likes to walk around. We try to get him to sit in his chair, but said she couldn't remember who put the sheet on Resident #2. When asked if she knew how to calm Resident #2, Nurse Aide G said, (LPN BB) gives him snacks - she wasn't there that night. I did not suggest a snack. It's something (LPN BB) does. Nurse Aide G said although Resident #2 needed 1:1 care on 12/23/16, It's not a facility they staff for 1:1. In an interview, on 1/19/17 at 4:18 PM, Activities Aide N reported Resident #2 enjoyed a number of activities (pegboard with knobs and shapes, a foam hammer board, round foam building blocks) that were available to the nursing staff on the midnight shift. Activities Aide N also reported Resident #2 enjoyed and was calmed by listening to organ music. Activities Aide N said no staff members had discussed with her or requested assistance with diversional activities for Resident #2 when he was agitated at night and said The nurse always has the key. In a telephone interview, on 1/24/17 at 8:10 AM, RN H, who was working on 12/23/16 at the time of the incident, was asked why staff restrained Resident #2. RN H replied, I don't know. He was a high fall risk. Maybe to prevent him form falling. It's ok to protect the resident from falling if a very high risk. I think its ok to protect hi from falling .the sheet was around him from about 3:30 AM - 4:30 AM .I did not see them put it on him. In another interview with DON B, on 1/24/17 at 9:20 AM, this Surveyor asked if she had reported any nurses' license or Nurse Aide's certifications to the State licensing board, and she replied she had not because, I still feel it was not willful, therefore, not abuse. When asked if the Regional Director of Operations S had old her that, she said, No. In an interview, on 1/24/17 at 11:30 AM, this Surveyor asked if Administrator A thought the incident on 12/23/16 was mistreatment, or a form of abuse, and Administrator A replied, Basically, I am going with what (DON B) is saying. They (staff) needed to control (Resident #2) . No, I absolutely do not thing they mistreated him. In an interview, on 1/24/17 at 1:16 PM, an interview with SSD/Social Services Director V revealed resident #2's RP O had reported to her Resident #2 was racially biased. Despite this, SSD V stated she did not think racial bias played a part in Resident #2's behavior on 12/23/16 because he was normally cooperative, and displayed no aggression, with other black staff members. SSD V reported there were known activities that Resident #2 enjoyed, such as an interactive black toy cat and hot cocoa and cookies, that were available and should have been used as diversional interventions on 12/23/16. SSD V also stated that Resident #2's increase in undesirable behaviors (agitation) may have increased since he was placed on [MEDICATION NAME] (0.5 mg 1 tablet 3 times a day); an antipsychotic medication which began 12/22/16 at 3:00 PM). In a telephone interview, on 1/25/17 at approximately 1:30 PM, Medical Director J, who was on call the night of the incident, stated he did not know anyone tried to call him on 12/23/13 about Resident #2 until someone told him on 1/25/17, and he had never listened to his voice mails. Medical Director J said using a restraint to prevent falls or for behaviors was not a reason to tie him to a chair, and said if staff couldn't reach him, they could have waited until 5:00 AM when he normally wakes, or they should have called DON B. Medical Director J said the incident should have been reported to the State, the nurse should have been suspended, and they should have called the police. Medical Director J said he had discontinued Resident #2's [MEDICATION NAME] gel due to difficulties getting it from the Pharmacy, which he attributed to being very expensive. Medical Director J said, It ([MEDICATION NAME] gel) should have been here. Notification of Immediate Jeopardy, which began on 12/23/16, and was presented to Administrator A and DON/Director of Nursing B on 1/23/17 at 5:30 PM. Immediate Jeopardy is due to the facility's failure to assure residents are free from mistreatment. This deficient practice placed Resident #2 and an 20 additional residents, identified by the facility to have dementia with behavioral health needs, be High Risk for mistreatment with the potential for psychological harm, injury and/or death. Immediate Jeopardy was removed on 1/24/17 when the facility had the following in place: · On 12/29/16, a Behavioral Health consult visit was completed by NP/Nurse Practitioner CC and found not exhibit any adverse effects from the event on 12/23/16. · On 1/9/17, facility began emergency physician coverage with a new Physician group, available for 24 hour Physician calls. · On 1/11/17, [MEDICATION NAME] Gel was reinstated and is currently available and is a routine medication and prn/as needed mediation. Nursing staff were instructed to re-order the medication 7-days in advance of order renewal. · On 1/12/17 A physical assessment was completed by Annette Taylor, NP, and was found not to have any adverse physical effects from the event on 12/23/16. · On 1/20/17, Resident #2 was assessed by SSD/Social Services Director V on and does not exhibit any psychosocial adverse effects for the event on 12/23/16. · On 1/20/17, Resident #2's Behavior Management Program was reviewed by the Clinical Team and Social Services Department. Interventions were implemented on 1/20/17 are currently being evaluated for effectiveness. The interventions include the use of the interactive cat, sensory box, and offering snacks. · On 1/20/17, Resident #2's Care Plan was reviewed by the Social Services department, was updated to include the use of the black interactive cat, and providing snacks and hot cocoa, and calling him by his preferred names. · On 1/20/17, a PAINAD (Pain in Advanced Dementia) assessment was completed. Resident #2 received a score of 4 which indicates moderate pain. Physician Z was notified on 1/20/17 and changes in treatment were obtained to include Tylenol 650 mg every 6 hours. · On 1/20/17, Resident #2's Activity Care Plan and was reviewed and updated to include the use of a sensory box which is available at the Nurse's Station, and the use of a black interactive cat. Resident #2's Care Card was updated with this information on 1/20/17. · On 1/23/17, RN E and Nurse Aide G, who the facility deemed responsible for applying the restraint to Resident #2 on 12/23/16, were suspended. · On 1/24/17, RN H and Nurse Aide F, who the facility deemed assisted in the event of 12/23/16, were suspended and are awaiting disciplinary action. · On 1/24/17, the facility identified 20 additional residents who have Dementia with Behavioral Health needs to be at high risk for unauthorized restraint use. 0 of the 20 resident currently have restraints and there was no evidence of prior use of restraints. · On 1/24/17, 39 residents with a BIMS/Brief Interview for Mental Status score of 9 or greater (indicating moderate to intact cognition) were interviewed by SS Director V, SW/Social Worker DD, or and Social Services Intern EE, and 39 of 39 residents stated they have not been restrained. · On 1/20/17 and again on 1/24/17, Administrator A and DON/Director of Nursing B were re-educated by RDO/Regional Director of Operations S on the following policies: Abuse and Neglect-Clinical Protocol, dated 09/20/2012; Abuse Prevention Program, dated October, 2010; Reporting Abuse to Facility Management, dated October, 2010; Non-Drug Management of Problem Behavior; dated November, 2012; Crisis Behavior Intervention, dated November, 2012; and Use of Restraints, dated 02/15/2012. · On 1/19/17 the ADON/Assistant Director of Nursing C was educated on the afore mentioned policies by Regional Clinical Coordinator W. Subsequently . · On 1/19/17, ADON C began reeducating staff. 96 of 125 employees had been educated by 1/20/17. Additional staff have been educated prior to the start of their shift on 1/21/17, 1/22/17 and 1/23/17. As of 1/24/17, 110 of 125 employees have been re-educated. Staff who have not received the education will be re-educated prior to the start of their next scheduled shift. ( ) DPS B. This citation pertains to MI 958. Based on interview and record review, the facility failed to prevent neglect for 1 of 5 residents reviewed for abuse (Resident #1), from a total of 7 sampled residents, resulting in a fall, dehydration, [MEDICAL CONDITION], acute kidney failure, pneumonia,[MEDICAL CONDITIONS], and the potential for death. Findings include: According to WebMD, 2017, If you have [MEDICAL CONDITION], you have too much potassium in your blood. The body needs a delicate balance of potassium to help the heart and other muscles work properly. But too much potassium in your blood can lead to dangerous, and possibly deadly, changes in heart rhythm. <www.webmd.com/a-to-z-guides/[MEDICAL CONDITION]-causes-symptoms-treatments> According to MedLine Plus, 2017, Dehydration occurs when your body loses too much fluid. This can happen when you stop drinking water or lose large amounts of fluid . Not drinking enough fluids can cause muscle cramps. You may feel faint. Usually your body can reabsorb fluid from your blood and other body tissues. But by the time you become severely dehydrated, you no longer have enough fluid in your body to get blood to your organs, and you may go into shock, which is a life-threatening condition. <http://www.webmd.com/fitness-exercise/tc/dehydration-topic-overview> According to MedLine Plus, 2017, Septic shock is a serious condition that occurs when a body-wide infection leads to dangerously low blood pressure .Septic shock has a high death rate. The death rate depends on the person's age and overall health, the cause of the infection, how many organs have failed, and how quickly and aggressively medical therapy is started.<https://medlineplus.gov/ency/article/ 8.htm> Resident #1 According to the hospital History and Physical, dated 12/15/16 at 9:09 PM, Per EMS the patient was found unresponsive by staff. Placed on [MEDICAL CONDITION] at scene. In the ED the patient was [MEDICAL CONDITION] (rapid heart rate), febrile (fever), tachypneic (abnormal breathing) and hypoxic (low oxygen level). She was intubated in the ED (Emergency Department) for [MEDICAL CONDITION], thick secretions (in her lungs) were noted with suction. Labs showed high K (potassium) 9.2 (normal 3.5- 5.0), CRP 21.7 (an indicator of inflammation in the body/normal is < 3). Her hospital Admitting [DIAGNOSES REDACTED]. The resident has a high probability of sudden, clinically significant deterioration, which requires the highest level of physician preparedness to intervene urgently . According to Resident #1's Minimum Data Set, dated dated [DATE], and face sheet, she was a [AGE] year old woman admitted to the facility on [DATE] for rehab post spinal fusion, who was independent in decision making, was taking a diuretic (HCTZ/hydrocholorothiazide/removes fluid from the body), and had a history of [REDACTED]. According to a Hydration Risk Evaluation, dated 12/04/16, at 3:58 PM, Resident is at risk for dehydration - Yes Dry lips, attempts to refuse fluids to avoid having to go to the BR (bathroom). According to Resident #1's Care Plans, dated 12/06/16, she had potential for fluid deficit r/t/ Diuretic use .Monitor and document changes in mental status .Monitor/document/report nurse/MD (medical doctor) PRN (as needed) any s/sx (signs and symptoms) of dehydration .cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing .dizziness . Although Resident #1 refused to consume inadequate fluids (had a fluid intake deficit), had a fall and changes in mental status, her physician was not notified of suspected dehydration. In an interview, on 1/19/17 at 3:10 PM, Unit Manager D reported she and Medical Director J found Resident #1 unresponsive on 12/15/16 at approximately 8:30 - 9:00 AM, and was aroused only with a sternal rub. Regarding finding Resident #1 unresponsive, Unit Manager D said, It was a change for her . She was typically alert and oriented. Unit Manager D said she did not call Resident #1's RP/Responsible Party regarding the change of status. When asked if Medical Director J listened to Resident #1's lungs, Unit Manager said, I don't remember him listening to her lungs. I remember him looking at her eyes. He said to monitor her. Review of Resident #1's Care Plans revealed no plan to promote [MEDICAL CONDITION] hygiene (such as deep breathing, ambulating, or incentive spirometer) although she had a history of [REDACTED]. The facility failed to intervene when the Resident showed a serious lack of fluid intake. Her average fluid intake for the first week was 500 cc/day (documented by Dietary department 12/08/16). Her fluid intake continued to be approximately 500 cc/day, but according to the Dietary Manager she should have had 1,500 cc/day. (According to On 12/11/16 at 2011, Resident #1 was found on the floor). On 12/11/16 at 21:07 LPN K documented Resident 's BP 92/60, this nurse has pushed fluids this shift explain that she was lethargic last night on same shift and got possibly dehydrated. Needed multiple encouragements to keep drinking water. In an interview with LPN K she reported she did not update Resident #1's Care Plan or Nurse Aide Care Guide to alert other staff of possible dehydration and measures to monitor and/ or increase fluid intake and output. No labs were drawn while at the facility. LPN L, who was Resident #1's day nurse on 12/15/16 was unaware (until made aware by this Surveyor) that Resident #1 was found unresponsive the morning of 12/15/16. In an interview, on 1/19/17, Resident #1's RP P reported the facility never called him to let him know they found Resident #1 unresponsive the morning of 12/15/16. RP P said, I didn't find out until the EMT (Emergency Medical Team) called me and told me she was in heart failure, and she was making a gurgling noise on the way to the hospital. At the hospital they found she had pneumonia, dehydration, and put her on antibiotics. She had breathing tubes, acute [MEDICAL CONDITION] due to dehydration. At the very least, this is neglect. They didn't call me when she was unresponsive. They didn't tell me she was making gurgling noises. On 12/15/16 at 16:32, LPN K documented in a Nursing Progress Note .lethargic most of the day. Would awake for brief periods with light touch and some shaking. Shortly after would fall back to sleep. All morning and afternoon medications held due to possible risk of aspiration due to drowsiness. (Medical Director J) was in on rounds this morning (8:00 AM), notified of resident's condition and hold on medication. He attended to her and ordered that she be monitored throughout the day, but LPN K said she was unaware of the seriousness of Resident #1's situation - she was not informed she had been found unresponsive nor told to encourage fluids or listen to lung sounds/promote [MEDICAL CONDITION] hygiene. In an interview, on 1/19/17 at 3:10 PM, Unit Manager D reported (Resident #1) had been real lethargic, we backed off on pain meds, but still pretty lethargic. Unit Manager D said since the facility changed ownership, approximately 6 months ago, they no longer use a form that helped nursing staff determine/document change of condition. Review of Resident #1's Medical Record revealed only one Progress Note (dated 12/03/16) but no physician progress notes [REDACTED].#1 on 12/23/16. In an interview, on 1/19/17 at 5:15 PM, DON/Director of Nursing B said she was unaware of what Resident #1's condition was during transport and upon admission to the hospital, and therefore, she had not recognized any problem(s) or had not done a follow-up investigation or staff education. DON B also said the facility does not typically investigate the causal factors for readmission. In an interview, on 1/25/17 at 12:10 PM, Nurse Aide AA said she only worked 1 time with Resident #1, but remembered she refused to go to the Dining Room. Didn't like to get up. Used the bedpan .She had Chap Stick all the time .I wondered why she didn't want to get up for meals or go to the bathroom . Nurse Aide AA said no one told her to encourage Resident #1 to increase her fluid intake and there was nothing on Resident #1's Nurse Aide Care Guide instructing staff to do so. Nurse Aide AA reported encouraging fluids was not on Care Guides, only fluid restrictions, and she was not sure how she would know who needed her encouragement. In a telephone interview, on 1/25/17 at approximately 1:30 PM, Medical Director/Resident #1's facility Physician J confirmed a sternal rub was performed on Resident #1 to awaken her the morning of 12/15/16, and said if staff would have told him her fluid intake had averaged 500 cc/day, and nursing suspected dehydration, his medical approach would have been very different. Medical Director J said, I thought her drowsiness was from pain meds. Dehydration should have been addressed in morning meeting beforehand if they noticed. I would have started sub Q (IV) fluids. Medical Director J said he was unaware of what condition Resident #1 was in when she arrived at the hospital and asked, What happened to her? When asked if the facility reviews re-hospitalization s, he said they definitely did because, he wants to know what went wrong. asked why he did not write a Progress Notes about his examination of Resident #1 on 12/15/17, he said, There should be a note. Although the Immediate Jeopardy was removed on 1/24/17 for resident #2, the facility remained out of compliance with scope and severity of isolated actual harm that is not immediate jeopardy for resident #1. ( )

This citation pertains to MI 433. Based on interview and record review, the facility failed to prevent staff from restraining one of 5 residents reviewed for restraints (Resident #2), from a total of 7 sampled residents, resulting unauthorized use of a non-medical device as a restraint for Resident #2 with the potential for psychological harm, injury and/or death, and placing an additional 20 Residents, deemed by the facility at risk for unauthorized use of restraint, at risk for psychological harm, injury and/or death. Findings include: Review of Resident #2's Minimum Data Set, dated dated [DATE], revealed he was a [AGE] year old man, admitted to the facility on [DATE], who had severe cognitive impairment, severe vision impairment, no range of motion impairments, ambulated with limited assistance, was in Hospice, and had [DIAGNOSES REDACTED]. On 1/19/17 at 12:10 PM and on 1/24/17 at 11:20 AM, this Surveyor observed Resident #2 laying quietly in bed, apparently sleeping. According to Intake Information, dated 1/03/17, On 12/23/16, a mid-night nurse or CNA (Nurse Aide) tied (Resident #2) to his wheelchair with a sheet that was wrapped around his stomach, then knotted in the back of his wheelchair. They tied him up so he could not get out . (sic). In an interview, on 1/19/17 at 12:14 PM, MDS Coordinator I reported she entered the facility on 12/23/16 at approximately 5:15 AM and saw Resident #2 in a wheelchair with a sheet tied around back of the wheelchair. MDS Coordinator I said, (RN/Registered Nurse E) said they put the sheet on Resident #2 because he had been 'combative, hitting, spitting'. (RN H) came and untied (Resident #2) .I stayed with him. He kept getting up, hitting and grabbing me. We had been noticing hallucinations and a pattern of being more combative (with Resident #2). Definitely, ignorance on their part (RN E and H). Other nurses approached me about it; they were upset it happened. It was a physical restraint. They did it to restrain him. Physician orders [REDACTED].#2. Review of Resident #2's Care Plans revealed there was no restraint intervention for Falls or Behaviors. In a telephone interview, on 1/19/17 at 1:23 PM, RN E (assigned to Resident #2 on 12/22/16 from 6:00 PM - 12/23/16 at 6:30 AM) - reported she and 3 other staff (herself, RN H, and Nurse Aides F and G) restrained Resident #2 because he was aggressive, stumbling and she was afraid he would fall. (According to Federal Regulations, restraint use is not justified to prevent falls.) RN E said, He was spitting, calling names, hitting. RN E said she took him to his room and he took a Christmas ornament and hit her in the face with it. RN E said, I took him in the hallway and told him 'You have to be still'. RN E reported Resident #2's [MEDICATION NAME] gel (antianxiety medication) was not available and Resident #2 spit out his oral [MEDICATION NAME] (0.5 mg scheduled at 11:00 PM) and 0.5 mg 2 tablets/10 mg (prn/as needed) given at 4:33 AM was spit out too.He kept spitting out the pills. RN E said she had tried to reach the physician on call (Medical Director J) 3 x but he did not return her calls and so around 4:00 AM, One of the Nurse Aides suggested we wrap something around him to keep him down . I was there when she (Nurse Aide G) was doing it. He was still trying to get up out of the wheelchair at 5:00 AM with the sheet tied. When asked if she had been educated or disciplined, RN E said, DON told me to call 911 if it happens again .we can only use restraints for desperate measures. According to a Witness Statement, dated 12/30/16 (7 days after the incident), RN E documented, .around 4 AM in the morning (4:00 AM), (Resident #2) woke up from sleep and was walking the hallway stumbling .also entering other resident's room .The CNA (Nurse Aide G) assigned to (Resident #2) followed (Resident #2) with his wheelchair preventing him from falling. (Resident #2) became very violent and refused to get into his wheelchair .he started kicking, punching and scratching staff. He was uncontrollable . Call lights were on. Other residents needed help, so I asked the CNA to wheel him to the hallway .The other nurse from the North wing (RN H) had to intervein (intervene) .He became more physically and verbally aggressive, calling us 'Black monkeys' So we decided to keep him in his wheelchair and used a fitted bed sheet to confine (Resident #2) .He was confined in his wheelchair for 20 (minutes) .(sic). In an interview, on 1/19/17 at 4:10 PM, Nurse Aide G, who was the Nurse Aide assigned to Resident #2 at the time of the incident on 12/23/16, stated, (Resident #2) likes to walk around. We try to get him to sit in his chair, but said she couldn't remember who put the sheet on Resident #2. In a telephone interview, on 1/24/17 at 8:10 AM, RN H, who was working on 12/23/16 at the time of the incident, was asked why staff restrained Resident #2. RN H replied, I don't know. He was a high fall risk. Maybe to prevent him form falling. It's ok to protect the resident from falling if a very high risk. I think its ok to protect hi from falling .the sheet was around him from about 3:30 AM - 4:30 AM .I did not see them put it on him. In a telephone interview, on 1/25/17 at approximately 1:30 PM, Medical Director J, who was on call the night of the incident, stated using a restraint to prevent falls or for behaviors was not a reason to tie (Resident #2) to a chair. Notification of Immediate Jeopardy, which began on 12/23/16, and was presented to Administrator A and DON/Director of Nursing B on 1/23/17 at 5:30 PM. Immediate Jeopardy is due to the facility's failure to assure residents are free from unauthorized restraints. This deficient practice placed Resident #2 and an 19 additional residents identified by the facility to have dementia with behavioral health needs be High Risk for unauthorized, nonmedical restraint with the potential for psychological harm, injury and/or death. Immediate Jeopardy was removed on 1/24/17 when the facility had the following in place: · On 12/29/16, a Behavioral Health consult visit was completed by NP/Nurse Practitioner CC and found not exhibit any adverse effects from the event on 12/23/16. · On 1/9/17, facility began emergency physician coverage with a new Physician group, available for 24 hour Physician calls. · On 1/11/17, [MEDICATION NAME] Gel was reinstated and is currently available and is a routine medication and prn/as needed mediation. Nursing staff were instructed to re-order the medication 7-days in advance of order renewal. · On 1/12/17 A physical assessment was completed by(NAME)Taylor, NP, and was found not to have any adverse physical effects from the event on 12/23/16. · On 1/20/17, Resident #2 was assessed by SSD/Social Services Director V on and does not exhibit any psychosocial adverse effects for the event on 12/23/16. · On 1/20/17, Resident #2's Behavior Management Program was reviewed by the Clinical Team and Social Services Department. Interventions were implemented on 1/20/17 are currently being evaluated for effectiveness. The interventions include the use of the interactive cat, sensory box, and offering snacks. · On 1/20/17, Resident #2's Care Plan was reviewed by the Social Services department, was updated to include the use of the black interactive cat, and providing snacks and hot cocoa, and calling him by his preferred names. · On 1/20/17, a PAINAD (Pain in Advanced Dementia) assessment was completed. Resident #2 received a score of 4 which indicates moderate pain. Physician Z was notified on 1/20/17 and changes in treatment were obtained to include Tylenol 650 mg every 6 hours. · On 1/20/17, Resident #2's Activity Care Plan and was reviewed and updated to include the use of a sensory box which is available at the Nurse's Station, and the use of a black interactive cat. Resident #2's Care Card was updated with this information on 1/20/17. · On 1/23/17, RN E and Nurse Aide G, who the facility deemed responsible for applying the restraint to Resident #2 on 12/23/16, were suspended. · On 1/24/17, RN H and Nurse Aide F, who the facility deemed assisted in the event of 12/23/16, were suspended and are awaiting disciplinary action. · On 1/24/17, the facility identified 20 additional residents who have Dementia with Behavioral Health needs to be at high risk for unauthorized restraint use. 0 of the 20 resident currently have restraints and there was no evidence of prior use of restraints. · On 1/24/17, 39 residents with a BIMS/Brief Interview for Mental Status score of 9 or greater (indicating moderate to intact cognition) were interviewed by SS Director V, SW/Social Worker DD, or and Social Services Intern EE, and 39 of 39 residents stated they have not been restrained. · On 1/20/17 and again on 1/24/17, Administrator A and DON/Director of Nursing B were re-educated by RDO/Regional Director of Operations S on the following policies: Abuse and Neglect-Clinical Protocol, dated 09/20/2012; Abuse Prevention Program, dated October, 2010; Reporting Abuse to Facility Management, dated October, 2010; Non-Drug Management of Problem Behavior; dated November, 2012; Crisis Behavior Intervention, dated November, 2012; and Use of Restraints, dated 02/15/2012. · On 1/19/17 the ADON/Assistant Director of Nursing C was educated on the afore mentioned policies by Regional Clinical Coordinator W. Subsequently . · On 1/19/17, ADON C began reeducating staff. 96 of 125 employees had been educated by 1/20/17. Additional staff have been educated prior to the start of their shift on 1/21/17, 1/22/17 and 1/23/17. As of 1/24/17, 110 of 125 employees have been re-educated. Staff who have not received the education will be re-educated prior to the start of their next scheduled shift. Although the Immediate Jeopardy was removed on 1/24/17, the facility remained out of compliance with scope and severity of isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to sustained compliance could not be verified by the state agency. ( )

This citation pertains to MI 03 and MI 567. Based on observation, interview, and record review, the facility failed to prevent the formation or worsening of pressure ulcers for 3 of 7 sampled residents (Resident #1, #2, and #4) reviewed for pressure ulcers, from a total of 8 sampled residents, resulting in the formation of pressure ulcers for Residents #1 and #4, and worsening of a pressure ulcer for Resident #2 that led to hospitalization due [MEDICAL CONDITION] of the the wound and an immediate jeopardy situation, this deficient practice placed 38 facility residents assessed/identified by the facility to be High Risk for pressure ulcer development/worsening with the potential for serious harm, injury, and/or death. Findings include: On [DATE] at 2:40 PM, Administrator A was informed of Immediate Jeopardy at F-314 due to the facility's failure to provide appropriate monitoring and adequate care and to prevent a Stage IV pressure ulcer for a pressure ulcer that was known to have foul odor and the resident exhibiting an ongoing elevated temperature that resulted in [MEDICAL CONDITION]. This deficient practice placed 38 facility residents assessed/identified by the facility to be High Risk for developing pressure ulcers, to be at risk for pressure ulcer development and resulting serious harm, injury, and/or death. On [DATE], at approximately 8:00 AM, during the Entrance Conference, the facility CMS 802 (Roster form) was requested. It was received at approximately 8:45 AM and identified 3 residents as having pressure ulcers (Residents #4, #17, and #60). However, in an interview, on [DATE] at 9:00 AM, Nurse Aide T, named 6 residents she believed were currently residing in the facility and currently had pressure ulcers (#4, #5, #6, #9, #12, #17). On [DATE] at 9:00 AM, ADON D submitted a list of 6 residents who had pressure ulcers (Residents #8, #9, #10, #11, #12, and #13- all facility acquired). On [DATE] at 3:11 PM, ADON D submitted a list of 8 residents who had pressure ulcers (Residents #4, #7, #8, #9, #10, #11, #12, and #13 - all facility acquired). On [DATE] at 4:00 PM, ADON D submitted another list containing 10 residents who had pressure ulcers on [DATE] (Residents #4, #7, #8, #9, #10, #13, #17, and #36 that were facility acquired, and Resident ##11 and #12 that were community acquired). According to Mayo Clinic, DEC. 13, 2014, At stage II: The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost; The wound may be shallow and pinkish or red; The wound may look like a fluid-filled blister or a ruptured blister. At stage III, the ulcer is a deep wound: The loss of skin usually exposes some fat; The ulcer looks crater-like; The bottom of the wound may have some yellowish dead tissue; The damage may extend beyond the primary wound below layers of healthy skin. A stage IV ulcer shows large-scale loss of tissue: The wound may expose muscle, bone or tendons; The bottom of the wound likely contains dead tissue that's yellowish or dark and crusty; The damage often extends beyond the primary wound below layers of healthy skin .A pressure ulcer is considered unstageable if its surface is covered with yellow, brown, black or dead tissue. It ' s not possible to see how deep the wound is. <http://www.mayoclinic.org/diseases-conditions/bedsores/basics/symptoms/CON- 848> According to the Facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated [DATE]: Assessment and Recognition 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores . 2. In addition, the nurse shall assess and document/report the following: a. vital signs b. Full assessment of pressure sore including location, stage, length, width, and dept, presence of exudates or necrotic tissue c. pain assessment d. Resident's mobility status e. Current treatments, including support surfaces 3. The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage I pressure area that has not yet ulcerated at the surface. 4. The physician will help the staff define the type .and characteristics (necrotic tissue, status of the wound bed, etc.) of an ulceration. Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown .and macerated or friable (delicate nature of) skin. 2. The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing, etc. Treatment/Management 1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches . 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue . 3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors; for example: a. Healing or Prevention Likely . b. Healing or Prevention Possible . c. Healing or Prevention Unlikely: The resident is likely to decline or die because of his/her overall medical instability . Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive, or non-healing wounds . Resident #2 did not reside at the facility at the time of the investigation. He had Full Code Status. Resident #2's MDS/Minimum Data Set, dated dated [DATE], revealed he was a [AGE] year old man, admitted to the facility on [DATE], who had severe cognitive impairment, was totally dependent on staff for care, had a Foley catheter, a feeding tube, wore oxygen, had [MEDICAL CONDITION](but was not on a vent), a Stage II pressure ulcer, and had [DIAGNOSES REDACTED]. The MDS also indicated Resident #2, Does not have a condition or chronic disease that may result in life expectancy of < 6 months. In a telephone interview, on [DATE] at 8:28 AM, RP/Responsible Party for Resident #2 (M) reported, the afternoon nurse (LPN Q) disregarded him one evening when he told him his brother (Resident #2) needed attention. RP M said, I told him 3 times one shift my brother needed attention, but he wouldn't answer me the first two times. My brother didn't look right, he was warm and his eyes were closed. When (LPN Q) came to look at him the third time I complained, he said, 'He looks all right to me'. He (LPN Q) smiled at me sarcastically and laughed. He had to be transferred to the hospital a day and a half later. He's still at the hospital. It was close. In an interview, on [DATE] at 11:23 AM, LPN Q stated he knew RP M had the above concerns, and said in a disgruntled tone, (RP M) is very particular. The resident was fine . (Resident #2) is basically comatose .(RP M) pressed my buttons. According to Resident #2's Hospital Admission History and Physical, dated [DATE] at 6:04 PM, At baseline, patient is conversive, alert and oriented. Today he is intermittently non-verbal. A fever at (facility) was 101 degrees Farenheit. In the ER, he was found to have a stage 4 ulcer, [MEDICAL CONDITION] (rapid heart beat), requiring oxygen, and hypotensive. At first, BP was responsive to fluids, however became less responsive after 3 L of fluids. CXR, CT chest/abdomen/pelvis was negative for acute abnormalities. He was started on [MEDICATION NAME] (antibiotic) for a presumed infection stemming from the decubitus ulcer .Assessment: Active Problems:[MEDICAL CONDITION] . [MEDICAL CONDITION] ,[DATE] (secondary to) decubitus ulcer .(sic). Review of Resident #2's Medical Record, and requests for the Transfer form and Discharge documentation from the facility revealed there was no Transfer form, Nursing Notes, or physician progress notes [REDACTED].#2's discharge on [DATE], LPN/Licensed Practical Nurse S reported she was on duty when Resident #2 was transferred to the hospital on [DATE]. She said, I saw him probably 7:00 - 7:30 AM; he was diaphoretic, as usual. We sent him out by 9:30 AM .he had a rash across his chest .I thought he had pneumonia and needed IV antibiotics. Around 8:30 AM, (Medical Director C) saw him. He didn't mention the pressure ulcer or why Resident #2 had a rash. LPN S had no explanation as to why there were no Nurses' Notes/physician progress notes [REDACTED]. According to Resident #2's Admission Nursing Assessment, dated [DATE] (admitted ) at 7:00 PM, under Section C. Skin Conditions, was documented, Sacrum indicating there was a skin condition there, but no measurements, description, or staging (a description of the extent of tissue damage), the tissue surrounding the wound, etc. were documented. It also noted Resident #2 had Hammer toes (permanently bent) and boggy, soft heels, but there measurement or color of the affected area was not documented. (Review of Resident #2's Medical Record found no further assessment of his heels or toes). According to Rutgers University, [DATE], boggy or spongy heel can indeed indicate the start of a pressure ulcer there, esp. if you also have any skin discoloration, usually black and blue or a blister. The treatment is to keep all pressure off the area completely, bridging with pillows in bed, and wearing shoes with very loose stretchy fabric or cut out heels until this is completely cleared. <http://sci.rutgers.edu/forum/showthread.php?3278-quot-spongy-quot-heel> According to Rutgers University, [DATE], boggy or spongy heel can indeed indicate the start of a pressure ulcer there, esp. if you also have any skin discoloration, usually black and blue or a blister. The treatment is to keep all pressure off the area completely, bridging with pillows in bed, and wearing shoes with very loose stretchy fabric or cut out heels until this is completely cleared. <http://sci.rutgers.edu/forum/showthread.php?3278-quot-spongy-quot-heel> Resident #2's Norton Plus Pressure (sic) Ulcer Scale, dated [DATE], revealed Resident #2 was at High Risk of skin breakdown. According to a Nursing Progress Note the day of his admission to the facility, dated [DATE] at 8:27 PM, Unit Manager I documented Has sacral decubitus measures 4 cm x 4.5 cm, 1 cm deep .mod amt (moderate amount) serous (clear) drainage . Unit Manager I did not document the Stage of the ulcer, the condition of the surrounding tissue, or if there was any odor. No other Nurses' Progress Notes mentioned Resident #2's pressure ulcer. Resident #2 had 3 Weekly Skin Assessments, and they revealed: [DATE] at 3:28 PM - Stage IV ulcer (no measurements or description or mention of Resident #2's heels). [DATE] at 1:53 PM - Stage 3 Decubitus (no measurements or description or mention of Resident #2's heels). [DATE] at 1:53 PM - Sacrum - Stage 3 decubitus (no measurements or description or mention of Resident #2's heels). According to Resident #2's Skin Care Plan, dated [DATE], Lodger (resident) was admitted with a pressure ulcer to sacrum. He is at continued risk for skin breakdown related to being dependent on staff for all positioning, bowel incontinence and use of oxygen and Foley catheter in which tubing could cause potential pressure area .The resident will have intact skin, free of redness, blisters or discoloration .The lodger's (resident's) Pressure ulcer will progress through the healing process and remain free from infection .Daily skin evaluations by licensed nurse . Evaluate/record/monitor wound healing: Measure length, width, and depth were (sic) possible. Evaluate and document status of wound perimeter, wound bed and healing progress Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection .Obtain and monitor lab/diagnostic work as ordered .pressure relief mattress . This Care Plan did not mention tissue tolerance, turning interventions, which type of wheelchair cushion he was to have, or how long Resident #2 was to be allowed sitting in the wheelchair, use of a foot cradle or heels up device, or to monitor the wound for infection. Resident #2's Care Plans did not specify which route to use to obtain his temperature most accurately and consistently. Review of Resident #2's SOC Notes (Standards of Care) notes (to be done weekly), revealed only one measurement after admission measurements, dated [DATE], 3.2 x 2.0 x 0.10: Showing improvement, but there was no indication when the measurement was obtained or by whom, no staging, or any description other than the measurements. It was revealed in an interview with ADON D (on [DATE] at 3:00 PM) and confirmed in a subsequent interview with DON B ([DATE] at 9:47 AM), the SOC notes were traditionally written approximately 1 week after measurements were actually obtained. DON B and ADON D both reported the day wounds were actually measured, they were supposed to enter the measurements into Gentell (the the facility's pressure ulcer supplies vendor electronic reporting system - a system not interfaced with PCC/Point Click Care Electronic Medical Record and never placed in their charts). The the date the measurements were obtained was not routinely documented in the SOC note(s), and the SOC note(s) were not written until approximately one week after the measurements were actually done (the day varied). This made it impossible to accurately track the status of the wound via the Residents' legal medical records. Measurement of Resident #2's pressure ulcer from Gentell data showed only 1 entry: Evaluation Date: [DATE] .5.0 / 3.0 / 2.00 cm .Stage II (sic). This information did not appear in Resident 2's Electronic Medical Record, but the facility presented them as evidence the wound had been measured weekly. On [DATE] at approximately 9:00 AM, the ADON D reported the staff nurses were allowed to recommend treatments suggested by their vendor Gentell, but admitted on ly she and DON B had had Gentell training which included measuring, staging pressure ulcers, and recommended treatments. ADON D also reported that DON B was the facility's Wound Nurse ever since the Wound Certified Nurse Practitioner, who had been doing all assessment and ordering treatments left employment of the facility at approximately the same time the facility changed ownership in [DATE]. In an interview, on [DATE] at 3:00 PM, ADON D said wound clinics were only recommended for residents with venous ulcers. In an interview on [DATE] at approximately 10:20 AM, Assistant Director of Nursing (ADON) D stated, We don't order special wheelchair cushions. According to Resident #2's an admission physician progress notes [REDACTED].multiple decubitus ulcers stage III, but Medical Director C Examination revealed he did not examine Resident #2's wound. He also documented, Discharge potential is good. Rehab potential is good . physician progress notes [REDACTED].#2's sacrum pressure ulcer. In a physician progress notes [REDACTED]. It is getting worse due unavoidable causes (sic) .Wound: Increased to a Stage 4 pressure ulcer -New TX (treatment) ordered. There was no other description of the wound, and no evaluation of pressure relieving devices/recommended practices, and no recommendation for specialist consult documented. In a telephone interview regarding Resident #2, on [DATE] at approximately 3:05 PM, Medical Director C reported, I don't look at them. I go by what they (nurses) tell me. When asked why he documented, It is getting worse due unavoidable causes but did not document what the unavoidable causes were, Medical Director C said in a frustrated tone, He's got multiple co-morbidities, recurrent pressure ulcer infections, increased respiratory secretions, increased temperatures, very contracted, he's on a trach. Have you seen the guy? He drools all the time, and he shakes and trembles all over . When asked why he did not send Resident #2 to a wound clinic, he said, It would be very hard for him to be treated at a wound clinic. He has [MEDICAL CONDITION]. In an interview, on [DATE] at 4:45 PM, Administrator A reported there was no way for Gentell information to be entered into the PCC system, other than printing it out and scanning it into PCC, but that had not been happening. Administrator A said having to document in various places was not working well because it was too time consuming and cumbersome to have to document the same information more than once, or to have to print, scan an file Gentell information into the Medical Records in a timely fashion. According to [DATE]- 12 Issue of McKnight's Long Term Care News, An audit of 155 patient records found large gaps between clinical practice and wound documentation in nursing homes . researchers found they lacked key details about pressure ulcers and preventative interventions, even when patient exams showed measures like pressure-relieving mattresses were in use .The researchers theorize inaccuracies were linked to nurses who do not have time, skills and knowledge to update patient records .They suggest more training for high-quality care and documentation, as well as adopting electronic health records with decision-support tools .The researchers estimate incomplete reporting in 30% to 62% of pressure wound cases. In 45% of their cases, pressure ulcers were not graded . <http://www.mcknights.com/issue/December/[DATE]/> In an interview, on [DATE] at 9:25 AM, LPN/Licensed Practical Nurse H reported she performed dressing changes for Resident #2's wound on [DATE] and a foul odor was present. LPN H stated Resident #2 often had a fever. There was no documentation of odor (present/not present) anywhere in Resident #2's medical record. Review of all of Resident #2's Nurses's Notes revealed the only measurements in the Nurses' Notes were those documented on the day of admission, and there were no other descriptions of the wound in the Nurses' Notes or TARs/Treatment Administration Records, although the TARs revealed Resident #2's Pressure Ulcer Dressing was changed two times a day. LPN H reported nurses lost the ability to document the characteristics of wounds in the Treatment Record in May, 2016 when a new company took over the facility. In a telephone interview, on [DATE] at 9:47 AM, DON B denied she was the facility's Wound Nurse. She said, I am not the Wound Nurse, I am the Director of Nursing. I help them out. I go around once a week to make sure things are in place .I do not call the doctors for new orders, the floor nurses do that. This Surveyor asked DON B about the Gentell note, dated [DATE], in which ADON D documented Resident #2's Pressure ulcer as Stage II 5.0 x 3.0 x 2 cm (Medical Director C documented Stage IV on [DATE]). DON B stated she saw Resident #2's pressure ulcer also, and argued with ADON D that Resident #2's Pressure Ulcer was not a Stage II, but unstageable due to excessive slough, but she allowed ADON D to document it as Stage II. DON Asaid she did not know the nurses were not documenting the condition of the wounds and said, They are supposed to do so when they do the dressing changes twice a day. DON B said she did not recommend wounds to be treated at wound clinics to the physician because, I don't like them (wound clinics), and said she did not get a wound culture of Resident #2's pressure ulcer because there was no odor. In a subsequent interview with DON B, on [DATE] at 10:41 PM, she reported she knew there was a serious problem with lack of pertinent and/or inaccurate documentation of pressure ulcers prior to [DATE], and had reported it to Administrator A. In an interview, on [DATE] at 11:13 AM, Senior Regional clinical Consultant G reported the Gentell wound products only covers residents with Part D insurance, and she confirmed that Gentell information is not part of residents' Medical Record. In an interview, on [DATE] at 11:46 AM, Clinical Nutritional Assistant R reported Resident #2's, .pressure ulcer did not decline due to his nutrition. His labs are good. As a matter of fact, he gained 7 pounds since his admission .I followed him for skin and nutrition. A physician progress notes [REDACTED].Continue [MEDICATION NAME] 750mg PO (orally/Resident #2 was NPO due to inability to swallow adequately) QD (every day) x 7 days. Resident #2's MAR indicated [REDACTED]. Laboratory data, dated [DATE], showed E Coli in Resident #2's urine at >100,000 CFU/ML, and a note, not dated, was written on the Lab that read, (Medical Director C) notified at 12:10 PM .continue on this ([MEDICATION NAME]/[MEDICATION NAME]/antibiotic). But, Resident #2's MAR indicated [REDACTED]. It was (administered twice a day for 9 days: [DATE] @ 10 PM - [DATE]). The most recent lab in Resident #2's Medical record, (dated [DATE]) showed WBC (white blood count/an indicator of infection) was 5.7 K/uL (within normal limits). But, Resident #2's MAR/Medication Administration Records revealed Resident #2 was also administered Bactrim ,[DATE] MF one tablet via feeding tube two times a day for UTI/urinary tract infection (ordered for 14 days - [DATE] at 7:00 PM - [DATE] at 7:00 AM). Resident #2's MAR indicated [REDACTED]. Resident #2 received both [MEDICATION NAME] for [MEDICAL CONDITION] and Bactrim for UTI for 6 days ([DATE] - [DATE]). According to Resident #2's October and November, 2016 MARs, [MEDICATION NAME] (pain reliever) 640 mg was administered routinely 4 times a day via the feeding tube for pain, beginning [DATE]. [MEDICATION NAME] also reduces/relieves fevers, which may mask an undiagnosed fever related to infection: According to Drugs.com, [DATE], regarding the effects of [MEDICATION NAME] for a fever, If it is an infection brewing you may not get rid of the fever till you get on antibiotics. <https://www.drugs.com/answers/what-if-after-an-hour-you-take-tylenol-you-still- 0.html> Vital Signs records revealed staff were not consistent with the way they measured Resident #2's temperatures, sometimes axillary (above 98.6º F/Fahrenheit axillary is a raised temperature) and sometimes oral, but despite his receiving round-the-clock [MEDICATION NAME], Resident #2's temperature showed elevation (a sign of infection) for 3 days prior to his discharge to the hospital: · [DATE] at 2:23 AM, 98.7 (Axillary) · [DATE] - 7:20 AM, 99.6 F (Oral) · [DATE] - 3:51 PM, 99.2 F (Oral) · [DATE] - 11:37 AM, 100.1 F (Axilla) · [DATE] - midnight, 102.9 F (Axilla) · [DATE] - 5:30 AM, 99.5 (Axilla) · [DATE] at 10:59 AM, 99.8 (Oral) The Interdisciplinary Group (IDG) Hospice plan of care dated [DATE] revealed Resident #1 was admitted [DATE] with the [DIAGNOSES REDACTED]. Resident #1's initial Minimum Data Set (MDS) assessment dated [DATE] indicated he was admitted in a persistent vegetative state and was totally dependent in activities of daily living (ADL) care. Resident #1's nurses Progress Notes, Standard of Care (SOC) skin meeting note, dated [DATE] at 11:54 AM revealed he was admitted with an unstageable pressure ulcer on the sacrum (lower back) that was now a stage 2. There was no mention of exudate or pain present in the above documentation. Resident #1's nurses Progress Notes, SOC skin meeting note, dated [DATE] at 3:40 PM, revealed a Stage 2 coccyx (tailbone) pressure, without mention of pain, description of wound edges and surrounding tissue. Resident #1's nurses Progress Notes, SOC skin meeting note, dated [DATE] at 3:32 PM, indicated a Stage 2 pressure ulcer on the sacrum (lower back). Documentation did not include exudate, pain, or color of the wound bed. Resident #1's nurses Progress Notes, Standard of Care (SOC) skin meeting note, dated [DATE] at 4:19 PM revealed an unstageable pressure ulcer on the coccyx with measurements and a note that the wound had regressed from the previous week. There was no mention in the documentation of exudate, pain, wound bed description and description of the wound edges and surrounding skin. Resident #1's nurses Progress Notes dated [DATE] at 12:28 PM indicated he had a small open area on the right buttock. There was no stage, measurement, exudate, pain, wound bed or description of the surrounding tissue mentioned in the documentation. According to Resident #1's nurses Progress Notes dated [DATE] at 8:19 AM, Resident was pronounced deceased at 7:28 AM. In an interview on [DATE] at 12:45 PM, Assistant Director of Nursing (ADON) D stated wound measurements documented in the nurses progress notes under SOC skin were measurements from the previous week, not the date of the note. ADON D was unable to produce measurements/assessments with the actual date and time of assessment for Resident #1. On [DATE] at 11:35 AM, Resident #4 was observed in bed lying on her back and when turned to the side by Licensed Practical Nurse (LPN) H and Register Nurse (RN) K a diamond pattern from the cloth incontinence pad was observed imprinted on her buttocks and upper thighs. During the same observation, LPN H stated to Resident # 4 that she had been lying on her back-side since breakfast. During the same observation, Resident #4 was observed with 2 open areas on the right buttock that appeared as a shallow crater with a red wound bed that was bleeding. During the same observation, LPN H measured one of the open areas with the length recorded as the width measurement and the width recorded as the length measurement. LPN H was unable to measure the depth, I would have to guess, our DON (Director of Nursing) measures the depth. RN K stated during the same observation that she did not know what the physician had ordered to cover the wound. Resident #4 was placed back on her buttocks without a dressing and instructed to eat lunch and after lunch the wound would be covered with a dressing. Resident #4's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview for Mental Status (BIMS, screener for detecting cognitive impairment) score was 13 out of 15, indicating she was cognitively intact. The same MDS assessment indicated Resident #4 required extensive assistance of 2 people for turning and repositioning in bed. Resident #4's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] and with the [DIAGNOSES REDACTED]. Resident #4's Norton Pressure Ulcer Risk assessment dated [DATE], revealed she was at high risk for pressure ulcers, chair-bound and with very limited mobility. The same assessment indicated Resident #4 had double incontinence. Resident #4's [MEDICATION NAME] (diverts the normal flow of urine from the kidneys and ureters into a specially created stoma) care plan with target completion date of [DATE], revealed she was incontinent of bowel but had a [MEDICATION NAME] for urine collection. Resident #4's Skin Assessment dated [DATE] revealed she had an open wound to bilateral buttocks. The same Skin Assessment indicated instructions to Describe all abnormal skin areas. Include length, width, and depth of each area and stage of each pressure area. There was no other documentation on this day describing the depth and stages of Resident #4's open wounds to both buttocks. Resident #4's nurses Progress Notes dated [DATE] at 10:49 AM, titled a standard of care (SOC) skin note, revealed follow up wound right inner buttocks 4.30 cm (centimeters) x (by) 3.5 cm x 0.1 cm. No other information was presented in the nursing note on [DATE] signed by Minimum Data ns to Describe all abnormal skin areas. Include length, width, and depth of each area and stage of each pressure area. There was no other documentation on this day describing the depth and stages of Resident #4's open wounds to Set (MDS) Nurse J. MDS Nurse J was interviewed via telephone on [DATE] at 12:40 PM regarding the nurses progress note dated [DATE] and stated that she did not measure or observe Resident #4's wound(s). MDS nurse J stated during the same interview that the Assistant Director of Nursing (ADON) gave her the measurements and instructed her to document in Resident #4's medical record. In an interview on [DATE] at 12:45 PM, Assistant Director of Nursing (ADON) D stated Resident #4 did not have any pressure ulcers, that she had excoriation on her buttocks. ADON D stated in the same interview that Resident #4's wound measurements documented in the nurses progress notes were from last week, that she was unsure of which day, and confirmed that no measurements were taken on [DATE]. There was no indication in the nurses progress note on [DATE] at 12:40 PM that the measurements were from a week prior, stage of the pressure ulcer, pain, or description of the surrounding tissue. Centers for Medicare & Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.14, [DATE] defined a Stage 2 pressure ulcer as a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. The same source indicated Stage 2 pressure ulcers were often related to friction (one surface or object rubbing against another) and/or shearing force (stress resulting from applied forces), and the care plan should incorporate efforts to limit those forces on the skin and tissues. Resident #4's nurse assistant Activities of Daily Living (ADL) Care Plan (no date), photo-copied on [DATE], stored on the back of Resident #4's closet door, revealed she had no pressure ulcers and did not indicate instructions to use a cushion in her specialty wheelchair. ( ) The Immediacy was removed on [DATE] when the following were verified as being implemented: · On [DATE], Senior Director of Nursing, RN, Wound Care Certified Nurse, RN AA, provided face-to-face re-education for ADON D on wound care assessment, documentation and staging, to include documentation in PCC with each dressing change. ADON D was re-educated on the Gentell program for recording wound documentation weekly by Wound Care Consultant BB. ADON D was appointed the Wound Care Nurse and the job description reviewed and signed. · On [DATE], Skin Assessments were completed for 75 of 75 in-house residents, including one new admission by Unit Managers I, CC, DD, and EE, and MDS Nurse J. These skin assessments were completed by 10:00 PM. No new untreated pressure ulcers were identified. A total of 11 residents are being treated for [REDACTED]. · Beginning on [DATE], weekly wound assessments (include: length x width x depth, tunneling if present, undermining if present, exudate if present, wound bed, odor, pain, wound bed description, peri wound edges and the surrounding skin), measurements, and staging,

This citation pertains to MI 03 and MI 567. Based on observation, interview, and record review, the facility's Medical Director failed to effectively oversee Resident Care related to the prevention of pressure ulcers in 6 of 8 residents reviewed with history of pressure ulcers (Resident #2, #4, #5, #6, #7, & #8) and 32 of 32 supplemental residents reviewed for high risk of pressure ulcer development (Resident #9-#40), and failed to thoroughly assess source of infection for one resident (Resident #2), in a total sample of 8 residents and 32 supplemental residents, and a total census of 74 residents, resulting in the development of and/or worsening of pressure ulcers, and these Residents not maintaining and/or achieving their highest practicable well-being. Findings include: Resident #4 On 12/2/16 at 11:35 AM, Resident #4 was observed in bed lying on her back and when turned to the side by Licensed Practical Nurse (LPN) H and Register Nurse (RN) K a diamond pattern from the cloth incontinence pad was observed imprinted on her buttocks and upper thighs. During the same observation, LPN H stated to Resident # 4 that she had been lying on her back-side since breakfast. During the same observation, Resident #4 was observed with 2 open areas on the right buttock that appeared as a shallow crater with a red wound bed that was bleeding. During the same observation, LPN H measured one of the open areas with the length recorded as the width measurement and the width recorded as the length measurement. LPN H was unable to measure the depth, I would have to guess, our DON (Director of Nursing) measures the depth. RN K stated during the same observation that she did not know what the physician had ordered to cover the wound. Resident #4 was placed back on her buttocks without a dressing and instructed to eat lunch and after lunch the wound would be covered with a dressing. Resident #4's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview for Mental Status (BIMS, screener for detecting cognitive impairment) score was 13 out of 15, indicating she was cognitively intact. The same MDS assessment indicated Resident #4 required extensive assistance of 2 people for turning and repositioning in bed. Resident #4's Admission Record dated 12/2/16 revealed she was admitted to the facility on [DATE] and with the [DIAGNOSES REDACTED]. Resident #4's Norton Pressure Ulcer Risk assessment dated [DATE], revealed she was at high risk for pressure ulcers, chair-bound and with very limited mobility. The same assessment indicated Resident #4 had double incontinence. Resident #4's [MEDICATION NAME] (diverts the normal flow of urine from the kidneys and ureters into a specially created stoma) care plan with target completion date of 3/3/17, revealed she was incontinent of bowel but had a [MEDICATION NAME] for urine collection. Resident #4's Skin Assessment dated 9/26/16 revealed she had an open wound to bilateral buttocks. The same Skin Assessment indicated instructions to Describe all abnormal skin areas. Include length, width, and depth of each area and stage of each pressure area. There was no other documentation on this day describing the depth and stages of Resident #4's open wounds to both buttocks. Resident #4's nurses Progress Notes dated 12/1/16 at 10:49 AM, titled a standard of care skin note, revealed follow up wound right inner buttocks 4.30 (centimeters) cm x (by) 3.5 cm x 0.1 cm. No other information was presented in the nursing note on 12/1/16 signed by Minimum Data Set (MDS) Nurse J. MDS Nurse J was interviewed via telephone on 12/2/16 at 12:40 PM regarding the nurses progress note dated 12/1/16 and stated that she did not measure or observe Resident #4's wound(s). MDS nurse J stated during the same interview that the Assistant Director of Nursing (ADON) gave her the measurements and instructed her to document in Resident #4's medical record. In an interview on 12/2/16 at 12:45 PM, Assistant Director of Nursing (ADON) D stated Resident #4 did not have any pressure ulcers, that she had excoriation on her buttocks. ADON D stated in the same interview that Resident #4's wound measurements documented in the nurses progress notes were from last week, that she was unsure of which day, and confirmed that no measurements were taken on 12/1/16. There was no indication in the nurses progress note on 12/1/16 at 12:40 PM that the measurements were from a week prior, stage of the pressure ulcer, pain, or description of the surrounding tissue. Resident #4's nurse assistant Activities of Daily Living (ADL) Care Plan (no date), photo-copied on 12/2/16, stored on the back of Resident #4's closet door, revealed she had no pressure ulcers and did not indicate instructions to use a cushion in her specialty wheelchair. The physician progress notes [REDACTED].#4 had a Stage 2 pressure ulcer on the left buttock. The physician progress notes [REDACTED].#4's wounds. There was no documentation related to the type or characteristics of Resident #4's wounds. Resident #5 Resident #5's most recent MDS assessment dated [DATE] revealed her cognition was severely impaired and she was totally dependent on 2 nursing staff for turning and repositioning while in bed. Resident #5's Admission Record dated 12/2/16 revealed she had the [DIAGNOSES REDACTED]. Resident #5's Skin Assessment dated 11/22/16 indicated the right buttock had a 0.3 cm (centimeter) open area, continue on treatment . There was no mention in the above skin assessment notes of the stage, complete length/width/depth measurements, exudate, pain, description of the wound bed and surrounding tissue. On 12/2/16 at 3:00 PM, Assistant Director of Nursing (ADON) D stated Resident #5 did not have a pressure ulcer since 7/1/16 and presented a Wound Are/Size Trend Report that a left inner buttock wound was healed on 7/1/16. According to the Medical Directors Progress note dated 8/25/16 at 12:00 PM, Resident #5's chronic gluteal wounds are open again. There was no mention of the stage or wound characteristics. Resident #6 Resident #6's most recent MDS assessment dated [DATE] indicated her cognition was severely impaired, required extensive assist in turning/repositioning in bed, and had a Stage 2 pressure ulcer. Resident #6's nurse assistant Activities of Daily Living (ADL) Care Plan (no date), photo-copied on 12/6/16, stored on the back of Resident #6's closet door, revealed she was independent with bed mobility. Resident #6's ADL nursing care plan dated as revised on 8/3/16 revealed she was independent with bed mobility and occasionally needed limited assistance. Resident #6's Skin Assessment dated 11/18/16 revealed the right buttock had a stage II (2) pressure ulcer, TX (treatment) in place. The same assessment did not include length/width/depth measurements, exudate, pain, wound bed description, or a description of the surrounding tissue. There was no indication in Resident #6's medical record that the medical director assessed the pressure ulcer in November 2016. Resident #7 Resident #7's initial MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15, indicating he was cognitively intact. The same MDS assessment indicated the absence of behaviors and rejection of care. The same MDS assessment revealed Resident #7 required extensive assistance with bed mobility (turning and positioning). Resident #7's Skin Assessment dated 11/16/16 indicated he was a [AGE] year old admitted on [DATE] with 2 abnormal skin areas on his right foot. Resident #7's Skin Assessment dated 11/30/16 indicated a pressure ulcer measuring 3.0 centimeters (cm) by 2.0 cm on the right buttock and a pressure ulcer on the left buttock measuring 5.0 cm by 3.0 cm. The same Skin Assessment indicated instruction to Describe all abnormal skin areas. Include length, width, and depth of each area and stage of each pressure area. There was no other documentation on this day describing the depth and stages of Resident #7's facility acquired pressure ulcers. On 12/6/16 at 10:00 AM, Resident #7's wheelchair cushion was observed with several flattened interconnected air cells. Resident #7 was observed sitting in his wheelchair in the hallway on 12/6/16 at 10:30 AM. In an interview on 12/7/16 at 10:15 AM, Assistant Director of Nursing (ADON) D stated she inspected Resident #7's wheelchair cushion, after notification by surveyor on 12/6/16, found that it was not properly inflated and gave Resident #7 a new cushion for his wheelchair. Resident #8 On 12/6/16 Resident #8's wheelchair cushion thickness was observed with worn, flattened, compressed foam. According to a 2010 article in the Journal of the American Geriatrics Society, titled A Randomized Clinical Trial on Preventing Pressure Ulcers with Wheelchair Seat Cushions retrieved on 12/9/16 from http://www.medscape.com/viewarticle/ 9, Skin protection cushions used with fitted wheelchairs lower pressure ulcer incidence for elderly nursing home residents and should be used to help prevent pressure ulcers. Resident #8's MDS assessment dated [DATE] indicated his cognition was severely impaired, behavioral symptoms were not exhibited, did not reject care necessary to achieve goals and was at risk of developing pressure ulcers. Resident #8's electronicAdmission Record dated 12/6/16 indicated he was admitted [DATE] following a stroke and with [MEDICAL CONDITION] (limited ability to use or understand words) and dysphagia (difficulty swallowing). The same Admission Record revealed additional [DIAGNOSES REDACTED]. Progress Notes dated 12/1/16 indicated Resident #8 had a indwelling urinary catheter and was receiving an antibiotic for a urinary tract infection. Resident #8's Norton Plus Pressure Ulcer Scale (assessment tool to determine pressure ulcer risk) dated 12/3/16 indicated he was at high risk for pressure ulcer development. The same assessment indicated Resident #8 was chair bound with very limited mobility. Resident #8's Risk of Significant Skin Breakdown care plan, date initiated 8/13/14 indicated he had a wheelchair cushion and to reposition every two hours. According to the Physicians Wound Care Rounds progress note dated 12/3/16, Resident #8 had two Stage 2 pressure ulcers on the left buttock and another Stage 2 pressure ulcer on the right buttock that were facility acquired. The same document indicated Resident #8 had a pressure relieving cushion for his wheelchair and instructions to follow a strict turning schedule. Centers for Medicare & Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.14, October 2016 defined a turning and repositioning program as a consistent program for changing the resident's position and realigning the body that is organized, planned, documented, monitored and evaluated for effectiveness based on an assessment of the resident's needs. In an interview on 12/2/16 at 3:20 PM, Assistant Director of Nursing (ADON) D stated turning/repositioning schedules were not individualized to meet resident needs, tissue tolerance was not assessed on any facility residents and that the facility used the standard every 2 hours turning schedule. In an interview on 12/7/16 at 1:30 PM, Director of Nursing (DON) B stated all facility residents with pressure ulcers were on a every 2 hour turning schedule and there were no residents that were care planned to be repositioned more frequently in their wheelchairs or in beds. DON B stated in the same interview that she was not aware of assessing residents individually for tissue tolerance. The National Pressure Ulcer Advisory Panel's Quality of Care Regulations Made Easy: . retrieved 12/7/16 from http://www.npuap.org/wp-content/uploads/2014/03/NPUAP-F-tag-final-March-2014.pdf, The skin assessment should include an evaluation of the skin integrity and tissue tolerance (ability of the skin and its supporting structures to endure the effects of pressure without adverse effects) after pressure to that area has been reduced or redistributed. According to Pressure Injury (ulcer) Prevention Points by the National Pressure Ulcer Advisory Panel, April 2016, retrieved on 12/7/16 from www.npuap.org, indicated to reposition weak or immobile individuals in chairs hourly and use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs. In an interview on 12/6/16 at 2:25 PM, Assistant Director of Nursing (ADON) D stated residents in wheelchairs should be repositioned more frequently that when in bed, but was unable to answer why more frequent wheelchair positioning was not on facility residents care plans. In an interview on 12/7/16 at 10:15 AM, Assistant Director of Nursing (ADON) D stated she inspected Resident #8's wheelchair cushion, after notification by surveyor on 12/6/16, found that the foam cushion was worn out and issued Resident #8 a new wheelchair cushion. ADON D stated in the same interview that she did not know how old Resident #8's wheelchair cushion was and that the facility was going to put something in place to check wheelchair cushions to ensure residents were not bottoming out. According to an article titled Cushion Comfort dated 4/1/13, retrieved on 12/9/16 from http://quest.mda.org/article/cushion-comfort, bottoming out indicated the cushion was worn-out, no longer supporting the hip bones and the resident would be sitting on the cushion base with no support, increasing pressure ulcer risk. The same reference revealed most wheelchair cushions have an expected life of two years or less. ( ) On 12/01/16, at approximately 8:00 AM, during the Entrance Conference, the facility CMS 802 (Roster form) was requested. It was received at approximately 8:45 AM and identified 3 residents as having pressure ulcers (Residents #4, #17, and #60). On 12/02/16 at 9:00 AM, ADON D submitted a list of 6 residents who had pressure ulcers (Residents #8, #9, #10, #11, #12, and #13- all facility acquired). On 12/02/16 at 3:11 PM, ADON D submitted a list of 8 residents who had pressure ulcers (Residents #4, #7, #8, #9, #10, #11, #12, and #13 - all facility acquired). On 12/02/16 at 4:00 PM, ADON D submitted another list containing 10 residents who had pressure ulcers on 12/01/16 (Residents #4, #7, #8, #9, #10, #13, #17, and #36 that were facility acquired, and Resident ##11 and #12 that were community acquired). According to Mayo Clinic, DEC. 13, 2014, At stage II: The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost; The wound may be shallow and pinkish or red; The wound may look like a fluid-filled blister or a ruptured blister. At stage III, the ulcer is a deep wound: The loss of skin usually exposes some fat; The ulcer looks crater-like; The bottom of the wound may have some yellowish dead tissue; The damage may extend beyond the primary wound below layers of healthy skin. A stage IV ulcer shows large-scale loss of tissue: The wound may expose muscle, bone or tendons; The bottom of the wound likely contains dead tissue that's yellowish or dark and crusty; The damage often extends beyond the primary wound below layers of healthy skin .A pressure ulcer is considered unstageable if its surface is covered with yellow, brown, black or dead tissue. It's not possible to see how deep the wound is. <http://www.mayoclinic.org/diseases-conditions/bedsores/basics/symptoms/CON- 848> According to the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 3/23/11: Assessment and Recognition 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores . 2. In addition, the nurse shall assess and document/report the following: a. vital signs b. Full assessment of pressure sore including location, stage, length, width, and dept, presence of exudates or necrotic tissue c. pain assessment d. Resident's mobility status e. Current treatments, including support surfaces 3. The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage I pressure area that has not yet ulcerated at the surface. 4. The physician will help the staff define the type .and characteristics (necrotic tissue, status of the wound bed, etc.) of an ulceration. Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown .and macerated or friable (delicate nature of) skin. 2. The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing, etc. Treatment/Management 1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches . 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue . 3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors; for example: a. Healing or Prevention Likely . b. Healing or Prevention Possible . c. Healing or Prevention Unlikely: The resident is likely to decline or die because of his/her overall medical instability . Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive, or non-healing wounds . Resident #2 Resident #2 did not reside at the facility at the time of the investigation. He had Full Code Status. Resident #2's MDS/Minimum Data Set, dated dated [DATE], revealed he was a [AGE] year old man, admitted to the facility on [DATE], who had severe cognitive impairment, was totally dependent on staff for care, had a Foley catheter, a feeding tube, wore oxygen, had [MEDICAL CONDITION](but was not on a vent), a Stage II pressure ulcer, and had [DIAGNOSES REDACTED]. The MDS also indicated Resident #2, Does not have a condition or chronic disease that may result in life expectancy of < 6 months. In a telephone interview, on 12/01/16 at 8:28 AM, RP/Responsible Party for Resident #2 (M) reported, the afternoon nurse (LPN Q) disregarded him one evening when he told him his brother (Resident #2) needed attention. RP M said, I told him 3 times one shift my brother needed attention, but he wouldn't answer me the first two times. My brother didn't look right, he was warm and his eyes were closed. When (LPN Q) came to look at him the third time I complained, he said, 'He looks all right to me'. He (LPN Q) smiled at me sarcastically and laughed. He had to be transferred to the hospital a day and a half later. He's still at the hospital. It was close. In an interview, on 12/01/16 at 11:23 AM, LPN Q stated he knew RP M had the above concerns, and said in a disgruntled tone, (RP M) is very particular. The resident was fine . (Resident #2) is basically comatose .(RP M) pressed my buttons. According to Resident #2's Hospital Admission History and Physical, dated 11/22/16 at 6:04 PM, At baseline, patient is conversive, alert and oriented. Today he is intermittently non-verbal. A fever at (facility) was 101 degrees Farenheit. In the ER, he was found to have a stage 4 ulcer, [MEDICAL CONDITION] (rapid heart beat), requiring oxygen, and hypotensive. At first, BP was responsive to fluids, however became less responsive after 3 L of fluids. CXR, CT chest/abdomen/pelvis was negative for acute abnormalities. He was started on [MEDICATION NAME] (antibiotic) for a presumed infection stemming from the decubitus ulcer .Assessment: Active Problems:[MEDICAL CONDITION] . [MEDICAL CONDITION] 2/2 (secondary to) decubitus ulcer .(sic). Review of Resident #2's Medical Record, and requests for the Transfer form and Discharge documentation from the facility revealed there was no Transfer form, Nursing Notes, or physician progress notes [REDACTED].#2's discharge on 11/22/16, LPN/Licensed Practical Nurse S reported she was on duty when Resident #2 was transferred to the hospital on [DATE]. She said, I saw him probably 7:00 - 7:30 AM; he was diaphoretic, as usual. We sent him out by 9:30 AM .he had a rash across his chest .I thought he had pneumonia and needed IV antibiotics. Around 8:30 AM, (Medical Director C) saw him. He (Medical Director C) didn't mention the pressure ulcer or why Resident #2 had a rash. LPN S had no explanation as to why there were no Nurses' Notes/physician progress notes [REDACTED]. According to Resident #2's Admission Nursing Assessment, dated 10/19/16 (admitted ) at 7:00 PM, under Section C. Skin Conditions, was documented, Sacrum indicating there was a skin condition there, but no measurements, description, or staging (a description of the extent of tissue damage), the tissue surrounding the wound, etc. were documented. It also noted Resident #2 had Hammer toes (permanently bent) and boggy, soft heels, but there measurement or color of the affected area was not documented. (Review of Resident #2's Medical Record found no further assessment of his heels or toes). According to Rutgers University, 8/26/2001, boggy or spongy heel can indeed indicate the start of a pressure ulcer there, esp. if you also have any skin discoloration, usually black and blue or a blister. The treatment is to keep all pressure off the area completely, bridging with pillows in bed, and wearing shoes with very loose stretchy fabric or cut out heels until this is completely cleared. <http://sci.rutgers.edu/forum/showthread.php?3278-quot-spongy-quot-heel> According to Rutgers University, 8/26/2001, boggy or spongy heel can indeed indicate the start of a pressure ulcer there, esp. if you also have any skin discoloration, usually black and blue or a blister. The treatment is to keep all pressure off the area completely, bridging with pillows in bed, and wearing shoes with very loose stretchy fabric or cut out heels until this is completely cleared. <http://sci.rutgers.edu/forum/showthread.php?3278-quot-spongy-quot-heel> Resident #2's Norton Plus Pressure (sic) Ulcer Scale, dated 10/19/16, revealed Resident #2 was at High Risk of skin breakdown. According to a Nursing Progress Note the day of his admission to the facility, dated 10/19/16 at 8:27 PM, Unit Manager I documented Has sacral decubitus measures 4 cm x 4.5 cm, 1 cm deep .mod amt (moderate amount) serous (clear) drainage . Unit Manager I did not document the Stage of the ulcer, the condition of the surrounding tissue, or if there was any odor. No other Nurses' Progress Notes mentioned Resident #2's pressure ulcer. Resident #2 had 3 Weekly Skin Assessments, and they revealed: 11/07/16 at 3:28 PM - Stage IV ulcer (no measurements or description or mention of Resident #2's heels). 11/14/16 at 1:53 PM - Stage 3 Decubitus (no measurements or description or mention of Resident #2's heels). 11/21/16 at 1:53 PM - Sacrum - Stage 3 decubitus (no measurements or description or mention of Resident #2's heels). According to Resident #2's Skin Care Plan, dated 10/20/16, Lodger (resident) was admitted with a pressure ulcer to sacrum. He is at continued risk for skin breakdown related to being dependent on staff for all positioning, bowel incontinence and use of oxygen and Foley catheter in which tubing could cause potential pressure area .The resident will have intact skin, free of redness, blisters or discoloration .The lodger's (resident's) Pressure ulcer will progress through the healing process and remain free from infection .Daily skin evaluations by licensed nurse . Evaluate/record/monitor wound healing: Measure length, width, and depth were (sic) possible. Evaluate and document status of wound perimeter, wound bed and healing progress Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection .Obtain and monitor lab/diagnostic work as ordered .pressure relief mattress . This Care Plan did not mention tissue tolerance, turning interventions, which type of wheelchair cushion he was to have, or how long Resident #2 was to be allowed sitting in the wheelchair, use of a foot cradle or heels up device, or to monitor the wound for infection. Resident #2's Care Plans did not specify which route to use to obtain his temperature most accurately and consistently. Review of Resident #2's SOC Notes (Standards of Care) notes (to be done weekly), revealed only one measurement after admission measurements, dated 11/16/16, 3.2 x 2.0 x 0.10: Showing improvement, but there was no indication when the measurement was obtained or by whom, no staging, or any description other than the measurements. It was revealed in an interview with ADON D (on 12/01/16 at 3:00 PM) and confirmed in a subsequent interview with DON B (12/01/16 at 9:47 AM), the SOC notes were traditionally written approximately 1 week after measurements were actually obtained. DON B and ADON D both reported the day wounds were actually measured, they were supposed to enter the measurements into Gentell (the the facility's pressure ulcer supplies vendor electronic reporting system - a system not interfaced with PCC/Point Click Care Electronic Medical Record and never placed in their charts). The the date the measurements were obtained was not routinely documented in the SOC note(s), and the SOC note(s) were not written until approximately one week after the measurements were actually done (the day varied). This made it impossible to accurately track the status of the wound via the Residents' legal medical records. Measurement of Resident #2's pressure ulcer from Gentell data showed only 1 entry: Evaluation Date: 11/18/16 .5.0 / 3.0 / 2.00 cm .Stage II (sic). This information did not appear in Resident 2's Electronic Medical Record, but the facility presented them as evidence the wound had been measured weekly. On 12/01/16 at approximately 9:00 AM, the ADON D reported the staff nurses were allowed to recommend treatments suggested by their vendor Gentell, but admitted on ly she and DON B had had Gentell training which included measuring, staging pressure ulcers, and recommended treatments. ADON D also reported that DON B was the facility's Wound Nurse ever since the Wound Certified Nurse Practitioner, who had been doing all assessment and ordering treatments left employment of the facility at approximately the same time the facility changed ownership in May 2016. In an interview, on 12/01/16 at 3:00 PM, ADON D said wound clinics were only recommended for residents with venous ulcers. In an interview on 12/7/16 at approximately 10:20 AM, Assistant Director of Nursing (ADON) D stated, We don't order special wheelchair cushions. According to Resident #2's an admission physician progress notes [REDACTED].multiple decubitus ulcers stage III, but Medical Director C Examination revealed he did not examine Resident #2's wound. He also documented, Discharge potential is good. Rehab potential is good . physician progress notes [REDACTED].#2's sacrum pressure ulcer. In a physician progress notes [REDACTED]. It is getting worse due unavoidable causes (sic) .Wound: Increased to a Stage 4 pressure ulcer -New TX (treatment) ordered. There was no other description of the wound, and no evaluation of pressure relieving devices/recommended practices, and no recommendation for specialist consult documented. In a telephone interview regarding Resident #2, on 12/01/16 at approximately 3:05 PM, Medical Director C reported, I don't look at them. I go by what they (nurses) tell me. When asked why he documented, It is getting worse due unavoidable causes but did not document what the unavoidable causes were, Medical Director C said in a frustrated tone, He's got multiple co-morbidities, recurrent pressure ulcer infections, increased respiratory secretions, increased temperatures, very contracted, he's on a trach. Have you seen the guy? He drools all the time, and he shakes and trembles all over . When asked why he did not send Resident #2 to a wound clinic, he said, It would be very hard for him to be treated at a wound clinic. He has [MEDICAL CONDITION]. According to December 2016, 37- 12 Issue of McKnight's Long Term Care News, An audit of 155 patient records found large gaps between clinical practice and wound documentation in nursing homes . researchers found they lacked key details about pressure ulcers and preventative interventions, even when patient exams showed measures like pressure-relieving mattresses were in use .The researchers theorize inaccuracies were linked to nurses who do not have time, skills and knowledge to update patient records .They suggest more training for high-quality care and documentation, as well as adopting electronic health records with decision-support tools .The researchers estimate incomplete reporting in 30% to 62% of pressure wound cases. In 45% of their cases, pressure ulcers were not graded . <http://www.mcknights.com/issue/December/01/2016/2782/> In an interview, on 12/02/16 at 9:25 AM, LPN/Licensed Practical Nurse H reported she performed dressing changes for Resident #2's wound on 11/01/16 and a foul odor was present. LPN H stated Resident #2 often had a fever. There was no documentation of odor (present/not present) anywhere in Resident #2's medical record. Review of all of Resident #2's Nurses's Notes revealed the only measurements in the Nurses' Notes were those documented on the day of admission, and there were no other descriptions of the wound in the Nurses' Notes or TARs/Treatment Administration Records, although the TARs revealed Resident #2's Pressure Ulcer Dressing was changed two times a day. LPN H reported nurses lost the ability to document the characteristics of wounds in the Treatment Record in May, 2016 when a new company took over the facility. In a telephone interview, on 12/02/16 at 9:47 AM, DON B denied she was the facility's Wound Nurse. She said, I am not the Wound Nurse, I am the Director of Nursing. I help them out. I go around once a week to make sure things are in place .I do not call the doctors for new orders, the floor nurses do that. This Surveyor asked DON B about the Gentell note, dated 11/18/16, in which ADON D documented Resident #2's Pressure ulcer as Stage II 5.0 x 3.0 x 2 cm (Medical Director C documented Stage IV on 11/01/2016). DON B stated she saw Resident #2's pressure ulcer also, and argued with ADON D that Resident #2's Pressure Ulcer was not a Stage II, but unstageable due to excessive slough, but she allowed ADON D to document it as Stage II. DON Asaid she did not know the nurses were not documenting the condition of the wounds and said, They are supposed to do so when they do the dressing changes twice a day. DON B said she did not recommend wounds to be treated at wound clinics to the physician because, I don't like them (wound clinics), and said she did not get a wound culture of Resident #2's pressure ulcer because there was n

Based on observation, interview and record review the facility failed to ensure that falls were thoroughly investigated, the root cause determined, interventions planned and followed and acceptable standards of trauma care were provided after a fall with suspected hip fracture for 2 residents (#4, #6) out of 6 assessed for falls from a total sample of 15 resulting in a decline in condition for Resident #4, and fractures and continued falls for both resident #4 and resident #6. Findings include: According to the facility's Pathway to Incident Reporting, revised 7/3/09, Document facts (not assumptions) in the resident's medical record: 1. How the resident was observed at the time of the incident: what is seen heard, touched, or smelled, or fall was unwitnessed; 2. Condition of resident including vital signs .; 3. If and how resident was moved following the incident; 4. Position of the bed, wheelchair, side rails, etc; 6. Name of physician and when physician was notified and any orders received and any treatment rendered; 8. If transferred to the hospital or physician's office; 9. Follow up to incident; 10. Intervention(s) to prevent re-occurrence. Administrator notifies state regulatory agency per state regulation. According to the facility's Falls Prevention and Management, revised 11/23/09, under Risk Factors Associated with Falls on page 3, 3. Care Giver Factors: h. Inadequate assessment or care plan interventions. n. Failure to assess each fall and plan further preventive interventions. General Trauma Interventions: Keep the victim lying down or in the position in which he or she is found . (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives, 7th edition, St. Louis: Mosby). According to the facility's Admission Record and the Minimum Data Set (MDS - resident assessment), dated 10/26/15, Resident #4 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. to speech, language and hearing), anemia, urinary retention (bladder doesn't empty) with urinary tract infections and peripheral vascular disease (poor circulation to legs), muscle wasting and weakness and unsteadiness on feet. According to the MDS, dated [DATE], Resident #4 had severe cognitive impairment, was sometimes understood and understood others, exhibited inattentiveness and disorganized thinking, could be combative with cares and showed no signs of depression. Resident #4 required the assist of 2 staff persons for bed mobility, transfers using a total mechanical lift, and walking with a walker, toileting, was incontinent of bowel, had a urinary catheter and and was totally dependent on nutrition provided through a tube inserted into his stomach. Resident #4 required assist of 1 staff person for pushing his wheel chair, hygiene and bathing. Resident #4 had a pressure wound on his left heel. According to the admission care plan for falls, dated 10/19/15, Resident #4's interventions were, Keep call light in reach, encourage use of call light, orient to room and call light and assess resident's footwear for proper fit and non-skid soles. On 3/22/16 at 1:46 p.m., Resident #4 was observed in his bed with pillows on both sides of his hips and upper body, under his fitted sheet. A fall mat was on the floor on the side of his bed away from the window, and his bed in the middle of his side of the room. Resident #4's bed was not in it's lowest position. According to the incident report, dated 10/26/15 at 7:01 p.m., Resident #4 was observed on floor on his right side, partly curled up, beside his wheelchair in the hallway. When asked what happened, Resident #4 continued to talk about his wife. He was assessed and returned to his room. Even though a new bruise high up on his right side of his ribs at the nipple line that was approximately 0.5 by 2 inches was discovered, No injuries Observed Post Incident was printed at the bottom of the page. The incident report reflected that Resident #4 had impaired memory and the environment was noisy. Under, Other info, Did not have lap buddy (cushioned device attached to a wheelchair that may be used to remind the person to call for help before standing, or as a restraint) on his lap, educated all CNA (certified nurse assistant) and staff that he needs to have that at all times when he is up in his wheelchair. This intervention was never added to the aide care guide, nor the nursing care plan, even after this fall. There was no documentation about the last time Resident #4 was observed and by whom, nor what he was doing, interviews of all staff to see if anybody noticed anything that might help establish a root cause. When requested, DON B was unable to find physician's orders [REDACTED].#4 ever having one. On 3/24/16 at 11:30 a.m., Registered Nurse (RN) T was interviewed via phone. When asked about the lap buddy for Resident #4 when he fell on [DATE], RN T said that he was constantly touching, picking, grabbing things, his shoes and the air with his hands. RN T verified that it was not a lap buddy, but a 2-3 inch thick foam piece, covered with leather with activities to keep a resident's hands busy tying, buttoning, lacing etc. Resident #4 did not have a lap buddy or any restraint. According to the incident report, dated 10/30/15 at 2:36 p.m., for Resident #4, Licensed Practical Nurse (LPN) Z was, Called to the North unit via overhead page. Upon arriving, observed Resident #4 lying on his left side on the floor beside his wc (wheelchair), his left side leaning against the doorway of room 66 (physical therapy room), his head inside of the room and his legs stretched outward into the hall. Two skin tears were documented, which were cleaned and dressed, and No other s/s (signs and symptoms), of injury, resident (total mechanical lift) into his wc. The question Resident Taken to Hospital was answered, N ( meaning, no). No injuries Observed Post incident was noted near the bottom of the first page. Two nurse's notes with the same date reflected this information. The witness section had 2 staff documented, but no names. According to the facility's Post Fall Assessment, Resident #4's fall on 10/30/15, question #3 was What is the position of their arms and legs and the answer was, Anatomically correct w/(with) legs extended. Anatomically correct means lying face up with arms and legs extended and slightly apart from the body with palms facing up. Question #13 was, What time were they last toileted and the answer was, 10/30/15 at 1330 (1:30 p.m.). Question #14 was, What did you do immediately to prevent further falls was answered with, 1:1 (indicating someone sat with him constantly) and toileted. A nurse's note, dated 11/2/15, by DON B reflected, Incident reviewed by ID (interdisciplinary) team. Resident guarding lt (left) hip upon assessment and noted outward rotation of lt foot. Resident (#4) also experiencing respiratory difficulty and was sent to the hospital and confirmed lt hip fx (fracture). On 3/23/16 at 4:30 p.m., PT P was interviewed. When asked to recall Resident #4's fall on 10/30/15, PT P said that he heard someone hit the floor and many footsteps. When he got up and looked out the therapy room door, Resident #4 was on the floor and DON B and ADON Y were present. PT P witnessed that Resident #4's left leg was externally rotated and he couldn't move the leg. This incident occurred late in the workday. On 3/24/16 at 9:10 a.m., LPN I was interviewed via phone. When asked to describe Resident #4's fall on 10/30/15, LPN I said that she was at lunch when he fell . LPN I did not recall where Resident #4 was when she assessed him, but she recalls that he grimaced when his left hip was touched and his left knee flexed. When asked if Resident #4 had a lap buddy ordered,, LPN I said that he did not. On 3/24/16 at 9:25 a.m., LPN Z was interviewed via phone. When asked to recall Resident #4's fall on 10/30/15, LPN Z said that he was seated at the north hall nursing station, charting on the computer. LPN Z had observed Resident #4 seated in his wheelchair by the nurse's station and room 66 (physical therapy room). Resident #4's nurse was at lunch. When he looked up after hearing staff rushing, Resident #4 was on the floor in room 66's doorway, beside his wheelchair. DON B and ADON Y assessed Resident #4, and ADON Y asked LPN Z to write up the incident report. LPN Z said that he did the best he could on the incident report, but had not been directly involved with the incident. Resident #4 was transferred to the hospital shortly after that. According to the hospital discharge summary, dated 11/17/15, Resident #4 had the fracture of his left hip surgically repaired. On 3/24/16 at 9:30 a.m., ADON Y was interviewed. When asked to recall the events of Resident #4's fall and fracture on 10/30/15, ADON Y said that she was in her office near the north hall nurse's station. She heard the thud and found Resident #4 on the floor by his wheelchair near the therapy room doorway. He was lying on his back, legs straight out, and both legs were externally rotated (feet leaned outwards). When his left foot was lifted and, then, his knee flexed, Resident #4 grimaced, so the assessment stopped. Assessment of the right leg caused no grimace from Resident #4. When asked, ADON Y could not recall if Resident #4 made any noises during the assessments. ADON Y said that Resident #4 was replaced in his wheelchair, then back into bed using a total mechanical lift for both. She could not recall who checked Resident #4's orthostatic blood pressure, pulse and heart rate. ADON Y did not witness Resident #4's difficulty breathing. When asked, LPN Y did not recall asking LPN Z to write up the incident report, but, I didn't do it. On 3/24/16 at 11:25 a.m., PT P was interviewed. When asked how Resident #4 was moved after his fall on 10/30/15. PT P said that he observed the use of a mechanical lift to move the resident from the floor into his wheelchair. On 3/24/16 at 11:35 a.m., ADON Y was asked why Resident #4 was mechanically transferred to his wheel chair, then to his bed after his fall and fracture on 10/30/15, ADON Y said that she couldn't remember what they did, but nodded and said, I see where you're coming from. According to Resident #4's electronic census, he returned from the hospital on [DATE]. Resident #4's plan of care reflected the following interventions, dated 11/17/15, Anticipate his needs, assess environment for potential hazards and remove them, low bed, if resident falls, attempt to determine causes for fall and take steps to prevent fall from happening again, keep bed locked at all times and wc (wheelchair) during TF (transfer), keep glasses clean and on him when up, keep room/walkway free from clutter, monitor resident frequently. According to an incident report, dated 11/20/15 at 11:30 p.m., Resident #4 was observed on his back near his bed, which was in low position, and was sent to the hospital. Again, no detailed investigation was done, no interviews, and no root cause was established. Planned interventions upon his return from the hospital were, low bed (which was already in place) and pillow on his right side, tucked under the bottom sheet. This intervention was never added to the nurse or aide care plans. According to the incident report, dated 11/28/15 at 9:00 p.m., Resident #4 was observed on floor by the side of his bed away from the window with his left foot caught in his blankets. He still had the adductor pillow between his legs that kept his legs apart. No interviews, investigations or root cause were documented. The intervention was pillows to both sides of his bed. According to the incident report, dated 11/28/15 at 9:00 p.m., Resident #4 was observed on the floor by his bed with the abductor pillow (used to keep legs slightly apart after hip surgery) in place between his legs. Resident #4 sustained some redness on the lower/side of his back. No interviews, investigation or root cause was documented. On 12/4/15 at 7:55 a.m., Resident #4 was observed on his left side beside his bed. The new intervention indicated on the incident report floor mats be placed on both side of his bed, but was not documented on the care plan. A review of the care plan for Resident #4 reflected that 1 new interventions, dated 12/3/15, Monitor resident during NOC (night) to ensure lower extremities are not getting tangled in bed linens. A nurse's note, dated 12/10/15 reflected, Incident reviewed by ID team. Interventions in place appropriate to prevent injury. No new interventions suggested. A review of the care plan for Resident #4 reflected that 2 new interventions, dated 12/7/15, were added: Ensure that resident is properly positioned in bed, and monitor frequently when in bed and tuck pillows under sheet on both sides of bed. On 3/23/16, the second day of the survey, the intervention, fall mat to right side of bed, was added to the care plan. On 3/23/15 at at 1:40 p.m., DON B mentioned that she and ADON Y had to work nursing shifts for the past 9 months due to shortage of nurses at the facility, especially at night. This made it hard to keep up with their other tasks/supervision. DON B said that nursing staff has to step up and do more, and the documentation for falls was fragmented. On 3/24/16 at 11:00 a.m., Director of Physical Therapy (DPT) O was interviewed. When asked to describe resident #4's physical therapy progress before and after his fall with fracture on 10/30/15, DPT O said that he walked with a cane prior to admission to a psychiatric hospital. DPT O said that Resident #4 was admitted with a left foot drop, and required rest breaks due to difficulty breathing. The admission therapy note, dated 10/20/15, indicated that Resident #4 required a walker and the moderate assistance of 2 staff persons to stand and ambulate 80 feet. As of 10/30/15, Resident #4 could walk 100 feet and transfer with a walker and the minimal assist of 1 person. Upon return to the facility, Resident #4 had a physician's orders [REDACTED]. He was unable to ambulate and required 2 assist with a partial mechanical lift for transfers. By 12/30/15, Resident #4 could only ambulate 40 - 50 feet with a walker and the moderate assist of 2 staff persons. DPT O said that Resident #4 continued to have pain in his left hip, and seemed unable to adjust to the presence of the artificial hip. Because of his pacemaker, Resident #4 was not able to have heat and ultra sound-type modalities for pain relief and strengthening. Resident #4 was currently transferred with a total mechanical lift and 2 staff persons. ( ) During the review of the Electronic Medical Record (EMR) for Resident #6, it was noted that she was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Nursing Progress Notes, Incident/Accident forms and a timeline completed by the Administrator's Assistant CC on 3/23/16, Resident #6 had three falls dated 7/16/15, 8/5/15 and 9/9/15. Resident #6 fractured her elbow on the 9/9/15 fall. There were no witnesses to any of the three falls. Reviewing the Incident/Accident and Post Fall Assessment forms for all three falls, there were no statements by whoever found her on the floor, no vital signs listed on either form (vitals were found later on the Vitals list but no correlation with the falls), and no root cause analysis of any of the falls. There was a space for last time they were toileted and what did you do immediately to prevent further falls. On the 7/15/15 fall and 8/5/15 fall those times were filled in, but on the fall with the fractured elbow on 9/9/15 that area was completely blank. Without adequate data on the falls it was impossible to do an adequate assessment to determine the root cause of the fall. The facility Pathway to Incident Reporting revised 7/30/09 stated If incident is of unknown origin, complete Injury of Unknown Origin Investigation. No Injury of Unknown Origin form was included for any of the three falls. The assumption was made, according to an interview with the Administrator on 3/24/16 at about 1:30p.m., that Resident #6 fell out of bed. The Post Fall Assessment form dated 9/9/15 stated was the resident using an assistive device? and the selection wheelchair was checked making it unclear whether she fell from her bed or from her wheelchair. That issue was not clarified on any subsequent documentation but all of the other mentions of the incident stated she fell out of bed. ( )

This citation pertains to MI 815. This citation has multiple deficient practice statements, DPS A and DPS B. DPS A. Based on interview and record review, the facility failed to provide care that met professional standards to accurately assess and develop interventions to maintain proper hydration in 1 of a total of 3 sampled residents (#101) reviewed for dehydration, resulting in Resident #101 being admitted to the hospital with [REDACTED]. Resident #101 subsequently died . Findings Include: Review of the face sheet and admission record dated [DATE] revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital's Inpatient Behavioral Health Progress Note dated [DATE] revealed Resident #101's past medical history included dementia, dehydration, insulin dependent diabetes, high blood pressure and altered mental status. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was moderately impaired cognitively and required extensive assistance with Activities of Daily Living (ADLs). Review of the admission physician orders [REDACTED].#101 was to receive 1 milligram (mg) of [MEDICATION NAME] (water pill) everyday. Review of the November Medication Administration Record [REDACTED]. According to an article from the National Institute of Health (http://www.ncbi.nlm.nih.gov/pubmed/ 926), "[MEDICAL CONDITION] is defined as a plasma sodium concentration greater than 145 meq/liter (or mmol/L)...Persistent [MEDICAL CONDITION], therefore, implies an inability to sense thirst or lack of access to water, since ingestion of water will prevent development of significant [MEDICAL CONDITION] persons have decreased thirst...frail nursing home residents are at an increased risk for the development of [MEDICAL CONDITION] because they rely on others for their water needs. Therefore, adequate water must be prescribed and given to these individuals..." According to an article titled, "[MEDICAL CONDITION] in Emergency Medicine" (http://emedicine.medscape.com/article/ 3-clinical#a0218), "[MEDICAL CONDITION] is due to too little water...The alteration can be in administration (too much salt or too little water)...The most common cause of [MEDICAL CONDITION] in elderly or institutionalized patients is lack of free water intake adequate to meet losses. Review of hospital lab report dated [DATE], Resident #101's blood sodium level 155 millimoles per liter (mmol/L, normal is ,[DATE] mmol/L). According to the National Institute for Health, severe [MEDICAL CONDITION] is defined as a blood sodium level equal to or greater than 155 mmol/L. According to the Department of Licensing and Regulatory Affairs' Clinical Practice Guidelines, it is expected that facilities, "staff should review and define each resident's hydration status, using a consistent protocol...When the staff and practitioner identify situations where an individual's hydration is at risk or may be impaired, they should seek additional information such as current or subsequent changes in food or fluid intake, level of consciousness, mental status, or urine output, or rapid or sudden changes in body weight...The staff and practitioner should identify the individual's risk for subsequent fluid and electrolyte imbalance, including impaired ability to take adequate fluids without assistance...The facility should be able to explain the basis for any conclusions that risk factors could not or should not be identified or addressed". Review of the facility's undated Hydration (NUR-522) policy revealed: 1. Complete Hydration Assessment HCM NUR 4123: a. New Admission 2. Follow the steps as outlines (sic) in the Pathway to Hydration Management. 3. Document on Care Plan outcomes of assessment. Review of the undated document titled "Pathway to Hydration Management", revealed that after completing the hydration assessment, if a resident was not found to be a risk for dehydration, no further action was required. Further review of the Pathway revealed that if a resident was found to be a risk for dehydration, interventions to prevent dehydration were to be put in place and a care plan was to be developed. Review of Resident #101's "Hydration Risk Assessment" (HCM NUR 4123) dated [DATE], nine days after admission, revealed a total score of 4. A total score greater than 6 represents HIGH RISK for dehydration. The assessment failed to account for the resident's [DIAGNOSES REDACTED]. Further, the assessment failed to account for the resident requiring assistance with fluids, which would have added 4 points to the assessment score. With an accurate assessment Resident #101's score would have been 10, 4 points higher than than what is to be determined HIGH RISK for dehydration, and initiation of a careplan would have been required. While reviewing Resident #101's Hydration Risk Assessment on [DATE] at 2:30 p.m. with DON #2, she stated, "Yes, I would probably have scored him higher...I remember (Resident #101) having very poor safety awareness, and was very confused". Review of Resident #101's complete medical record failed to reveal a care plan for dehydration or fluid maintenance. Review of the Initial Dietary Visit form dated [DATE] revealed Resident #101's total fluid needs was ,[DATE] cubic centimeters (cc) per day. Review of I/O (in/out) chart detailed report printed on [DATE] revealed that between [DATE] and [DATE] Resident #101 averaged a daily intake of 600 cc of fluid, more than 1,400 cc below Resident #101's daily requirement. In an interview on [DATE] at 1:35 p.m., Licensed Practical Nurse (LPN) #7 stated that Resident #101's fluid intake "was probably poor". In an interview on [DATE] at 11:40 a.m., Certified Nursing Assistant (CNA) #8 stated, "(Resident #101) hardly ate or drank". Review Hospital Encounter Notes dated [DATE] revealed Resident #101 was admitted to the hospital unresponsive with the [DIAGNOSES REDACTED]. DPS B. Based on interview and record review, the facility failed to provide care that met professional standards to immediately assess and monitor a resident with an acute change in condition and notify the physician of an abnormal neurological assessment in 1 resident (#101) of a total of 3 sampled residents reviewed for acute change in condition, resulting in delayed evaluation and treatment and Resident #101 being admitted to the hospital with [REDACTED]. Resident #101 subsequently died . Review of the face sheet in the medical record dated [DATE] revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was moderately impaired cognitively and required extensive assistance with Activities of Daily Living (ADLs). Review of a Hospital's Inpatient Behavioral Health Progress Note dated [DATE] revealed Resident #101's past medical history included dementia, dehydration, insulin dependent diabetes, high blood pressure and altered mental status. Review of Neurological Assessments forms dated [DATE] thru [DATE] revealed that Resident #101's pupil reaction to light was always "brisk" indicating appropriate reaction and a normal neurological assessment finding. Review of the forms failed to reveal that Resident #101 was ever drowsy or unresponsive. Review of a nurse's note dated [DATE] at 8:30 p.m. and written by Licensed Practical Nurse (LPN) #16 revealed Resident #101's "pupils sluggish to react to light. Not tracking (with) his eyes". Review of the nurse's notes failed to reveal that this abnormal neurological finding was relayed to the physician. Review of Resident #101's complete medical record failed to reveal that Physician #10 was notified of the abnormal neurological assessment findings of "pupils sluggish to react to light. Not tracking (with) his eyes". During a telephone interview on [DATE] at 12:32 p.m., Physician #10 stated he was not made aware of the abnormal findings of Resident #101's "pupils sluggish to react to light. Not tracking (with) his eyes". Physician #10 stated, "No, I do not remember being notified of that". Physician #10 stated, "If a nurse called me and told me that, I would send the resident to the hospital". During a telephone interview on [DATE] at 12:04 p.m. LPN #16 was asked if she remembered the night that Resident #101's abnormal findings of "pupils sluggish to react to light. Not tracking (with) his eyes" were assessed. LPN #16 stated, "I remember that yes, he was not acting right, he was gurgly (making gurgling noises) and we thought he may have aspirated (inhale something into the lungs). I don't recall if the doctor was called after that (abnormal assessment). I don't know if (LPN #7) did". In an interview on [DATE] at 1:35 p.m., LPN #7 stated she does not remember notifying the physician of Resident #101's abnormal findings of "pupils sluggish to react to light. Not tracking (with) his eyes", LPN #7 stated, "Yes, this is (an acute change in condition)...up until 8:00 p.m. he was fine, alert, eyes wide open, able to sit in his wheelchair". In an interview on [DATE] at 12:48 p.m., when asked if a neurological assessment of pupils sluggish to react to light, eyes not tracking was alarming, Registered Nurse (RN) #11 stated, "Yes, I would finish my assessment and call the physician immediately". In an interview on [DATE] at 1:24 p.m., RN #13 stated that if she were to assess a resident to have pupils sluggish to react to light and eyes not tracking, she would contact the physician immediately. In an interview on [DATE] at 8:00 a.m., when asked, if a neurological assessment revealed findings of "pupils sluggish to react to light, eyes not tracking", what would you do, RN #14 stated, "I would call the physician immediately". Review of the nurse's note addendum dated [DATE] at 1:10 p.m. revealed, that on [DATE] at 7:50 a.m., less than 12 hours after Resident #101's abnormal neurological assessment, Registered Nurse (RN) #14 contacted Physician #10 to inform Physician #10 that Resident #101 was non-responsive. The note revealed that Physician #10 ordered Resident #101 be sent to the emergency room for evaluation. Review of the Ambulance Service Patient Care Report dated [DATE], revealed the ambulance arrived the facility at 8:19 a.m. and found Resident #101 "laying unresponsive". Review Hospital Encounter Notes dated [DATE] revealed Resident #101 was admitted to the hospital unresponsive with [DIAGNOSES REDACTED]. Resident #101 subsequently died . ( )

This citation pertains to MI 815. Based on interview and record review, the facility failed to ensure adequate fluid intake to maintain proper hydration for 1 resident (#101) of 3 total sampled residents reviewed for hydration, resulting in Resident #101 being admitted to the hospital with [REDACTED]. Resident #101 subsequently died . Findings Include: Review of the face sheet and admission record dated [DATE] revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was moderately impaired cognitively and required extensive assistance with Activities of Daily Living (ADLs). Review of a Hospital's Inpatient Behavioral Health Progress Note dated [DATE] revealed Resident #101's past medical history included dementia and dehydration. According to an article from the National Institute of Health (http://www.ncbi.nlm.nih.gov/pubmed/ 926), "[MEDICAL CONDITION] is defined as a plasma sodium concentration greater than 145 meq/liter (or mmol/L)...Persistent [MEDICAL CONDITION], therefore, implies an inability to sense thirst or lack of access to water, since ingestion of water will prevent development of significant [MEDICAL CONDITION] persons have decreased thirst...frail nursing home residents are at an increased risk for the development of [MEDICAL CONDITION] because they rely on others for their water needs. Therefore, adequate water must be prescribed and given to these individuals..." According to an article titled, "[MEDICAL CONDITION] in Emergency Medicine" (http://emedicine.medscape.com/article/ 3-clinical#a0218), "[MEDICAL CONDITION] is due to too little water...The alteration can be in administration (too much salt or too little water)...The most common cause of [MEDICAL CONDITION] in elderly or institutionalized patients is lack of free water intake adequate to meet losses. Review of hospital lab report dated [DATE], Resident #101's blood sodium level 155 millimoles per liter (mmol/L, normal is ,[DATE] mmol/L). According to the National Institute for Health, severe [MEDICAL CONDITION] is defined as a blood sodium level equal to or greater than 155 mmol/L. Review of the Initial Dietary Visit form dated [DATE] revealed Resident #101's total fluid needs was ,[DATE] cubic centimeters (cc) per day. Review of I/O (in/out) chart detailed report printed on [DATE] revealed that between [DATE] and [DATE] Resident #101 averaged a daily intake of 600 cc of fluid, more than 1,400 cc below Resident #101's daily requirement. While reviewing Resident #101's Hydration Risk Assessment on [DATE] at 2:30 p.m. with DON #2, she stated, "Yes, I would probably have scored him higher...I remember (Resident #101) having very poor safety awareness, and was very confused". In an interview on [DATE] at 10:45, MDS Nurse, RN #15 stated, "We would care plan for risk of dehydration if a resident is on [MEDICATION NAME]". Review of the November Medication Administration Record [REDACTED]. Review of Resident #101's complete medical record failed to reveal a care plan for dehydration or fluid maintenance. In an interview on [DATE] at 1:35 p.m., Licensed Practical Nurse (LPN) #7 stated that Resident #101's fluid intake "was probably poor". In an interview on [DATE] at 11:40 a.m., Certified Nursing Assistant (CNA) #8 stated, "(Resident #101) hardly ate or drank". Review of the Initial Dietary Visit form dated [DATE] revealed Resident #101's total fluid needs was ,[DATE] cubic centimeters (cc) per day. Review of I/O (in/out) chart detailed report printed on [DATE] revealed that between [DATE] and [DATE] Resident #101 averaged a daily intake of 600 cc of fluid, more than 1,400 cc below Resident #101's daily requirement. Review Hospital Encounter Notes dated [DATE] revealed Resident #101 was admitted to the hospital unresponsive with the [DIAGNOSES REDACTED]. ( )

This citation pertains to MI 815. Based on interview and record review, the facility failed to provide a comprehensive assessment for dehydration for 1 resident (#101) of 3 total sampled residents reviewed for dehydration, resulting in Resident #101 being admitted to the hospital with [REDACTED]. Resident #101 subsequently died . Findings Include: Review of the face sheet and admission record dated [DATE] revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was moderately impaired cognitively and required extensive assistance with Activities of Daily Living (ADLs). Review of the hospital admission physician orders [REDACTED].#101 was to receive 1 milligram (mg) of [MEDICATION NAME] (water pill) everyday. Review of the [DATE] Medication Administration Record [REDACTED]. Review of a Hospital's Inpatient Behavioral Health Progress Note dated [DATE] revealed Resident #101's past medical history included [DIAGNOSES REDACTED]. According to an article from the National Institute of Health (http://www.ncbi.nlm.nih.gov/pubmed/ 926), "[MEDICAL CONDITION] is defined as a plasma sodium concentration greater than 145 meq/liter (or mmol/L)...Persistent [MEDICAL CONDITION], therefore, implies an inability to sense thirst or lack of access to water, since ingestion of water will prevent development of significant [MEDICAL CONDITION] persons have decreased thirst...frail nursing home residents are at an increased risk for the development of [MEDICAL CONDITION] because they rely on others for their water needs. Therefore, adequate water must be prescribed and given to these individuals..." According to an article titled, "[MEDICAL CONDITION] in Emergency Medicine" (http://emedicine.medscape.com/article/ 3-clinical#a0218), "[MEDICAL CONDITION] is due to too little water...The alteration can be in administration (too much salt or too little water)...The most common cause of [MEDICAL CONDITION] in elderly or institutionalized patients is lack of free water intake adequate to meet losses. Review of hospital lab report dated [DATE], Resident #101's blood sodium level 155 millimoles per liter (mmol/L, normal is ,[DATE] mmol/L). According to the National Institute for Health, severe [MEDICAL CONDITION] is defined as a blood sodium level equal to or greater than 155 mmol/L. Review of the facility's undated Hydration (NUR-522) policy revealed: 1. Complete Hydration Assessment HCM NUR 4123: a. New Admission 2. Follow the steps as outlines (sic) in the Pathway to Hydration Management. 3. Document on Care Plan outcomes of assessment. Review of the undated document titled "Pathway to Hydration Management", revealed that after completing the hydration assessment if a resident was not found to be a risk for dehydration, no further action was required. Review of Resident #101's "Hydration Risk Assessment" (HCM NUR 4123) dated [DATE], nine days after admission, revealed a total score of 4. A total score above 6 represents HIGH RISK for dehydration. The assessment failed to account for the resident's [DIAGNOSES REDACTED]. Further, the assessment failed to account for the resident requiring assistance with fluids, which would have added 4 points to the assessment score. With an accurate assessment Resident #101's score would have been 10, 4 points higher than than what is to be determined HIGH RISK for dehydration. While reviewing Resident #101's Hydration Risk Assessment on [DATE] at 2:30 p.m., The Director of Nursing DON #2 stated, "Yes, I would probably have scored him higher...I remember (Resident #101) having very poor safety awareness, and was very confused". Review of the Initial Dietary Visit form dated [DATE] revealed Resident #101's total fluid needs was ,[DATE] cubic centimeters (cc) per day. Review of I/O (in/out) chart detailed report printed on [DATE] revealed that between [DATE] and [DATE] Resident #101 averaged a daily intake of 600 cc of fluid, more than 1,400 cc below Resident #101's daily requirement. Review of Resident #101's complete medical record failed to reveal a care plan for dehydration or fluid maintenance. Review of Hospital Encounter Notes dated [DATE] revealed Resident #101 was admitted to the hospital unresponsive with the [DIAGNOSES REDACTED]. ( )

This citation pertains to MI 815. Based on interview and record review, the facility failed to notify the physician of an acute change in condition in 1 resident (#101) of 3 total sampled residents reviewed for an acute change of condition, resulting in delayed treatment after Resident #101 was noted to have an abnormal neurological assessment. Resident #101 was admitted to the hospital with [REDACTED]. Resident #101 subsequently died . Findings Include: Review of the face sheet in the medical record dated [DATE] revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was moderately impaired cognitively and required extensive assistance with Activities of Daily Living (ADLs). Review of a Hospital's Inpatient Behavioral Health Progress Note dated [DATE] revealed Resident #101's past medical history included dementia, dehydration, insulin dependent diabetes, high blood pressure and altered mental status. Review of Neurological Assessments forms dated [DATE] thru [DATE] revealed that Resident #101's pupil reaction to light was always "brisk" indicating appropriate reaction and a normal neurological assessment finding. Review of the forms failed to reveal that Resident #101 was ever drowsy or unresponsive. Review of a nurse's note dated [DATE] at 8:30 p.m. and written by Licensed Practical Nurse (LPN) #16 revealed Resident #101's "pupils sluggish to react to light. Not tracking (with) his eyes". Review of the nurse's notes failed to reveal that this abnormal neurological finding was relayed to the physician. Review of Resident #101's complete medical record failed to reveal that Physician #10 was notified of the abnormal neurological assessment findings of "pupils sluggish to react to light. Not tracking (with) his eyes". During a telephone interview on [DATE] at 12:32 p.m., Physician #10 stated he was not made aware of the abnormal findings of Resident #101's "pupils sluggish to react to light. Not tracking (with) his eyes". Physician #10 stated, "No, I do not remember being notified of that". Physician #10 stated, "If a nurse called me and told me that, I would send the resident to the hospital". During a telephone interview on [DATE] at 12:04 p.m. LPN #16 was asked if she remembered the night that Resident #101's abnormal findings of "pupils sluggish to react to light. Not tracking (with) his eyes" were assessed. LPN #16 stated, "I remember that yes, he was not acting right, he was gurgly (making gurgling noises) and we thought he may have aspirated (inhaled something into the lungs). I don't recall if the doctor was called after that (abnormal assessment). I don't know if (name of LPN #7) did". In an interview on [DATE] at 1:35 p.m., LPN #7 stated she did not remember notifying the physician of Resident #101's abnormal findings of "pupils sluggish to react to light. Not tracking (with) his eyes". LPN #7 did agree that this was an acute change in condition, and further stated, " up until 8:00 p.m., (Resident #101) was fine, alert, eyes wide open, able to sit in his wheelchair". In an interview on [DATE] at 12:48 p.m., when asked if a neurological assessment of pupils sluggish to react to light, eyes not tracking was alarming, Registered Nurse (RN) #11 stated, "Yes, I would finish my assessment and call the physician immediately". In an interview on [DATE] at 1:24 p.m., RN #13 stated that if she were to assess a resident to have pupils sluggish to react to light and eyes not tracking, she would contact the physician immediately. In an interview on [DATE] at 8:00 a.m., when asked, if a neurological assessment finding was "pupils sluggish to react to light, eyes not tracking", what would you do, RN #14 stated, "I would call the physician immediately". Review of the nurse's note addendum dated [DATE] at 1:10 p.m., two days after the initial change in condition, revealed, that on [DATE] at 7:50 a.m., approximately. 12 hours after Resident #101's abnormal neurological assessment, Registered Nurse (RN) #14 contacted Physician #10 to inform Physician #10 that Resident #101 was non-responsive. The note revealed that Physician #10 ordered Resident #101 be sent to the emergency room for evaluation. Review of the Ambulance Service Patient Care Report dated [DATE], revealed the ambulance arrived the facility at 8:19 a.m. and found Resident #101 "laying unresponsive". Review of Hospital Encounter Notes dated [DATE] revealed Resident #101 was admitted to the hospital unresponsive with [DIAGNOSES REDACTED]. ( )

This citation pertains to MI 867 Based observation, interview and record review the facility failed to prevent the elopement and ensure the safety of one resident (Resident #1) of 6 residents reviewed for elopement from a total sample of 6, resulting in: 1) the elopement of Resident #1, on 9/29/2013 for approximately one and a half hours, unbeknownst to facility staff and 2) The potential for serious harm, injury and or death for all 23 resident that had been identified by the facility as at risk for elopement. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 was an [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #1 had a moderately impaired cognitive status and continuous disorganized thinking. Review of the orders dated 8/5/13, from the previous facility that Resident #1 resided, revealed " wanderguard on at all times to prevent elopement". Review of Resident #1's Wandering and At Risk for Elopement assessment dated [DATE], revealed "Does the resident have the following: 1. Physical capability of wandering or elopement?" The box with "No, stop" was circled. There was no other documentation for the assessment dated [DATE]. In an interview on 10/2/13 at 3:53 PM, Licensed Practical Nurse (LPN) #4 reported that he performed the wandering and at risk for elopement assessment on 8/17/13. LPN #4 reported that Resident #1 "presented as very immobile...he didn't present as being physically capable of eloping" and that "he didn't catch" that Resident #1 had a wanderguard at the previous facility. When queried if Resident #1 would have been considered an elopement risk had he had caught that (the wanderguard) on admission, LPN #4 stated" it definitely would have made me think harder. I didn't know at that time...I didn't see that in the admission papers. I was focused on the meds...yes until he proved otherwise". When queried how staff was aware of who is at risk for wandering, LPN #4 stated "I would say they are aware, it's usually the same people that go to the doors". ( / ) Review of the Physician's Admission Order Sheet (undated), revealed Resident #1 had an order for [REDACTED]. The physician's orders [REDACTED]. Review of the Nurse's Notes dated 8/30/13, revealed "DC code alert-no attempts to leave the facility". Review of the Routine MAR (medication administration record) dated 9/1/13 through 9/30/13, revealed Resident #1's code alert was not discontinued and he had a code alert in place until 9/27/13. The Nurse's Notes dated 9/19/13 at 5:00 PM, revealed Resident #1 had made "2 attempts to get out of facility. Resident wheeled himself to northwest exit by the door...reminded resident that the door is off limits to residents. He does not seem to understand and minute later he did the same thing..." The Nurse's Notes dated 9/19/13 at 6:30 PM, revealed "resident sat by the front door entrance in his w/c (wheelchair), will continue to monitor for elopement risk. Resident has a code alert ordered". The Nurse's Notes dated 9/27/13 revealed Resident #1 was "up and down @ 1st of shift, trying to go outside @ emergency exit doors..." In a telephone interview on 10/2/13 at 2:28 PM, LPN #5 reported that on 9/26/13-9/27/13 (midnight shift), Resident #1 was "restless and looking for a way to go outside. He actually went to the northeast door and he tried to go outside the door". LPN #5 reported that the alarm sounded because Resident #1 pushed on the door handle. LPN #5 reported that Resident #1 was redirected and then "he tried again". ( ) In an interview on 10/2/13 at 1:55 PM, LPN #6 reported that she was the nurse who wrote the order to discontinue Resident #1's code alert on 9/27/13. When queried who decided to discontinue a code alert, LPN #6 stated "usually I would talk to my manager or somebody about that...talk about whether or not they are still capable of eloping, still a risk for eloping...might want to d/c if not in any shape or condition to elope". When queried if she was aware that Resident #1 attempted to elope on the prior shift, LPN #6 stated, "No, I wasn't at all". At that time, LPN #6 read the nurses note dated 9/27/13 at 3:00 AM and queried if after reading that note, did she think Resident #1 should have had a code alert in place. LPN #6 stated "I do. I expected to find one on him". LPN #6 reported that she would have considered that as an elopement attempt and that she was not aware of the attempt. ( / ) Review of the facility's "Wandering and At Risk for Elopement" Policy and Procedure dated 9/15/09 revealed "1. Complete wandering and at risk for elopement assessment...a. new admission, b. comprehensive assessment MDS, c. quarterly MDS, d. if resident has a new behavior of wandering". Review of the Wandering and At Risk or Elopement Assessment, revealed Resident #1 did not have any additional elopement assessments performed between 8/17/13 and 9/29/13. The Nurse's Notes dated 9/27/13 at 10:00 AM, revealed Resident #1's "code alert D/C ' d, not an elopement risk". Review of the physician's orders [REDACTED]. In an interview on 10/2/13 at 9:45 PM, The Director of Nursing (DON #2) was queried as to who determined to discontinue a code alert, Director of Nursing (#2) stated it was "up to the unit manager. Going forward we will scrutinize it even more with a safety committee instead of one person taking responsibility". ( / ) In an interview on 10/2/13 at approximately 1:35 PM, Licensed Nurse Unit Manager (UM) #3 reported that she worked on 9/27/13 and she was not aware that Resident #1 had prior attempts to elope. When queried if Resident #1 had a code alert on 9/27/13, UM #3 stated "no he did not...It had been discontinued". When queried as to why Resident #1's code alert was discontinued, UM #3 stated "um, at the time it was discontinued he was very lethargic, had been in bed for a couple of days, wasn't even getting up without assistance." UM #3 reported that LPN #6 approached her on 9/27/13 because she did not find the code alert on Resident #1. UM #3 stated "she (LPN #6) did check with me and I told her to go ahead and D/C". When queried if she had any knowledge of an elopement attempt on the shift prior to when the code alert was discontinued, UM #3 stated "I didn't. I didn't look at his chart. I wasn't aware of any attempts". When queried if she should have reviewed the chart, UM #3 stated "other than looking at the wander assessment, which on admission it was no...In hindsight, definitely I would do it totally differently". During the interview on 10/2/13 at 1:35pm, the surveyors asked UM #3 to review the nursing note from 9/27/13 and queried if she considered the nursing note to be an elopement attempt by Resident #1. UM #3 stated "certainly looks like it was". When queried if the code alert should have been discontinued on 9/27/13, UM #3 stated "no, not with that information". UM #3 reported that if a resident didn't have any attempts to elope, she would discontinue the code alert. When queried as to what she classified as an attempt to elope, UM #3 stated "...if they had actually made an attempt to go outdoors..." During the interview on 10/2/13 at 1:35pm, UM #3 reported that she did not work on 9/29/13, but as she took a friend home, she noticed a familiar looking gentleman moving down the sidewalk in his wheelchair near the corner of Birch Row and Gibson. UM #3 stated "I dropped my friend off and came back around to check it out. He was still moving down the sidewalk in his wheelchair. I got out of the car and said hello. He (Resident #1) said he was lost. At that point, I knew who he was...I called the facility and asked if they were missing him." UM #3 reported that she first observed Resident #1 at approximately 7:30 PM and returned him to the facility at approximately 7:45 PM in her vehicle. ( / ) Review of an iPhone Maps application, revealed that the corner of Birch Row and Gibson was 0.5 miles away from the facility. On 10/2/13 at 12:00 PM, a viewing of the surveillance video at the Marathon gas station, across the street from the facility, revealed that Resident #1 was outside of the facility at 6:15:45 PM, in his wheelchair, headed east toward Hagadorn Rd. Traffic was flowing steadily. At 6:21:49 PM, Resident #1 was sitting in his wheelchair at the intersection of Hagadorn Rd. and Lake Lansing Rd. At 6:22:57 PM, Resident #1 began crossing Lake Lansing Rd. At 6:25:34 PM, Resident #1 was headed west down the sidewalk in in his wheelchair in front of the Marathon Gas Station. Resident #1 was out of view at 6:27:44 PM. In a telephone interview on 10/3/13 at 8:45 AM, Licensed Practical Nurse LPN #7 reported that on 9/29/13, she last saw Resident #1 around 5:30 PM and she was not aware that Resident #1 was missing. LPN #7 reported that she found out Resident #1 was missing when she received a telephone call from UM #3. LPN #7 reported that admissions staff performed elopement risk assessments. When queried how staff identified residents who were at risk for wandering, LPN #7 stated "when the alarms go off". ( ) In a telephone interview on 10/3/13 at 9:42 AM, Registered Nurse RN #9 reported that Resident #1 had set off the exit door alarm on 9/29/13 between 5:30 and 6:00 PM. RN #6 reported that she last saw Resident #1 around 6:00 PM at the nurse's station and "he seemed ok". RN #6 reported that she was unaware that Resident #1 had left the facility and that she became aware when LPN #7 informed her after receiving a phone call from UM #3. ( ) Review of Resident #1's Incident Report dated 9/29/13 at 7:45 PM, "...nurse received phone call that resident was out of facility and staff member would be returning him back to facility..." On 10/2/13, Administrator #1 provided the surveyors with a list of 23 "at risk for elopement" residents. Review of the list revealed 17 of the 23 residents had wanderguards/code alerts in place. In an interview on 10/2/13 at 3:30 PM, DON #2 reported that the list contained residents who "we felt were confused and move about". When queried why 6 of the residents did not have a wanderguard, DON #2 reported that the facility only had 17 wanderguard bracelets available and had ordered more. DON #2 reported that the plan was for all 23 residents to have wanderguards in place. Observations on 10/02/13 revealed that exit doors had an alarm that sounded if pushed open. The front entrance door was equipped with a wanderguard system, but was not locked or alarmed. ( ) The Facility Administrator was notified of Immediate Jeopardy on 10-3-13 at 12:32 pm due to the facility's failure to prevent the elopement and ensure the safety of Resident #1 when he left the faciity on [DATE] for approximately one and a half hours, unbeknownst to facility staff. Resident #1 was found by off duty Unit Manager (UM) #3, 0.5 miles away from the facility This deficient practice places 23 residents, who have been identified by the facility as an elopement risk, at risk for serious harm, injury, and/or death. A corrective action plan was requested from the facility to remove the immediate jeopardy. On 10/3/13, the surveyors confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. A new "Wandering and at Risk for Elopement Assessment" HCM NUR 4122 form was completed on all Residents on 9/30/2013, in order to reassess their risk for elopement. 2. A number of new Residents previously assessed as low risk for elopement were added to the "At Risk for Elopement List" after completion of the HCM NUR 4122 form. Care Plans initiated for those residents added by 10/1/13. 3. On Monday, 9/30/2013 Residents on the 'At Risk for Elopement" list had their pictures taken and added to the Elopement Binder. 4. Additional Code Alert Transmitters were ordered on [DATE] and arrived 10/4/13. 5. Starting on 10/3/13 and until additional transmitters arrive, the front door to the facility will be guarded 24 hrs. a day, 7 days per week. 6. On 10/3/13 additional door alarms were installed at the front door and service door. 7. RTF Inc., was contacted on 10/3/13 regarding changing the existing Code Alert system to a key pad security system that will require a four digit code to exit. However this will take approximately two months to accomplish due to work permits required by the Fire Marshall and alterations to the fire alarm system. 8. on 10/3/13 an in-service was conducted by the ADON for all licensed nursing personnel and reviewed the new procedure for accomplishing the elopement risk assessment and rules for discontinuing any wander guard device. 9. Starting on 10/3/13 in-services will be conducted for all personnel prior to coming on duty regarding the new security procedures and the importance of being aware of the at risk for elopement residents. 10. Effective 10/3/13 door alarms will be checked daily by the maintenance personnel. The Code Alert transmitters will be checked per shift using the "Transmitter Tester" provided on each nursing unit. 11. New policy was written on 9/30/13 and was distributed to all personnel outlining the new procedures for issuing and discontinuing wander guard devices. 12. In the new policy, effective 9/30/13, nurses will not be permitted to discontinue the wander guard device, only the Safety Committee will have the authority to do that. 13. Effective 9/30/13, the DON or representative will monitor the "At Risk for Elopement" (ARFE) list and make recommendations for removal to the Safety Committee. 14. Effective with the October 2013 Safety Committee meeting, scheduled for 10/15/13, The Safety Committee will review all residents monthly that are on the ARFE list and discuss any motions made to remove a wander guard device from a resident. 15. Effective with the October 2013 QA Meeting, the results of the Safety Committee decisions will be presented to the QA Committee monthly by the Safety Committee Chairman. Although the Immediate Jeopardy was removed on 10/3/13, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all of the staff had not yet been in-serviced and sustained compliance had not been verified by the state agency. ( & )

This citation pertains to intake MI 642 Based on observation, interview, and record review the facility failed to ensure the safety and prevent accidents in 1 (Resident #101) of 3 residents from a total of 3 sampled residents when Resident #101 who was assessed to be a high risk for falling was found without interventions in place to ensure his safety and who fell and fractured his left hip, resulting in significant pain and suffering. Findings include: Review of a facility "Face Sheet", dated 10/05/2011 revealed Resident #101 was a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A "Minimum Data Set" (MDS) assessment dated [DATE] indicated Resident #101 was totally dependent on one staff member for assistance with bed mobility and transfers. An assessment of "Functional Limitation in Range of Motion" which is coded for limitations that interfere with daily functions or placed resident at risk of injury indicated Resident #101 had impairments on both sides of his lower extremities and normally used a wheelchair for mobility. Record Review of a "Facility Investigation Report-5 Working Days", dated 11/04/2011 revealed on 10/30/11 Resident #101 sustained a left hip intertrochanteric fracture when he attempted to reposition himself in his wheelchair without locking the brakes and fell to the floor. The action taken by the facility in response to the incident was to install auto-locking breaks in the wheelchair to ensure Resident #101's safety. Record review of a "Nurse's Note", dated 10/30/2011 at 11:25 a.m. revealed "Certified Nurse Aide (CNA) called this writer to resident room, observed resident laying on the floor on his left side. He was holding onto the foot board of his bed with 2 hands. He alerted staff not to try to move him. He stated that he lifted up his butt off the wheelchair in order to reposition and position his butt farther back in the wheelchair and it rolled back. He stated he landed on his left hip and 'I heard it pop'." During an interview on 11/16/2011 at 9:45 a.m., Resident #101 told this surveyor that he stood up from his wheel chair to straighten pictures on a bulletin board over his bed, then sat down again but was not positioned correctly in his wheel chair. When he attempted to reposition himself in his wheelchair he fell to the floor on his left side when his wheelchair slid out from behind him because he had forgotten to lock his wheelchair brakes. He heard his hip 'pop' and could hear the bones grinding against each other and was in excruciating pain, unable to reach his call light to summon help. He stated there was not an alarm in his wheel chair. Resident #101 was observed in his room in his wheelchair on 11/16/2011 at 9:45 a.m. A pressure alarm was in place and functioning. No auto-locking brake device was installed on the chair Resident #101 was sitting in. An interview with the Director of Nursing, on 11/16/2011 at 9:50 a.m. revealed she did not know why the auto locking breaks were not installed on Resident #101's chair. A care plan for "Accidents/Falls/Injury" dated 10/17/2011 revealed Resident #101 was at risk for accidents, falls, and injury due to being unaware of safety needs related to narcotic use along with wanting to be as independent as possible, gait/balance problems r/t (related to) bilateral lower extremity wounds and increase pain with movement. Interventions included assisting the resident with transfers, and placing a sensor alarm to the bed, check placement and function every shift. A care plan for "Activities of Daily Living", dated 10/17/2011 was written to provide directives to care givers with information to meet the day to day needs of Resident #101. The care plan indicated Resident #101 required staff assistance with transfers and a four wheeled walker for pivot transfers only. Resident #101 was NOT to walk with nursing staff, and a sensor alarm was to be in place on his bed with placement and function checked every shift. Record review of a "Treatment Administration Record", for the month of October 2011, revealed Resident #101 was to have a sensor alarm on his bed, "Check every shift for placement and function" and is documented on by staff every shift indicating it was on Resident #101's bed and functioning. A note on the back of the treatment record, dated 10/08/2011 indicated the bed alarm had been removed due to Resident #101's refusal. Record review of a "Nurse's Note", dated 10/14/2011 reported "...resident transferred independently from wheelchair to bathroom without asking for assistance, advised to request help when needed." Record review of a "Nurse's Note", dated 10/18/2011 revealed "...resident transferred independently from wheelchair to bed without asking for assistance, resident advised to use the call light for assistance." Record review of a Nurse's Note", dated 10/19/2011 revealed, "...resident observed transferring independently without asking for assistance, "I can do it by myself", therapy notified to evaluate resident." Record review of a "Physical Therapy-Therapist Report and Discharge Summary", dated 10/31/2011 revealed Resident #101 was able to transfer from bed to wheelchair and wheelchair to bed with supervision. An "Analysis of Functional Outcome/Clinical Impression" documented in the report indicated Resident #101 made steady progress toward his goals. Resident not consistent in using a 4 wheeled walker during functional transfers and requires minimal verbal cues to use 4 wheeled walker. Record review of an "Occupational Therapy-Therapist Progress Report and Discharge Summary", dated 10/31/2011 revealed Resident #101 had been making good progress in therapy service and was supervision level for functional transfers as well, however Resident recently fell and broke his hip, was discharged to the hospital for treatment. Resident had been educated about the importance of safety with functional transfers and calling for help, rather than transferring himself. Review of the clinical record, including Nurse's Notes, Care Plans, physician progress notes [REDACTED].#101 from the date of his original admission on 10/05/2011-10/30/2011 when he was discharged to the hospital with a hip fracture did not reveal any interventions were in place for Resident #101 to ensure his safety while in bed or in his wheelchair after repeated incidents of self-transferring without calling for assistance or supervision were documented. Record review of a hospital emergency department "Physician Clinical Report", dated 10/20/2011 revealed Resident #101 had a comminuted intertrochanteric fracture of the left hip. A hospital "Operative Report", dated 11/01/2011 revealed Resident #101 was a [AGE] year old man with multiple medical problems including congestive heart failure, significant non-healing ulcers of his bilateral lower extremities, end-stage renal disease requiring dialysis, that presented with a left hip fracture. The pros and cons of treatment of [REDACTED].

THIS CITATION PERTAINS TO INTAKES MI 165 AND MI 243 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO UTILIZE SAFETY DEVICES FOR 1 OF 3 SAMPLED RESIDENTS (#503) FROM A TOTAL SAMPLE OF 3 RESIDENTS, RESULTING IN 1.) RESIDENT #503 FALLING FROM THE COMMODE (CALL LIGHT WAS NOT WITHIN REACH) AND 2.) RESIDENT #503 FALLING ON THE WAY TO THE BATHROOM (GAIT BELT NOT UTILIZED) SUSTAINING A FRACTURE WITH SUBSEQUENT hospitalization AND SURGERY. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET REVEALED RESIDENT #503 WAS A [AGE] year OLD WOMAN admitted to the facility on [DATE]. THE physician progress notes [REDACTED]. THE MINIMUM DATA SETS (MDS'S) DATED 9/29/11 AND 10/10/11 REFLECTED RESIDENT #503 HAD NO COGNITIVE DEFICITS AND REQUIRED LIMITED TO EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S). RESIDENT #503 NO LONGER LIVED AT THE FACILITY AT THE TIME OF THE INVESTIGATION. REVIEW OF A FACILITY INCIDENT REPORT DATED 10/4/11 AT 5:00 AM REVEALED THAT RESIDENT #503 HAD "USED THE COMMODE, REACHED FOR THE CALL LIGHT, LEANED FORWARD AND fell on THE FLOOR." THE REPORT DOCUMENTED THAT RESIDENT #503 SUSTAINED AN ABRASION (SCRAPE) OF HER RIGHT KNEE AND [DIAGNOSES REDACTED] (A REDDENED AREA) ON THE BASE OF HER NECK. IN AN INTERVIEW ON 10/20/11 AT 2:15 PM, LPN #2 SAID SHE PUT RESIDENT #503 0N THE COMMODE ON 10/4/11. LPN #2 SAID SHE LEFT THE ROOM AND WAS JUST OUTSIDE THE DOOR TO GIVE RESIDENT #503 PRIVACY UNTIL SHE WAS FINISHED WITH THE COMMODE. LPN #2 SAID SHE TOLD RESIDENT #503 THAT SHE WOULD STEP OUTSIDE BUT DIDN'T TELL HER SHE WOULD BE RIGHT OUTSIDE HER DOOR. LPN #2 SAID RESIDENT #503'S CALL LIGHT WAS ON THE GRAB BAR AND THAT IT WAS OUT OF REACH OF RESIDENT #503 WHEN SHE WAS ON THE COMMODE. REVIEW OF A FACILITY INCIDENT REPORT DATED 10/10/11 AT 12:30 AM REVEALED THAT RESIDENT #503 WAS BEING ASSISTED INTO THE BATHROOM BY A NURSE (LICENSED PRACTICAL NURSE (LPN) # 2) AND RESIDENT #503'S WALKER. THE INCIDENT REPORT REFLECTED "RESIDENT'S FEET BECAME WEAK SUDDENLY AND WAS LOWERED TO THE FLOOR ... RESIDENT COMPLAINED OF PAIN ... ON LEFT KNEE". REVIEW OF THE PHYSICIAN ORDER [REDACTED]. A SECOND ORDERED DATED 10/10/11 (NO TIME) REVEALED RESIDENT #503 SUSTAINED AN ACUTE DISCPLACED FRACTURE OF DISTAL FEMUR (UPPER LEG) AND RESIDENT #503 WAS TO BE TRANSFERRED TO THE HOSPITAL. REVIEW OF THE EMERGENCY RUN SHEET DATED 10/10/11 AT 11:24 AM REVEALED RESIDENT #503 "fell WHILE BEING ASSISTED TO BATHRROM". RESIDENT #503 COMPLAINED OF PAIN SCORE OF 10 ON A SCALE OF 1-10. IN AN INTERVIEW ON 10/20/11 AT 2:15 PM LPN #2 SAID SHE HAD GIVEN RESIDENT #503 HER MEDICATION ABOUT 12 MIDNIGHT OR 12:30 AM ON 10/10/11 AND RESIDENT #503 SAID SHE WANTED TO GO TO THE BATHROOM EVEN THOUGH THE COMMODE WAS AT HER BEDSIDE. LPN #2 SAID SHE WAS TOLD IN REPORT THAT RESIDENT #503 WAS ABLE TO WALK WITH 1 PERSON ASSIST (1 PERSON HELPING). LPN #2 SAID SHE DID NOT HAVE A GAIT BELT (A WEBBED BELT TO HELP STABILIZE AN AMBULATORY RESIDENT) WITH HER, BUT THAT THERE WAS ONE IN HER MEDICATION CART. LPN #2 SAID RESIDENT #503 WAS WALKING AHEAD OF LPN #2 ON HER WAY TO THE BATHROOM AND RESIDENT #503 COLLAPSED IN THE BATHROOM DOORWAY. LPN #2 SAID SHE GRABBED RESIDENT #503 UNDER HER ARMPITS AND THEY BOTH WENT TO THE FLOOR. LPN #2 SAID SHE THEN OBTAINED HELP FOR THE RESIDENT. REVIEW OF THE MEDICAL RECORD REVEALED A PHYSICIAN ORDER [REDACTED]. A FALL RISK CARE PLAN DISCLOSED AN INTERVENTION DATED 10/3/11 FOR "1 ASSIST WITH TRANSFER/GAIT BELT". REVIEW OF THE HOSPITAL CLINICAL REPORT DATED 10/10/11 (NO TIME) REVEALED RESIDENT #503 WAS admitted to the hospital with [REDACTED]. THE HOSPITAL OPERATIVE REPORT DATED 10/12/11 REVEALED RESIDENT #503 REQUIRED surgery for [REDACTED]. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS FOR 3 OF 3 RESIDENTS (#3, 1 AND 9) REVIEWED FOR PRESSURE ULCERS FROM A TOTAL OF 17 SAMPLED RESIDENTS, RESULTING IN AN UNSTAGEABLE LEFT HEEL PRESSURE ULCER FOR ONE RESIDENT #1, A STAGE 2 LEFT OUTER ANKLE PRESSURE ULCER FOR RESIDENT #3 AND A STAGE 2 BILATERAL BUTTOCK PRESSURE ULCERS FOR RESIDENT #9. FINDINGS INCLUDE: ACCORDING OT THE [DIAGNOSES REDACTED]. THE PHYSICIAN'S ADMISSION SUMMARY DATED 10/19/10 REFLECTED THAT THE RESIDENT HAD A WOUND VAC treatment for [REDACTED]. THE RESIDENT ALSO HAD AN INDWELLING URINARY CATHETER TO PROMOTE WOUND HEALING. THE NURSING CARE PLAN DATED 12/30/10 REFLECTED THAT THE PROBLEMS RELATED TO THE DEVELOPMENT OF THE PRESSURE ULCER WERE RELATED TO DIABETES, IMMOBILITY, INCONTINENCE AND POOR PERSONAL HYGIENE. ON 5/12/11 AT 12 NOON, THE NORTH UNIT MANAGER, (STAFF " I ") AGREED THE RISK FACTORS REGARDING INCONTINENCE AND POOR HYGIENE DID NOT MATCH HER CONDITION SINCE SHE HAD A URINARY CATHETER, [MEDICAL CONDITION] AND WAS PROVIDED GOOD HYGIENE AND PERSONAL CARE. THE CARE PLAN INTERVENTIONS FOR PRESSURE ULCER INCLUDED, TO INCREASE PROTEIN NEEDS, PROVIDE SUPPLEMENTS AND VITAMINS, MONITOR LABORATORY VALUES, MONITOR SIGNS OF INFECTION, MONITOR PAIN AND MONITOR WOUND STATUS. THERE WAS NO INTERVENTION OR STRATEGY TO REPOSITION THE RESIDENT, PROVIDE SUPPORT SURFACES OR PRESSURE REDISTRIBUTION (EITHER PRESSURE REDUCTION OR PRESSURE RELIEF) DEVICES. THE NURSING NOTES DATED 12/1/10 REFLECTED THAT THE RESIDENT HAD AN UNSTAGEABLE (REFERS TO A STAGE 4 DUE TO COVERING OF DEAD TISSUE) LEFT HEEL PRESSURE ULCER, MEASURING 6 CM IN DIAMETER. THIS WAS THE FIRST ENTRY DESCRIBING THAT THE RESIDENT HAD DEVELOPED A NEW PRESSURE AREA. ON 5/12/11 AT 2:00 P.M., THE DIRECTOR OF NURSING STATED THAT THE WOUND STARTED AS A BLISTER. HOWEVER, NONE OF THE 3 FORMS ("DAILY ULCER DOCUMENTATION", "WEEKLY SKIN ASSESSMENT FOR BRADEN SCALE HIGH RISK 16 AND BELOW AND OTHER SKIN PROBLEM" AND "WEEKLY ULCER ASSESSMENT"), UTILIZED BY THE FACILITY TO MONITOR THE SKIN ISSUES HAD DOCUMENTED THE PRESENCE OF A BLISTER ON THE RESIDENT'S LEFT HEEL. ON 5/11/11 AT 2:00 P.M., THE DRESSING CHANGE ON THE RESIDENT'S LEFT HEEL WAS OBSERVED IN HER ROOM. THERE WERE 2 WOUNDS, ONE WITH DARK SCAB MEASURING APPROXIMATELY 2.5 CM LONG AND 2 CM WIDE WITH UNKNOWN DEPTH. ANOTHER WOUND WAS ROUND, RED, SLIGHTLY RAISED, OPEN IN THE CENTER WITH MODERATE AMOUNT OF SEROSANGUINEOUS DRAINAGE. IT MEASURED APPROXIMATELY 3.5 CM LONG, 3.5 CM WIDE AND 0.5 CM DEEP. THE UNIT NURSE, (STAFF "K") WHO PERFORMED THE PROCEDURE STATED THAT THE WOUND USED TO BE ONE, BUT WITH MULTIPLE DEBRIDEMENTS (ON 2/22/11 AND 4/5/11) IT BECAME SEPARATED. THE NURSING NOTES DATED 4/5/11 REFLECTED THE NURSE PRACTITIONER DEBRIDED THE RESIDENT'S LEFT HEEL ULCER DUE TO INCREASED ODOR AND DRAINAGE. THE RESIDENT'S LEFT FOOT LOOKED SIGNIFICANTLY SWOLLEN COMPARED TO THE RIGHT FOOT. ALTHOUGH THE PHYSICIAN'S PROGRESS NOTES (MARCH 4, 8, 22, 29/2011) REPEATEDLY DENIED THE PRESENCE OF [MEDICAL CONDITION], THE NURSING NOTES DATED 11/20/10 DOCUMENTED THE RESIDENT AS HAVING "MODERATE NON-PITTING [MEDICAL CONDITION] TO BILATERAL LOWER EXTREMITIES". THE DIETARY PROGRESS NOTES DATED 2/9/11 AND 4/7/11 REFLECTED THAT THE RESIDENT HAD FLUCTUATING WEIGHT ISSUES DUE TO BOTH INCREASED AND DECREASED APPETITE. THE RESIDENT'S WEIGHT RECORD INDICATED THE RESIDENT WEIGHED 150.6 POUNDS ON ADMISSION (10/14/10) AND THE MOST RECENT WEIGHT RECORD (5/7/11) SHOWED THE RESIDENT WEIGHED 183 POUNDS, A GAIN OF 32.4 POUNDS IN A 7 MONTH PERIOD. ON 5/12/11 AT 9:00 A.M., THE CLINICAL NUTRITIONAL ASSISTANT, (STAFF "D") STATED THAT THE RESIDENT WAS NONCOMPLIANT WITH HER DIET, SNACKED EXCESSIVELY ON CHIPS, OREO COOKIES, CANDIES AND CHEESE DESPITE THE REPEATED COUNSELING FOR HEALTHIER SNACK CHOICES. HOWEVER, THE NURSE PRACTITIONER NOTE DATED 5/6/11 REFLECTED THE RESIDENT WAS PRESCRIBED [MEDICATION NAME] INDEFINITELY, A MEDICATION TO PROMOTE APPETITE, BECAUSE EVERY TIME HER [MEDICATION NAME] STOPPED THE RESIDENT STOPPED EATING AND THE RESIDENT LOST WEIGHT. REVIEW OF THE LABORATORY EVALUATION FOR WOUND HEALING INCLUDED [MEDICATION NAME] LEVEL OF 2.9 G/DL (NORMAL: 3.6-5.0) ON 10/14/10, 3.4 G/DL ON 2/7/11 AND 2.8 G/DL ON 4/4/11. THE HEMOGLOBIN A1C, ANOTHER LABORATORY VALUE IMPORTANT FOR WOUND HEALING WAS 6.5 % (NORMAL: 4-7%) ON 1/3/11. THE HEMOGLOBIN, ANOTHER IMPORTANT ELEMENT TO PROMOTE WOUND HEALING WAS 7.6 G/DL (NORMAL:12.0-15.0) ON 11/11/10 AND 4/4/11. SHE WAS GIVEN [MEDICAL CONDITION] ON BOTH OCCASIONS. ON 5/12/11 AT 12 NOON, THE UNIT MANAGER "I" WAS ASKED WHAT CAUSED THE RESIDENT'S HEEL ULCER. SHE DID NOT PROVIDE CLEAR ANSWERS EXCEPT TO DESCRIBE THE RESIDENT AS BEING NON-COMPLIANT WITH POSITIONING AND NOT GETTING UP FROM THE BED. THE SOCIAL PROGRESS NOTES DATED 3/16/11 REFLECTED THE RESIDENT HAD INCREASED ANXIETY TO THE POINT THAT IT WAS PARALYZING PRIMARILY DUE TO PAIN (RELATED TO PRESSURE ULCERS) AND ISSUES WITH BEING UP AND OUT OF BED. THE OBRA CONTACT NOTES DATED 2/25/11 ALSO DESCRIBED THE RESIDENT AS HAVING INCREASED ANXIETY DUE TO INCREASED PAIN IN HER ANKLE/HEEL. SHE WAS EXTREMELY FEARFUL TO GET UP OR MOVE BECAUSE SHE WAS AFRAID OF THE INCREASED PAIN. ON 5/12/11 AT 2:00 P.M., THE DIRECTOR OF NURSING WAS ASKED WHAT TYPE OF PREVENTIVE NURSING INTERVENTIONS WERE PLACED BEFORE THE DEVELOPMENT OF THE RESIDENT'S LEFT HEEL PRESSURE ULCER. SHE SAID ALTHOUGH THERE WERE NO CLEAR DOCUMENTATION OF THE INTERVENTIONS, " WE FOLLOW STANDARD NURSING CARE PRACTICES LIKE TURNING, BRIDGING HEELS, CLEANING AND PROVIDING PAIN MEDICATIONS". HOWEVER, NONE OF THE SKIN ASSESSMENTS, NURSING NOTES AND NURSING CARE PLANS REFLECTED BRIDGING OF HEELS OR USE OF PRESSURE RELIEVING DEVICES PRIOR TO 12/1/10 WHEN THE ULCER WAS FIRST DISCOVERED. ( ) ACCORDING TO THE physician's orders [REDACTED]. THE NURSING CARE PLAN DATED 9/10/10 REFLECTED THAT THE RESIDENT HAD A DECLINE IN ACTIVITIES OF DAILY LIVING (ADL) AND HAD BEEN PLACED UNDER HOSPICE CARE. HOWEVER, ON 5/10/11 AT 9:30 A.M., DURING AN INITIAL TOUR, THE SOUTH UNIT MANAGER, (STAFF "A") STATED THE RESIDENT WAS IMPROVING WITH HER HEALTH AND SHE NO LONGER NEEDED HOSPICE CARE. IT WAS DISCONTINUED ON 4/8/11. ON 5/11/11 AT 9:00 A.M., DURING AN INTERVIEW, THE RESIDENT WAS PLEASANT, COOPERATIVE AND PROPELLED HERSELF WELL IN HER WHEELCHAIR. THE NURSING CARE PLAN RELATED TO SKIN BREAKDOWN DATED 9/10/10 REFLECTED THAT THE RESIDENT HAD THE POTENTIAL PROBLEM FOR SKIN BREAKDOWN RELATED TO A HISTORY OF [MEDICAL CONDITION] ON HER LEFT LEG, A HISTORY OF [MEDICAL CONDITION], INCREASED INCONTINENT EPISODES, DECLINE IN FUNCTIONAL STATUS, DECLINE IN MOBILITY, HISTORY OF SKIN TEARS, FRAGILE SKIN AND A [DIAGNOSES REDACTED]. THE "WEEKLY SKIN ASSESSMENT FOR BRADEN SCALE HIGH RISK 16 AND BELOW AND OTHER SKIN PROBLEM" FORM DATED 4/18/11 REFLECTED THAT THE RESIDENT HAD AN OPEN AREA ON HER LEFT LATERAL ANKLE. THE DAILY WOUND DOCUMENTATION DATED 4/20/11 THROUGH 4/27/11 REFLECTED THAT THE RESIDENT HAD A WOUND OVER THE LEFT LATERAL ABOVE ANKLE. THE WEEKLY ULCER assessment dated [DATE] REFLECTED THAT THE RESIDENT'S ULCER WAS LOCATED IN THE LEFT OUTER ANKLE. ON 5/11/11 AT 9:30 A.M., THE UNIT MANAGER "A" WAS NOT SURE WHETHER ALL OF 3 PRESSURE ULCER FORMS DESCRIBED THE SAME PRESSURE ULCER OR NOT. THE NURSING NOTES DATED 5/2/11 REFLECTED, " ...TREATMENT TO LEFT LOWER LEG ABOVE ANKLE EVALUATED; OBSERVED STAGE 2 ON LEFT OUTER ANKLE AREA OPEN MEASURING 0.5 CM X 0.5 CM...NO ODOR OR DRAINAGE NOTED...SMALL AMOUNT OF YELLOW SLOUGH PRESENT...SURROUNDING SKIN [MEDICATION NAME] PLACED... " ON 5/11/11 AT 9:45 A.M., THE DRESSING CHANGE WAS OBSERVED IN THE RESIDENT'S ROOM. THE LEFT OUTER ANKLE HAD A STAGE 2 (PARTIAL THICKNESS SKIN LOSS INVOLVING THE EPIDERMIS, DERMIS OR BOTH) PRESSURE WOUND MEASURING 0.5 CM LONG AND 0.7 CM WIDE WITH UNKNOWN DEPTH. IT LOOKED LIKE A SHALLOW CRATER WITH SMALL AMOUNT OF SEROSANGUINOUS DRAINAGE. THE SURROUNDING SKIN WAS RED AND RAISED MEASURING 2 CM LONG AND 2.5 CM WIDE. THE RESIDENT WITHDREW HER LEFT LEG, STATING THE PAIN FELT RAW. THE UNIT MANAGER "A" WHO PERFORMED THE DRESSING CHANGE STATED THE WOUND LOOKED WORSE THAN PREVIOUS DATES AND WOULD CONTACT THE PHYSICIAN AND EVALUATE THE TREATMENT. THE UPDATED SKIN CARE PLAN DATED 5/2/11 REFLECTED THAT THE RESIDENT DEVELOPED THE LEFT OUTER ANKLE PRESSURE ULCER BECAUSE SHE PREFERRED TO LIE ON HER LEFT SIDE. THE INTERVENTIONS INCLUDED ASSISTING THE RESIDENT TO LIE ON HER RIGHT SIDE AND BACK AND PLACING A BLUE FOAM BOOT ON HER LEFT FOOT. HOWEVER, THERE WERE NO PREVENTIVE MEASURES SUCH AS BRIDGING OF HEELS, AVOIDING POSITIONING ON BONY PROMINENCES OR USE OF POSITIONING DEVICES. ( ) ACCORDING TO THE physician's orders [REDACTED]. ON 5/10/11 AT 9:00 A.M., THE SOUTH UNIT MANAGER, (STAFF "A") STATED THAT THE RESIDENT HAD AN OPEN AREA ON HER BUTTOCKS. BUT SHE WAS NOT SURE WHETHER THE RESIDENT'S BUTTOCKS CURRENTLY HAD TWO OPEN AREAS OR NOT. THE NURSING NOTES DATED 9/21/10 THROUGH 4/29/11 REFLECTED THE RESIDENT'S RIGHT BUTTOCK HAD AN OPEN AREA ON 9/21/10, 10/16/10, 11/6/10, 2/8/11 AND 4/29/11. ON 11/6/10 AND 4/29/11, BOTH RIGHT AND LEFT BUTTOCKS WERE DOCUMENTED AS HAVING OPEN AREAS. THE WEEKLY SKIN assessment dated [DATE] REFLECTED THAT THE LEFT BUTTOCK HAD A STAGE 2, THICK SKIN MEASURING 0.6 CM LONG 0.4 CM WIDE. THE RIGHT BUTTOCK ALSO HAD A STAGE 2, THICK SKIN MEASURING 0.5 CM LONG AND 0.3 WIDE. THE NURSING NOTES DATED 4/29/11 REFLECTED, " ...CALLED TO THE RESIDENT'S ROOM BY FAMILY MEMBER...COMPLAINT OF FEELING HOLES IN HER BUTT AGAIN... LEFT CHEEK 0.25 CM X 0.25 CM...RIGHT CHEEK 0.5 CM X 0.5 CM... " ON 5/11/11 AT 4:00 P.M., THE DRESSING CHANGE WAS OBSERVED IN THE RESIDENT'S ROOM. THE LEFT BUTTOCK HAD AN OPEN WOUND THAT MEASURED 1 CM X 0.5 CM. THE RIGHT BUTTOCK HAD AN OPEN IRREGULARLY SHAPED WOUND THAT MEASURED 3 CM X 2 CM. THE ENTIRE BUTTOCKS HAD A ROUGH, DARKLY PIGMENTED AND MACERATED SKIN SURFACE. THE RESIDENT SCREAMED AND YELLED DURING THE ENTIRE PERIOD OF THE PROCEDURE. ON 5/11/11 AT 4:00 P.M., THE UNIT MANAGER "A" STATED THE RESIDENT WAS UP MORE THAN SHE WOULD HAVE LIKED AND PREFERRED TO SEE HER LYING MORE IN BED. THE UNIT MANAGER "A" ADDED THAT THE RESIDENT COULD MOVE A LITTLE BUT SHE COULD NOT TURN HERSELF FROM SIDE TO SIDE. ON 5/10/11 AT VARIOUS TIMES THE RESIDENT WAS RARELY OBSERVED IN HER ROOM. ON 5/11/11 AND 5/12/11 BETWEEN 9:00 A.M. AND 10:30 A.M., THE RESIDENT WAS OBSERVED SITTING IN HALL WAY ACROSS FROM THE NURSING STATION. THE RESIDENT WAS NOT REPOSITIONED WHILE IN THE CHAIR. THE NURSE PRACTITIONER'S NOTE DATED 4/19/11 REFLECTED THE RESIDENT DID NOT PROPEL HER WHEELCHAIR, REFUSED ALL MEDICATIONS INCLUDING PROTEIN SUPPLEMENT FOR WOUND HEALING OR LAB WORK. HOWEVER, THE RESIDENT MAINTAINED HER WEIGHT (158.4 POUNDS ON 4/10/10 AND 156.8 POUNDS ON 5/1/11). THE FACILITY POLICY, UNDATED, REGARDING PREVENTIVE MEASURES FOR PRESSURE ULCERS INCLUDED PROVIDING SPECIALTY MATTRESSES ON BED AND IN WHEELCHAIR. HOWEVER, THE NURSING CARE PLAN LACKED THESE INTERVENTIONS. ( )